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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

 

 

Diabetes insipidus management and diagnosis (111)

Warning

Objectives

Children with a suprasellar tumours are at risk of developing panhypopituitarism, along with diabetes insipidus. This guideline has been written to aid in the diagnosis, post-operative management, monitoring and potential complications of diabetes insipidus. It also includes an algorithm for the management of a high urine output and a four hourly fluid balance chart.

Scope

Children with suprasellar tumours with the features of diabetes insidipidus. 

Audience

Healthcare professionals involved in the care of neurosurgical patients. 

Children with suprasellar tumours, particularly craniopharyngiomas, are at risk of developing panhypopituitarism together with diabetes inspidus. Some of these children may have symptoms at diagnosis. Baseline investigations may not always demonstrate an endocrinopathy. The patient may have inadequate ACTH and cortisol secretion, which may mask DI. This may be unmasked once hydrocortisone (dexamethasone) is started, or worsen DI requiring a change of dose of DDAVP. Therefore close monitoring is required during this time.

The diagnosis of diabetes inspidus is based on: elevated plasma osmolality due to hypernatreamia AND inappropriately dilute urine.

Management is to maintain plasma Na+ in the normal range and prevent large fluctuations. 

The management of postoperative craniopharyngioma should take account of the triphasic pattern of vasopressin or antidiuretic hormone (ADH) secretion. This is as follows:

  • Days 1-2 postop – diabetes insipidus (DI)
    • initial hypothalamic damage with ADH insufficiency,
  • Days 2-8 postop – syndrome of inappropriate ADH secretion (SIADH)
    • necrosis of the posterior pituitary, with a large release of ADH
  • Day 5+ → - Diabetes insipidus (usually permanent)
    • ADH deficiency once the necrotic phase is over

The severity and duration of the first 2 phases are variable and treatment with both fluids and DDAVP must be cautious.

 Click here to download Diabetes insipidus 4 hourly balance sheet

Algorithm

Management of high urine output flowchart

Symptoms/signs of Diabetes Insipidus

  1. Polyuria
  2. Polydipsia, but only if thirst centre is intact
  3. Dehydration/weight loss

Consider Diagnosis of DI

A combination of the following (at least 3 out of 4):

  1. Urine output 5ml/kg/hour for 2 consecutive hours
  2. Plasma sodium > 145mmol/L
  3. Osmolality: plasma > 295 mOsmol/kg H2O AND urine < 450 mOsmol/kg H2O
    Urinary Specific Gravity (SG) < 1.005 (bedside test –same sample of urine as above)
  4. Weight loss (if available) > 5% compared to a recent measurement

Post operatively

  1. Fluids 0.9% saline with dextrose . Hypotonic saline is viewed with extreme caution in neurosurgery and should only be used to treat a demonstrated hypernatraemia.

    If catheterised:
    Insensible losses (300ml/m2/day) – (See BNF for Children –back pages to work out m2)
    + estimated % dehydration replaced over 48 hr
    + previous hours urine output (either IV or orally if tolerating enteral fluids)

    OR

    If uncatheterised:
    Maintenance fluids + estimated % dehydration replaced over 48 hrs. The maintenance fluid should then be reviewed twice daily and adjusted according to fluid balance, weight and U+Es.

  2. Measure hourly urine output and specific gravity. ( 4hourly balance sheet)

    (NB specific gravity can be crudely converted to osmolality by multiplying the last two digits by 40. For example urine SG of 1.005 = osmolality of 05 X 40 = 200 mOsm/Kg, SG 1015 = 15 x 40 =600 etc.)

  3. If urine output exceeds 5ml/kg/hour and urine SG < 1.005 in the first few hours on return from theatre then DI is likely. If the patient is awake and able to drink with intact thirst, he should be allowed to drink freely and sodium should be monitored closely

    Check plasma sodium and if 150mmol/l or greater and rising, discuss with endocrine team and consider a small stat dose of DDAVP. If in doubt it is safer to keep input/output in balance by allowing the patient to drink freely.

The aim is to avoid over-treatment resulting in rapid hyponatraemia, cerebral oedema and fits, therefore a conservative dose is initially given:

Subcutaneously – 0.04 microgram/kg (Maximum of 1 microgram)

Maximum dose can be increased to total dose of 2 micrograms following discussion with endocrine team.

1 month-2 years - 400nanograms/(0.04mcg/kg)

2-12 years - 0.5-1 microgram

12-18years - 1-2 microgram

OR

Orally (these are available in 120 DDAVP melts microgram tablets)

Dissolve 120mcg in 12mls water, 1ml=10mcg

<2 years age 7.5 micrograms

>2 years age 15 micrograms

>10 years age 30 micrograms

If already on DDAVP, a dose of 25-50% of their usual dose may be needed.
Initially, these doses may need to be repeated every 4-24 hours if urine output does not normalise, as there is a wide variation in individual response. A breakthrough of urine output to pre-treatment levels should occur before another dose in given i.e.>5ml/kg/hr for 2 consecutive hours.

Monitoring of treatment-(Balance Sheet)

Click here to download Diabetes insipidus 4 hourly balance sheet

Measuring input/output 4 hrly, together with U+Es will prevent large Na+ fluctuations.
At least twice per day clinical and biochemical re-assessment is important to avoid over or under treatment. The goal is to be normovolaemic and “normonatraemic”. Hyponatraemia is more dangerous than hypernatraemia in post op patients because it can result in severe brain swelling and raised intracranial pressure. Therefore far better to under-correct than to overcorrect for DI.

  1. Strict fluid input and output-4 hourly balances
  2. Daily weight (8am and 8pm)
  3. Regular U+Es
    First 12 hours post op- 2-4 hourly U+Es
    4-6 hourly U+Es until day 3
    Aim to keep Na+ 140-150mmol/ for first 48 hours

More frequent U+Es may be required if concerns re hypo/hypernatraemia

Hypernatraemia Na+>150mmol/l

increase the intravenous fluid intake and/or give a further dose of DDAVP. If Na+ is > 155-160 ensure that intravenous fluid is 0.9% saline

Sodium within normal range (135-145 mmol/l)

Do not give further DDAVP. Continue to monitor Na 4-6 hourly and fluid balance.
Caution patients may develop SIADH following a period of DI.

Hyponatraemia Na+<135 mmol/l

No further DDAVP should be given

The patient may have entered a period of SIADH and therefore consider:

If Na+<130mmol/l-Fluids should be restricted to 2/3rds of maintenance
Consider stat dose of frusemide 1mg/kg (IV or Orally)

If symptomatic/seizures, requires prompt treatment.
Give 4ml/kg of 3% saline over 15-20 mins and follow Hyponatraemia guideline

Avoid rapid changes in the plasma Na+

Possible complications

1. Over treatment with DDAVP

This will result in a strongly positive fluid balance, weight gain and rapidly falling plasma sodium levels and brain oedema. This is treated as follows:

  • No further DDAVP should be given

  • Fluids should be restricted to 2/3rds of maintenance

  • If symptomatic, an infusion of 1.8% or 3% saline (1-2 ml/kg/hr of 3%, 0.5-1 mmol/kg over 2-3 hrs) may be required, which should raise the plasma sodium levels by 10mmol/L.

  • 6 hourly U+E

  • Eventually urine output will increase and sodium levels will correct. If this occurs too rapidly then fluid regime may have to be adjusted again. The aim is to correct the sodium by <12mmol/L per day

  • DDAVP at a lower dose can then be re-introduced.

2. SIADH

Following neurosurgery (for suprasellar lesions) a period of DI (classically 4-8 days) may be followed by a period of high ADH secretion resulting in hyponatraemia due to free water retention and is accompanied by a normal urine output, low renin level and continued urine loss of sodium (>20mmol/L). This may last up to 2 weeks. This is treated as follows:

  • no further DDAVP should be given

  • Fluids should be restricted to 2/3rds of maintenance

  • 6 hourly U+E, with adjustment of fluid input accordingly

If symptomatic, then discuss with on call consultant about the need for 3% saline at 1-2 ml/kg/hr (0.5-1 mmol/kg/h) for two to three hours.

 

3. Cerebral salt wasting (CSW) -(Rare)

Following neurosurgery or in severe CNS trauma and in some cases of spontaneous intracerebral haemorrhage), polyuria and volume depletion may occur but accompanied by very high urine sodium losses (much greater than in SIADH) resulting in hyponatreamic dehydration and a urine:plasma osmolality ratio>1. This is treated as follows:

  • Manage input of fluids as
    Insensible losses (300ml/m2/day) (See BNF for Children –back pages to work out m2)
    • + estimated % dehydration replaced over 48 hr
    • + previous hrs urine output

      OR

      Maintenance fluids
    • + estimated % dehydration replaced over 48 hrs
      (The maintenance fluid should then be reviewed twice daily and adjusted according to fluid balance, weight and U+Es)
  • However, sodium content of fluids should be increased significantly according to 6 hrly U+E. Sodium supplements can also be given orally.

4. Corticosteroid deficiency

Following neurosurgery, the patient may have inadequate ACTH and cortisol secretion, which may mask DI. The need for hydrocortisone replacement should be discussed with the on call consultant and may require a synacthen test to diagnose. Once hydrocortisone replacement is started, this may unmask or worsen DI requiring a change of dose of DDAVP. Therefore close monitoring is required as above during this time period. Most tumour patients will be on perioperative dexamethasone so in practice this is not usually an issue until after the acute perioperative phase when steroids are tapered.

Summary

Consider DDAVP administration if:

Urine output 5ml/kg/hour for 2 consecutive hours

AND

Plasma sodium > 145mmol/L

AND

Urinary Specific Gravity (SG) < 1.005

Appendix

ACCURATE DIAGNOSIS OF SODIUM / WATER BALANCE IN NEUROSURGICAL PATIENTS DEPENDS ON MONITORING TRENDS

May need HOURLY assessments of

  • Serum Na
  • Urine volumes
  • Urine Na
  • Serum osmolality
  • Fluid Balance

SERUM NA

URINE VOL

URINE NA

SERUM OSM

FLUID BAL

 

Rising/ high

High

Low

High

Negative

Diabetes
insipidus

Low

Low

Normal/High

Low

Positive

SIADH

Low

High

High

Normal

Negative

Cerebral salt
losing

Editorial Information

Last reviewed: 04/11/2019

Next review date: 01/11/2022

Author(s): G Shaikh.

Version: 4

Approved By: Paediatric Clinical Effectiveness & Risk Committee

Document Id: 111