Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guidelines
  3. Paediatrics
  4. Back
  5. Emergency Medicine (Paediatric)
  6. Cardiac transplant patient - paediatric acute care management pathway (1080)
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

 

 

Cardiac transplant patient - paediatric acute care management pathway (1080)

Objectives

Management of acute presentations of paediatric cardiac transplant patients to the Emergency Department

  • Cardiology registrar: 84440
  • Consultant: Switchboard
  • All patients are triaged
  • Category 1 or 2 are initially assessed by ED staff
  • For patients asked to attend ED by cardiac services, Triage will contact the Cardiology registrar to review (out of hours the Level 3 Paediatric registrar)

Paediatric acute care management pathway flowchart

Background

  • Transplantation undertaken for failed surgical palliation of structural heart disease, cardiomyopathy and occasionally unrepaired congenital lesions
  • Delivered at Freeman Hospital ( Newcastle) and Great Ormond Street Hospital (London)
  • 20-30 transplants undertaken annually in the United Kingdom, two to three in Scottish recipients
  • Rarely more than 10 transplanted children living in Scotland
  • Shared care arrangement between Glasgow/Edinburgh and London/ Newcastle
  • Follow-up progressively relaxed to six monthly visits in both centres; net three monthly reviews
  • Ongoing visits to a distant centre, school and work absence, strict medication regimens, frequent venepuncture, adverse drug reactions, unplanned admissions and a sense of the transplant being life-controlling place heavy burden on patients and families
  • Most practitioners are unfamiliar with subtle but sinister clinical signs and in managing acute, unplanned presentations to ED. Parents know this and may be strongly directive during acute presentations

Important acute complications

Graft rejection

  • 20% of patients are treated for rejection in first year after transplant. Risk does not decrease over time
  • Asymptomatic, low grade rejection may be detected on routine surveillance biopsy
  • Symptoms consistent with reduced cardiac output may be diffuse such as lethargy, fatigue, vomiting and abdominal pain. Chest pain and breathlessness occur later and are very concerning
  • May be tachycardia, tachypnoea, gallop rhythm, new murmur, hepatomegaly, chest crackles
  • Requires urgent methylprednisolone and potentially antithymocyte globulin, immunoglobulin and plasmapheresis and transfer to transplant centre

Infection

  • Immunosuppressed children may show little evidence for infection due to inability to mount immune response; ongoing fever in the absence of signs must be carefully investigated
  • Denervated heart does not show a normal chronotropic response to stress and recently transplanted heart may show a high resting rate, slow increase in response to stress and reduced peak rate
  • Most infections are bacterial, followed by viral; risk is highest in the first year following transplant
  • Fever may also indicate graft rejection or malignancy

Adverse drug reactions

  • Calcineurin inhibitor such as cyclosporine or tacrolimus prescribed as primary immunosuppression. Dosing based on trough serum levels; narrow therapeutic window. May cause hypertension, IDDM, renal dysfunction, dyslipidaemia , hypomagnesaemia and hyperkalaemia
  • Mycophenylate mofetil (MMF) as a secondary agent. Causes gastrointestinal upset
  • Variable dose of prednisolone is usual; standard steroid adverse effects
  • Frequently an antihypertensive, iron and vitamin supplements, a statin and prophylactic azithromycin
  • Aggressive immunosuppression causes recurrent infections and malignancies, in particular post-transplant lymphoproliferative disease (PTLD)
  • Lighter immunosuppression associated with graft rejection and accelerated coronary vascular disease

Important chronic complications

  • Accelerated coronary artery disease; diffuse stenoses secondary to chronic immune rejection and effects of diabetes (drug-induced), hypertension and dyslipidaemia. Leading cause of graft loss; only definitive treatment is re-transplantation
  • PTLD seen in immunosuppressive-induced high EBV viral titres. Presentation highly variable; lymphadenopathy or adenotonsillar hypertrophy in the setting of recurrent fever, weight loss, fatigue or other unexplained symptoms is concerning

Editorial Information

Last reviewed: 12/02/2025

Next review date: 28/02/2028

Author(s): Dr Lindsey Hunter, Consultant Cardiologist; Dr Anne McGettrick, Consultant Intensivist; Dr Laura McLaren, Consultant Paediatrician; Dr Benjamin Smith, Consultant Cardiologist; Dr Steven Foster, Consultant Emergency Physician.

Version: 1.4

Approved By: Cardiac & Emergency Departments

Document Id: 1080

Related guidelines