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Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Dural Puncture – Management of Accidental Dural Puncture and Post Dural Puncture Headache (529)

Objectives

The aim of this guideline is to provide information on the management of accidental dural puncture (ADP), and the diagnosis and treatment of post dural puncture headache (PDPH) in the obstetric population.

Please report any inaccuracies or issues with this guideline using our online form

Postpartum headache is common, and can include causes such as tension headache, migraine and pregnancy-induced hypertensive disease. Rarer causes include subarachnoid haemorrhage, meningitis and cortical vein thrombosis.1

Post-dural puncture headache (PDPH) occurs in around 1-2% of patients who have received a labour epidural or a spinal anaesthetic. The mechanism is believed to be intracranial hypotension due to leakage of CSF through a hole in the dura. The needles used for spinal anaesthesia are small, and designed to reduce the risk of PDPH, so after a straightforward spinal anaesthetic the risk of PDPH is less than 1%. Epidural (Tuohy) needles are larger but do not normally breach the dura. However, if an accidental dural puncture (ADP) occurs, the incidence of PDPH may be as high as 60-80%.2

When an ADP occurs during the insertion of an epidural, this is normally obvious as CSF flows rapidly down the Tuohy needle. Management of ADP varies depending on local policy. 

  • The anaesthetist may remove the Tuohy needle and attempt to site another epidural at a different space. The anaesthetist must be vigilant when passing the epidural catheter as there is a possibility that its tip may enter the subarachnoid space via the hole in the dura. Additionally, all top ups must be given with caution as some local anaesthetic may reach the CSF.
  • Insertion of an intrathecal catheter has been shown to reduce the incidence of PDPH, but in order to maximise this benefit the catheter should be left in place for up to 24 hours.3 Concerns about sterility may mean that the catheter cannot be left this long. An intrathecal catheter must be labelled clearly as such and all top-ups must be administered by an anaesthetist. If an intrathecal catheter is inserted, the consultant anaesthetist covering the labour ward must be made aware.
  • Prophylactic epidural blood patch after ADP does not reliably reduce the incidence of PDPH.4 It also exposes the patient to the risks of blood patch when they may not have gone on to develop a PDPH in any case.

PDPH normally manifests 24-72 hours after the causative intervention. The characteristic headache is bilateral, frontal or occipital, and varies with posture, worsening within 15 minutes of standing and improving within 15 minutes of lying down. Associated symptoms may include nausea, neck stiffness, tinnitus, photophobia and hyperacusis (sensitivity to sound).5

Most PDPHs will resolve spontaneously, with about 70% resolving in a week. However, some may persist for several months.6

Simple treatment:

  • Strict bed rest is not of benefit in reducing the symptoms of PDPH; however a well-rested patient may be better able to cope with the headache.
  • Ensuring the patient is well hydrated may improve symptoms.
  • Abdominal binders may help relieve symptoms in some patients by increasing intraabdominal pressure. However, these can be uncomfortable and are not suitable if the patient has had an abdominal operation. They are not widely used.
  • Oral analgesia (paracetamol and NSAID if tolerated) should be prescribed regularly, and the patient encouraged to continue regular analgesia until the headache has subsided. If weak opioids are prescribed, ensure a laxative is also prescribed.
  • Caffeine is widely used because it is easy to administer, although its evidence base is not great. The assumed mechanism is vasoconstriction of cerebral blood vessels. 300-500mg caffeine daily has been recommended, which is the equivalent of 4-6 cups of coffee. Caffeine may cause tremor and arrhythmias in high doses.
  • If the patient is confined to bed, she may require thromboprophylaxis. If prophylactic LMWH is prescribed, ensure it is for a time of day to allow 12 hours to elapse after the dose, so that blood patch can be safely carried out if indicated.

Epidural blood patch

Epidural blood patch (EBP) is considered the gold standard treatment. Its success rate for PDPH following small gauge spinal needle puncture may be as high as 95%; for punctures involving larger needles, it is around 50-75%. The headache may return in about 30% of patients who receive an initially successful EBP. Up to 40% of patients may require a second blood patch.7 Remember to carefully consider other diagnoses in patients where an EBP has been unsuccessful.

It is recommended that EBP is performed 24-48 hours after the onset of PDPH symptoms, as some patients will respond to the simple treatments above. If the headache is so severe that the patient is having trouble caring for her baby, it may be sensible to offer EBP earlier.

Contraindications to EBP include:

  • Patient refusal.
  • Systemic infection.
  • Raised intracranial pressure.

Potential complications include:

  • Early/immediate:
    • Backache (30-70%).
    • Bradycardia (common).
    • Fever (common).
    • Second accidental dural puncture (uncommon).
  • Late:
    • Persisting radicular pain (may be more common than once believed).
    • Meningitis (rare).
    • Cranial nerve palsy (rare).
    • Seizures (rare).
    • Subdural haematoma (rare).

Technique of epidural blood patch

  • The patient should give informed consent. There is a GGC patient information leaflet available on the intranet here, and the Obstetric Anaesthetists’ Association one is here.
    Document consent on a new anaesthetic chart.
  • Make sure each case has been discussed with the consultant covering the labour ward (who may wish to be involved with the procedure).
  • It should be done in daylight hours, but this includes the weekend.
  • This is a two person job. As well as two anaesthetists (epiduralist and venepuncturist), there should be an anaesthetic assistant to help, and a midwife to look after the patient.
  • The patient have an intravenous cannula and be fully monitored, and should be sitting upright unless the severity of her symptoms prevents this, when the procedure should be done in the lateral position.
  • The venepuncturist should identify their intended puncture site before performing a full surgical scrub. The site should be prepped and draped as for an epidural insertion.
  • The epiduralist should identify their intended space (which does not need to be the same as the initial space where the ADP occurred), before scrubbing, preparing the patient’s back and applying a sterile drape.
  • The epiduralist should perform the epidural using loss of resistance to saline.
  • The venepuncturist should then remove 20mls of blood from the patient and carefully pass this syringe to the epiduralist, taking care to preserve sterility at all times.
  • The epiduralist should then slowly inject the blood into the Tuohy needle until either:
    • The patient complains of back pain or radicular pain.
    • All 20 mls have been injected.
  • The Tuohy needle should then be removed and the patient lain on her back.
  • Vital signs should be recorded every ten minutes for 30 minutes.
  • There is no need for the patient to remain supine for a prolonged period, although she should avoid heavy lifting or straining.
  • There is no need to obtain blood cultures at the same time as performing EBP.
  • If she is asymptomatic on mobilising after the procedure, the patient may be discharged.

It is a recommendation of the most recent MBBRACE report that “Any woman who suffers a dural tap or post-dural puncture headache must be notified to her GP and routine follow-up arranged.”8

It is the responsibility of the anaesthetic consultant involved in the management of the patient to ensure that GP is notified, and that the patient has had a follow up appointment arranged. Sample letters to the GP are in Appendix A and Appendix B below.

The follow up could either be a face-to-face appointment in around 6 weeks, or a telephone call at around the same time.

The patient should know who to contact if the headache recurs after discharge.

Department of Anaesthesia

XXXXXXX Hospital

Tel: 0141 XXXXXXX

01/09/2016

Dear Doctor,

Re: PATIENT NAME, CHI

Your patient had a spinal or epidural performed in the Maternity Hospital on DATE, and is at risk of developing a post dural puncture headache (PDPH).

A PDPH normally develops within 72 hours of the spinal or epidural procedure but may develop as much as a week later. The symptoms are normally of a severe, frontal or occipital, bilateral headache, which gets significantly worse when the patient stands. Some PDPHs respond to simple analgesia although it may take several weeks to resolve completely. 

An epidural blood patch is the definitive treatment for PDPH. If the patient develops a headache matching the above description, please do not hesitate to contact the obstetric anaesthetic consultant on the number above, so that she can be assessed and treated if appropriate. Out of hours please contact the on call resident anaesthetist on 0141 XXXXXX, page# XXXX.

Many thanks.

Kind regards,

Consultant Anaesthetist

Department of Anaesthesia

XXXXXXX Hospital

Tel: 0141 XXXXXXX

01/09/2016

Dear Doctor,

Re: PATIENT NAME, CHI

Your patient had a spinal or epidural performed in the Maternity Hospital on DATE, and developed a post dural puncture headache (PDPH).

This was treated with an epidural blood patch on DATE and she was discharged on DATE.

It is expected that up to 70% of patients’ PDPH symptoms will improve following a blood patch, although in a small proportion of patients the headache may recur.

If your patient develops a severe, worsening or persistent headache, or any neurological signs or symptoms, please do not hesitate to contact the obstetric anaesthetic consultant on the number above, so that the patient can be assessed and treated if appropriate. Out of hours please contact the on call resident anaesthetist on 0141 XXXXXXX, page# XXXXX.

Many thanks.

Kind regards,

Consultant Anaesthetist

Editorial Information

Last reviewed: 28/06/2022

Next review date: 30/06/2027

Author(s): Dr Roy Williamson.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 529