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May 2025 RDS newsletter now available. Expand this announcement to view.

Welcome to the May 2025 update from the RDS team

1.     RDS deployments

Three small-scale releases took place during April and May, including the following fixes and improvements:

  • Applying moderate severity security patch to Umbraco.
  • Fixes to:
    • Random ordering of tiles on mobile app
    • Simultaneous issuing of multiple copies of content review alerts
    • Content display on mobile app for the left hand menu navigation option
  • Whitelisting of Jotforms outcomes pages so that recommendations for action can be displayed following completion of a form or calculation.

2.     RDS performance

Two short outages took place on the mornings of 12th and 22nd May. Tactuum is still investigating the root cause and will report on this shortly.

3.     Redesign of Gentamicin and Vancomycin calculator interfaces

New designs have been produced which make the health board name and calculator title clear to the user on these calculator pages, with a warning message and link to ensure users access the right calculator for their board. These designs have been implemented in a test environment and are now under review.

4.     RDS Redesign, archiving and version control

We now plan to release at end of July 2025 the following major enhancements:  redesigned Right Decision Service homepage, new search and browse interface, upgraded archiving and version control, and capability to edit content adopted from the Shared Content Library. We will provide slides and demos in advance of the release to introduce users and editors to the new functionality.

5. Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Monday 16 June 12.30-1.30 pm
  • Tuesday 24 June 3.45-4.45 pm

Running usage statistics reports using Google analytics

  • Wednesday 11th June: 2-3pm

 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.

6.New RDS toolkits

The following toolkits were launched during March 2025:

7.New RDS developments

Work is progressing on a number of decision support systems that are part of the wider Right Decision Service platform, beyond the web and mobile apps:

  • The Patient Reported Outcome Measures system. A minimum viable product version will be available for functional testing by key stakeholders at end of July.
  • Pharmacogenomics decision support as an extension of the current high risk prescribing decision support integrated with primary care electronic health record systems. This is part of a European research and innovation project.
  • Planned Date of Discharge decision support system to be tested in NHS Lanarkshire. Will undergo user acceptance testing in July with a view to piloting from November.

8. Implementation projects

Public library services in Inverclyde, East Renfrewshire, Glasgow Life, Angus, Falkirk and Stirling have come forward to work with the RDS team, the Scottish Library and Information Council and local Realistic Medicine leads, to develop their role in engaging citizens in Realistic Medicine. This includes promoting the Being a partner in my care app: Realistic Medicine Together. This provides tools and resources to support conversations about what matters to the person,  shared decision-making and self-management.

 

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.

 

 

 

Adrenal insufficiency in children: management for children undergoing surgical procedures (238)

Objectives

Standardisation of the management of children with known or suspected adrenal insufficiency undergoing surgical procedures.

 

Scope

This clinical guidance should be used in children with known or suspected adrenal insufficiency who will undergo surgical procedures.

Conditions:

Children on daily replacement hydrocortisone treatment eg

  • Congenital adrenal hyperplasia
  • Congenital adrenal hypoplasia
  • Addison’s disease
  • Hypopituitarism eg congenital, brain tumour and post-radiotherapy

Children on high dose glucocorticoid treatment (Prednisolone, Deflazacort, Dexamethasone, Vamorolone) eg Inflammatory conditions like inflammatory arthritis, inflammatory bowel diseas, dDuchenne muscular dystrophy

Source for guidance

This clinical guidance adopts recommendations from the UK National Paediatric Adrenal Insufficiency Emergency Management Guidance developed by the British Society for Paediatric Endocrinology and Diabetes (2022). The British Society for Paediatric Endocrinology and Diabetes guidance has also been incorporated into the NICE guideline [NG243] Adrenal insufficiency: Identification and management (published 28th August 2024).

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MAJOR SURGERY (PROCEDURE EXPECTED TO LAST 90 MINUTES OR LONGER)

Major Surgery is defined as surgery last 90 minutes or longer, with variable recovery periods and expected delay in restarting oral intake.

(A) INDUCTION

At induction, give IV bolus hydrocortisone 2mg /kg (max 100 mg).

For premature infants and neonates < 28 days corrected gestational age, give IV bolus hydrocortisone 4 mg/kg.

(B) INTRAOPERATIVE

Start IV hydrocortisone infusion.

IV hydrocortisone infusion

Weight

Infusion rate
(50 mg hydrocortisone in 50 ml 0.9% saline

≤10kg

1 ml/hour

10.1 to 20kg

2 ml/hour

20.1 to 40kg

4 ml/hour

40.1 to 70kg

6 ml/ hour

Over 70kg

8 ml/ hour

Consider more concentrated infusion in those needing fluid restriction (e.g. 100mg hydrocortisone in 50mls 0.9% saline).

The hydrocortisone infusion can be run alongside 0.9% sodium chloride, 5% glucose and PlasmaLyte solutions

(C) POST-OPERATIVE

Continue hydrocortisone infusion and change to oral sick day hydrocortisone when clinically stable and tolerating oral fluids / diet.

Stop hydrocortisone infusion 30 min after tolerating the first oral sick day dose.

Discuss duration of oral sick day dose with treating medical team.

Oral sick day hydrocortisone

Weight(kg)

Sick day hydrocortisone:
Dose

Frequency

1

0.8 mg

4 x a day

2

1.2 mg

4 x a day

3

1.5 mg

4 x a day

4

2.0 mg

4 x a day

5

2.5 mg

4 x a day

6

2.5 mg

4 x a day

7

3.0 mg

4 x a day

8

3.0 mg

4 x a day

9

3.5 mg

4 x a day

10

4.0 mg

4 x a day

15

5.0 mg

4 x a day

20

6.0 mg

4 x a day

25

7.5 mg

4 x a day

30

7.5 mg

4 x a day

35

10.0 mg

4 x a day

40

10.0 mg

4 x a day

45

10.0 mg

4 x a day

50

10.0 mg

4 x a day

55

12.5 mg

4 x a day

60

12.5 mg

4 x a day

65

12.5 mg

4 x a day

70

15.0 mg

4 x a day

75

15.0 mg

4 x a day

80

15.0 mg

4 x a day

90

15.0 mg

4 x a day

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MINOR SURGERY REQUIRING GENERAL ANAESTHESIA (PROCEDURE EXPECTED TO LAST LESS THAN 90 MINUTES)

Minor Surgery is defined as a procedure lasting less than 90 minutes and the patient is expected to be eating and drinking by the next meal. This may include procedures such as MRI scans, endoscopy, dental extractions under general anaesthetic or other day case procedures.

(A) INDUCTION

At induction, give IV bolus hydrocortisone 2mg /kg (max 100 mg).

For premature infants and neonates < 28 days corrected gestational age, give IV bolus hydrocortisone 4 mg/kg.

(B) POST-OPERATIVE

Oral sick day dose for 24 hours

Weight(kg)

Sick day hydrocortisone:
Dose

Frequency

1

0.8 mg

4 x a day

2

1.2 mg

4 x a day

3

1.5 mg

4 x a day

4

2.0 mg

4 x a day

5

2.5 mg

4 x a day

6

2.5 mg

4 x a day

7

3.0 mg

4 x a day

8

3.0 mg

4 x a day

9

3.5 mg

4 x a day

10

4.0 mg

4 x a day

15

5.0 mg

4 x a day

20

6.0 mg

4 x a day

25

7.5 mg

4 x a day

30

7.5 mg

4 x a day

35

10.0 mg

4 x a day

40

10.0 mg

4 x a day

45

10.0 mg

4 x a day

50

10.0 mg

4 x a day

55

12.5 mg

4 x a day

60

12.5 mg

4 x a day

65

12.5 mg

4 x a day

70

15.0 mg

4 x a day

75

15.0 mg

4 x a day

80

15.0 mg

4 x a day

90

15.0 mg

4 x a day

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MINOR SURGERY NOT REQUIRING GENERAL ANAESTHESIA

Minor surgery is defined as a procedure lasting less than 90 minutes and the patient is expected to be eating and drinking by the next meal.

For example:

  • Skin biopsy under local anaesthetic
  • Minor dental procedures eg filling tooth, tooth extraction (no general anaesthesia)
  • Non-anaesthetic sedation (eg chloral hydrate) for MRI

Give oral sick day dose on the day of the procedure and continue for 24 hours.

If in pain after 24 hours, patient to contact treating medical team and may need to continue oral sick day dose.

Editorial Information

Last reviewed: 10/01/2025

Next review date: 31/01/2029

Author(s): Jarod Wong, Avril Mason, Roisin Boyle.

Approved By: Paediatric Clinical Guidelines Group

Document Id: 238