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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Sedation for diagnostic and therapeutic procedures on children with cardiac conditions on Ward 1E (391)

Objectives

The aim of sedation guideline is to provide evidence-based approach to the sedation of the cardiac patients on the cardiac ward during diagnostic or therapeutic procedures. This guideline is adapted from the NICE clinical guideline, Sedation in under 19s: using sedation for diagnostic and therapeutic procedures (CG112, last reviewed 2018).

Scope

This guideline is intended for all healthcare professionals caring for children on the cardiac ward 1E at the Royal Hospital for Children, Glasgow.

Audience

All medical and nursing staff caring for patients requiring sedation should be familiar with the guideline and have theoretical knowledge of the principles of sedation practice including the drug pharmacology and applied physiology. 

Introduction

Sedation is performed on patients to reduce fear, anxiety and to minimize movement. On the cardiac ward sedation is often required for children going to theatre, echocardiogram or removal of chest drain. This guideline is based on the NICE recommendations and can be used for children and young people under the age of 19 undergoing diagnostic or therapeutic procedures. The level of sedation used on patients on the ward setting should be minimal to moderate and conducted within hours of 8 am till 6 pm. Deep sedation should be avoided.

Levels of sedation:

The definitions of minimal, moderate and deep sedation used in this guideline are based on those of the American Society of Anaesthesiologists (ASA).

Minimal sedation: A drug induced state during which patients are awake and calm, and respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation: Drug induced depression of consciousness during which patients are sleepy but respond purposefully to verbal commands or light tactile stimulation. No interventions are required to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is maintained.

Deep sedation: Drug- induced depression of consciousness during which patients are asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function independently may be impaired. Patients may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 

Pre sedation

Pre sedation assessment, communication and patient information and consent

Health care professionals delivering sedation should have knowledge and understanding of and competency in:

  • Sedation pharmacology and applied physiology
  • Assessment of children and young people
  • Monitoring
  • Recovery care
  • Complications and immediate management, including paediatric life support

Health care professionals delivering sedation should have practical experience of:

  • Effectively delivering the chosen sedation technique and managing complications
  • Observing clinical signs (for example, airway patency breathing rate and depth, pulse, pallor and cyanosis and depth of sedation)
  • Using monitoring equipment
  • All members of the sedation team should have basic life support skills and at least one member with intermediate life support when delivering minimal and moderate sedation.

Patient-centred care and consent

Children and young people undergoing sedation and their parents and carers should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Informed consent should be obtained for sedation as well as the procedure and documented in the patient’s notes.

Fasting

Before starting sedation, confirm and record the time of last food and fluid intake in the healthcare record.

Fasting is not mandatory for:

  • Minimal sedation or
  • Moderate sedation during which the child or young person will maintain verbal contact with the healthcare professional.

Apply the 1-4-6 fasting rule for:

  • Deep sedation and moderate sedation during which the child or young person may not maintain verbal contact with the healthcare professional.

Drug Therapy

  • Choice of sedative agent depends on child factors, the experience of the clinical team and the rationale for sedation.
  • No drugs have a UK marketing authorisation specifically for sedation in all of infants, children and young people under 19 years. Refer to BNFc for up to date dosage instructions of conscious sedation for procedure.
  • As per the NICE guideline Midazolam and Chloral Hydrate will be used for the following patient group. Midazolam has a strong safety profile in inducing either minimal or moderate sedation.

Conscious sedation for Echocardiogram

For children and young people undergoing a transthoracic echocardiogram under sedation, the target level of sedation is classed as minimal to moderate: during which the child or young person will maintain verbal contact with the healthcare professional. Consider one of the following drugs EITHER:

  • Chloral Hydrate for children under 15kg :
    Oral Route : 50mg/kg (higher dose up to 100mg/kg may be used) as per BNF
    OR
  • Midazolam (oral): 0.5mg/kg as per BNFc (max dose of 20mg)

  • Ensure the patient only receives one of these drugs. They should NOT be prescribed both at the same time.

Alternatives if sedation is not successful

Trial of alternative sedation choice may be considered if safe and appropriate to do so.

Painful Procedures

For children and young people undergoing a painful procedure (for example suture laceration, chest drain removal), when the target level of sedation is minimal or moderate, consider:

  • Midazolam (oral)
  • Refer to BNFc for dosage of conscious sedation for procedure
  • Ensure adequate analgesia, monitor for combined effect of sedation and opiate analgesia (Administer analgesia at least 30 minutes prior to procedure)

Psychological Preparation

Ensure the child or young person is prepared psychologically for sedation by offering information about:

  • The procedure
  • Sensations associated with the procedure
  • Offer parent and carers to be present during sedation if appropriate
  • Obtain informed consent

Monitoring

For moderate sedation: continuously monitor and interpret and respond to changes in all of the following:

  • Depth of sedation
  • Respiration Rate
  • Oxygen Saturation
  • Heart rate
  • Pain and distress

The patient should have a patent airway throughout the procedure, be able to protect their airway, be haemodynamically stable and be easily aroused if they are sedated to a minimal/ moderate level. If they have any signs of the above then the person giving the sedation needs to be aware that the patient is over sedated and a senior person needs to be contacted or PICU informed perhaps.

Equipment

The following age appropriate equipment should be available:

  • Suction apparatus with Yankeur sucker attached
  • Oxygen with age appropriate mask and tubing
  • Self inflating resuscitation bag
  • Audible pulse oximeter and blood pressure monitoring
  • An emergency call system to summon additional help

Facilities for observation until the child has recovered from sedation to a point where it is safe to be discharged

Post sedation

After the procedure, continue monitoring until the child or young person:

  • Has a patent airway with return of airway reflexes
  • Has return of ventilatory function-normal Spo2 & RR for age
  • Shows protective and breathing reflexes
  • Is haemodynamically stable
  • Is easily roused
  • Ensure vital signs have returned to normal
  • The young person is awake

Discharge Criteria

Ensure the following criteria are met before the child or young person is discharged:

  • Vital signs have returned to normal
  • The child or young person is awake and there is no risk of further reduced level of consciousness
  • Patient can be discharged from 2-4 hours post dose of sedation
  • Nausea, vomiting and pain have been adequately managed.

Editorial Information

Last reviewed: 01/12/2022

Next review date: 30/11/2025

Author(s): Natalie Smith and Dr Maria Ilina.

Version: 4

Approved By: Cardiac Guideline Group

Reviewer name(s): Natalie Smith.

Document Id: 391

Related resources

The Royal Children’s Hospital Melbourne (2021) Clinical Practice Guidelines : Procedural sedation (rch.org.au)

References

Ahmed, J., Patel, W., Pullattayil, A.K and Razak, A. (2022) Melatonin for non operating room sedation in paediatric population: a systematic review and meta analysis. Archives of Disease in Childhood.Vol. 107, pp. 78-85

British National Formula for children (BNFC) (2022) British Medical Journal Group. London.

Chen, Z., Lin, M., Huang, Z., et al (2019) Efficacy of chloral hydrate oral solution for sedation in paediatrics: a systematic review and meta analysis. Drug design, Development and therapy. Vol. 13.pp, 2643-2653.

Conway, A., Rolley. J and Sutherland, JR (2018) Midazolam for sedation before procedures, Cochrane Database of Systematic Reviews. Issue 12. John Wiley and Sons, Ltd.

Layangool, T., Kirawittaya, T., Attachoo, A., Et al (2008) A comparison of oral chloral hydrate and sublingual midazolam sedation for echocardiogram in children. Journal of Medical Association Thailand. Vol 91, (supplement 3) pp. S45-52.

National Institute for Health and Clinical Excellence (2018) Sedation in children and young people. Sedation for diagnostic and therapeutic procedures in children and young people. NICE Clinical Guideline 112. NICE, London.

Wheeler, D.S., Jensen, R.A., Bradley Poss, W. (2001) A Randomised, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography. Clinical Pediatrics. Vol. 40, pp. 381-387.

Evidence method

The guidelines have been constructed after consultation with National Institute for health and clinical excellence for sedation in children and young people. A review of literature has been obtained from 2018 till present and includes a Cochrane Review and additional systematic reviews.