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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

 

 

Intraoperative Blood Cell Salvage, Obstetrics (555)

Warning Warning: This guideline is 1100 day(s) past its review date.
What's new / Latest updates

28/06/21 Rhesus Immunisation and Kleihauer Testing section revised.

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

Intra-operative cell salvage (IOCS) is a useful technique for blood replacement and its practice is well established in other areas of medicine; indeed, it used routinely in some areas of surgical practice. There is a strong case for its widespread use in obstetric surgery to avoid the well recognised risks and costs of blood transfusion.

Theoretical risks have slowed the introduction of the use of IOCS in obstetric settings but NICE reviewed the evidence in 2005 and supported its use subject to1:

  1. Data collection
  2. Reporting of complications to the Medicine and Healthcare Products Regulatory Agency
  3. Patients should be fully informed ‘whenever possible’ of the potential complications
  4. Performed by a multidisciplinary team who develop regular experience of intraoperative blood cell salvage

The use of IOCS in obstetrics has also been endorsed by the RCOG2, The Confidential Enquiry into Maternal and Child Health3 and the Joint Association of Anaesthetists of Great Britain and Ireland/Obstetrics Anaesthetists Association Guidelines4.

  1. To avoid the risks associated with conventional homologous or allogenic/donor blood transfusion:
    1. Infection (viruses, bacteria, prions)
    2. Acute incompatibility or reactions
    3. Hypothermia
    4. Cost
    5. Increasing scarcity of blood products
  1. To enhance the safety of caesarean section for patients who decline blood products from donors

1. Amniotic Fluid Embolism (AFE)

There have been no reported cases to date of AFE associated with the use of IOCS in obstetrics. AFE is now considered to be a type of anaphylactic reaction rather than an embolic disease. In addition, the washing and filter processes used in cell salvage have now been shown to effectively remove amniotic fluid contaminants, fetal squames and other debris.

2. Sensitisation to Fetal Red Cells

The cell salvage machine is unable to distinguish between maternal and fetal red cells. Therefore, in cases where blood is transfused back to the mother, the fetal red cell concentration may be higher than in the maternal circulation (and higher than that normally occurs naturally at delivery). Maternal sensitization to fetal red cell antigens may then occur. Rh (D) incompatibility is relatively common but sensitization can be prevented with adequate anti-D administration after delivery.

However, the development of antibodies to other antigens can occur and these may pose a risk of fetal anaemia and haemolytic disease of the newborn in future pregnancies. With modern management, good outcomes are usually achieved in such cases but treatment is invasive and poses risks to the mother and baby. Studies have shown fetal red cells still present in cell-salvaged blood during caesarean section5,6.

Patient selection for IOCS is at the discretion of the surgeon and anaesthetist caring for the patient and must be considered on a case-by-case basis. The following may be considered indications for cell salvage:

1. Elective CS procedures at increased risk of bleeding, e.g.:

  1. Placenta praevia
  2. Abnormally invasive placenta
  3. Maternal bleeding disorders
  4. Anticipated difficulty with cross-matching due to antibodies
  5. Lower uterine segment fibroids or classical incision
  6. Women on anticoagulants
  7. Past history of significant uterine atony
  8. Significant anaemia

2. CS for women who have declined blood products but are happy to accept IOCS (an advance directive is required to be signed and filed in the front of the notes as per the Refusal of Blood Products Guideline)

In units without availability of a cell salvage machine, these women should be offered planned delivery in a unit where IOCS is available.

3. Emergency CS procedures at increased risk of bleeding:

  1. Any of the above elective cases who present and require delivery as an emergency
  2. Placental abruption
  3. Laparotomy following post-partum haemorrhage or suspected intraabdominal bleed
  4. Full dilatation CS with deeply impacted head


Contra-indications for IOCS include:

  • Contamination of the surgical field with bowel contents or substances not licensed for IV use
  • Malignancy
  • Overt infection
  • Sickle cell disease (discuss with Haematology)

Only staff appropriately trained and competent should set up and use obstetric IOCS.

Patients should receive information about the risks and benefits of the IOCS preoperatively9.

Collection-only set up should be the standard in the majority of cases.

The use of a two suction set up is intended to reduce the exposure to the amniotic fluid.

The aspiration anticoagulation line should be used to collect the blood from the surgical site.

Standard theatre suction should be used to remove the amniotic fluid from the operative field during delivery of the baby.

Blood-stained swabs can gently be washed in a solution of normal saline and salvaged from a sterile bowl into the cell saver.

A Pall RS leucocyte depletion filter (LeukoGuard RS, Pall Biomedical Products Co., East Hills, NY) should be used for the re-transfusion of salvaged blood. The filter reduces flow rates considerably. The use of a filter on each port will double the flow rate when high volume return is required8.

The maximum capacity per filter is 450 ml of salvaged blood8.

The re-infusion bag should not be pressurised to reduce risk of air embolism and also the unknown effect on filter performance.

The salvaged blood bag should be labelled with a green patient identification label containing:

  • Full name
  • DOB
  • CHI number
  • Collection start date and time
  • Expiry date and time

Re-transfusion should be completed within four hours after completion of processing of salvaged blood.

The Intra-Operative Cell Salvage Monitoring Sheet (Appendix 1) should be completed at the end of the procedure.

  • When intra-operative cell salvage is used during Caesarean section, reinfused blood may contain fetal red cells.
  • The volume of fetal red cells in reinfused blood can vary from 1-20ml.
  • It is therefore recommended that a minimum dose of 1500 IU anti-D Ig is administered after reinfusion of salvaged cells if baby group is confirmed as RhD positive (or blood group unknown).
  • Maternal samples for estimation of FMH should be taken 30 – 45 mins after reinfusion of salvaged red cells. Depending on the Kleihauer result, an additional dose of anti-D should be administered if necessary and additional follow up Kleihauer sent as appropriate.
  • It is important that clinicians inform Blood Bank if intra-operative cell salvage is being used to ensure that the correct dose of anti-D Ig is issued. This information should be added to the pre-operative maternal request for Group & Save/Crossmatch.

Obstetrics Intra-Operative Cell Salvage Monitoring Sheet

IOCS autotransfusion record

Editorial Information

Last reviewed: 28/06/2021

Next review date: 01/04/2022

Author(s): Ruth Jewell.

Approved By: Obstetrics Clinical Governance Group

Document Id: 555

References
  1. National Institute for health and Clinical Excellence. No 144 November 2006.
  2. RCOG Green-Top Guideline No 47, Blood Transfusion in Obstetrics 2007
  3. Confidential Enquiry into Maternal and Child Health (CEMACH) (20002002). Why Mothers Die – Report of confidential enquiries into maternal deaths in the United Kingdom. Chapter 4 (Haemorrhage) p91-9 Prof M Hall
  4. OAA/AAGBI (2005) Guidelines for Obstetric Anaesthetic Services revised edition; p25
  5. Sullivan I, Faulds J, Ralph C. Contamination of salvaged maternal blood by amniotic fluid and fetal red cells during elective caesarean section. British Journal of Anaesthesia 2008; 101(2): 225-9
  6. Thornhill ML, O’Leary et al. An in-vitro assessment of amniotic fluid removal from human blood through cell saver processing. Anesthesiology 1991; 75: A830
  7. Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee, Transfusion Handbook9:5:  Prevention of haemolytic disease of the fetus and newborn (HDFN)
  8. UK Cell Salvage Action Group, ICS Technical Factsheet: Use of filters in ICS 2012
  9. AAGBI Transfusion and the anaesthetist (2009) Intra-operative Cell Salvage 2009
  10. Use of Anti-D Immunoglobin for the Prevention of Haemolytic Disease of the Fetus and Newborn. British Society for Haematology Jan2014, updated Feb2020