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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 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

 

 

Acute Renal Failure Management and Investigation, Paediatrics (353)

Objectives

The following guideline has been developed by clinicians within the Renal Unit at RHC Glasgow.

The objective of this guideline is to aid in the diagnosis, investigation and management or acute renal failure in children. It includes the management of fluid and electrolyte abnormalities in children with acute renal failure. 

Scope

This document is intended for use by clinicians in the Management and Investigation of Acute Renal Failure. For further information, contact a clinician within the Renal Unit. Ward office number 0141 452 4563

Definition of Acute Renal Failure

  • Oliguria - Urine Output: - <300ml/m2/day or 0.5ml/kg/hr
  • Anuria - Urine Output: - <1ml/kg/day
  • Hyperkalaemia - K >6.0 mmol/L on 2 separate occasions
  • Clinical Fluid Overload
  • Oedema
  • Triple rhythm
  • Hypertension

Paediatric-Modified RIFLE (pRIFLE) Criteria

Category Estimated CCl (eCCL) Urine Output
Risk eCCl decrease by 25% <0.5ml/kg/h for 8h
Injury eCCl decrease by 50% <0.5 ml/kg/h for 16h
Failure eCCl decrease by 75% or eCCL <35 ml/min/1.73 m2 <0.3 ml/kg/h for 24h or anuric for 12h
Loss Persistent failure >4 weeks  
End stage End-stage renal disease (persistent failure for >3 months)  

Aetiology

Pre-Renal Intrinsic Renal Post-Renal

Hypovolaemia

 Circulatory Insufficiency Posterior Urethral Valves

Peripheral vasodilatation

 Nephrotoxins Blocked Catheter

Impaired Cardiac Output

 "Renal Disease" Neurogenic Bladder

Renal Vessel occlusion

 Myo/haemoglobinuria Trauma

Nephrotoxic Drugs*

 Tumour infiltrate Calculi

Hepatorenal Syndrome

 Intratubular obstruction  
Increased intraabdominal pressure Latrogenic Factors

 
*Avoid giving Ibuprofen

Clinical Assessment of Acute Renal Failure

  • Patient Weight –Required Daily
  • Urine Output
  • Blood Pressure
  • Hydration Status
  • Blood Biochemistry and FBC
  • Cardiorespiratory Examination
  • Neurological Examination
  • Musculoskeletal Examination
  • Bruising/Bleeding
  • Drug HistoryInvestigations

Investigations

- U&E’s, LFT’s and CRP             - LDH
- Uric acid - FENa
- Magnesium - Urinalysis
- Glucose - Urinary Sodium, Osmolality
- Osmolality - Microscopy for casts
- FBC ± Blood film - Culture and sensitivity
- Coagulation Screen - Renal Ultrasound
- Group and Save  

Consider the following on clinical grounds

- Parathyroid hormone (if acute on chronic suspected)      - Serum for toxicology/ drug levels                                    
- C3 - Hepatitis Screen
- ASO titre, anti DNAse B - E. Coli Antibody
- Antinuclear antibodies/ anti-DNA binding - Stool culture
- Anti-GBM antibodies - AXR
- ANCA (anti neutrophil cytoplasmic antibody) - MCUG
- Blood culture - Isotope scan
  - XR left wrist and hand (signs of ROD in acute on chronic)        
  - Ophthalmology opinion

Urinary Electrolytes in Acute Renal Failure

  Pre-renal Intrinsic Post-renal
Urine Output Oliguria Oliguria - Polyuria Variable
Uosm (mosm)
(newborn)		 >500
(>350)		 <300
(<300)		 <350
(<300)

 
UNa (mmol/L)
(newborn)

<10
(31±19)

>40
(63±35)

>40
FENa (%)
(newborn)		 <1
(<2.5)		 >2
(>3)		 <2
(<3)

 
Lab studies Increased Urea
Lower Creatinine		 Hypocalcaemia
Hyperphosphataemia
Creatinine increases
by 45 –130 mmol/L/day		 Hyponatraemia
Hyperkalaemia
Hyperchloraemic
Acidosis
For calculation of FENa- http://www.mdcalc.com/fractional-excretion-of-sodium-fena/

Management of Acute Renal Failure

Fluid Management

  • Correction of Hypovolaemia
  • Fluid Overload(Red Flag):
    • Furosemide 2 - 5mg/kg over 1 hour
    • Fluid restriction
    • Minimalise drug infusion volumes
    • Accurate input/output
    • Daily weight
    • Dialysis 
  • Beware Polyuria 

Aim is to maintain isovolaemia erring on the side of minimal fluid overload.

As a rule of thumb, daily fluid requirements should equal insensible fluid losses plus output (urine, vomiting, drain losses, diarrhoea etc). Insensible fluid losses can be calculated as per the table below: 

Weight                 Insensible Fluid Loss
1-10kg

25ml/kg
10-20kg

12.5ml/kg
>20kg

5ml/kg

Electrolyte Abnormalities

Hyponatraemia

Flowchart

  • Salt loss > water loss 
    • Volume resuscitation
    • Sodium deficit (140-Na) x 0.65 x Body weight
    • Replace deficit with 0.9% saline, usual maintenance
  • Water gain > Na
    • Fluid restriction
    • Hypertonic saline with loop diuretic
    • Mannitol

Hypernatraemia

Flowchart

Hypernatraemia may be due to:

  • Extrarenal fluid loss in PICU patients
  • Excess sodium bicarbonate
  • Volume resuscitation
  • Water deficit
    - weight x 0.65 x ((Actual Na/140)-1))
    - Replace with 0.45% saline over 36-72 hrs
  • Central DI- DDAVP
  • Nephrogenic DI- Diuretic therapy

Hypocalcaemia

  • Emergency- 0.5ml/kg/hr of 10% Ca Gluconate
  • 50ml/kg Ca/kg/day
  • If resistant, check Mg

Hyperphosphataemia

  • Phosphate restriction
  • Phosphate binders e.g. Ca Carbonate

Hypophosphataemia

  • Polyuric states

Hyperkalaemia

flowchart

Acid–Base Disorders

These are invariably acidosis and are often mixed respiratory and metabolic especially in the intensive care setting. Treatment is generally only indicated if there is associated hyperkalaemia or if the acidosis is profound. 

Treatment of Acid-Base Disorders

  • Base Deficit (mmol) = Base Excess x Weight/3
  • Replace half of the deficit initially
  • Sodium Bicarbonate is hypertonic with a risk of CNS complications or hypernatraemia and is only effective with adequate ventilation.
  • Rapid correction of acidosis may cause hypocalcaemia and tetany or seizures
  • Therefore rapid correction to be avoided

Nutrition in Acute Renal Failure

Acute renal failure is a hypercatabolic state and requires aggressive nutritional support. Unlike adults there is no indication for dietary protein restriction, which should be delivered in amino acids or protein of high biological value. The majority of calories should however be delivered as carbohydrates. 

  • Calories 1400 kcal/m2/day
  • Protein 0.6g/kg/day (1.5g if dialysed)
  • Intralipid - medium chain triglycerides
  • Folate and Vitamin supplementation

Hypertension in Acute Renal Failure

May relate solely to salt and water overload and therefore in the presence of oligo/anuria and in the absence of hypovolaemia an initial trial of diuretic therapy is justified.

For further details of the management and investigation of hypertension – see appropriate protocol.

Drug therapy for the emergency treatment of hypertension is outlined below.

Agent Dose Onset Action Complications

Labetalol

1-5 mg/kg/hr

3-5 min 

Alpha & beta Blocker

Hypoglycaemia
Well tolerated

Nifedipine

0.25-0.5 mg/kg

sublingual

5-10 min Ca channel blocker

Headache,
nausea,
syncope

Sodium Nitroprusside

0.5-8 ug/kg/min as IV infusion

Instant

Direct vasodilator

Thiocyanate poisoning

Clonidine

2-6 ug/kg

~10 min

Central alpha 2 Agonist   

Depression
Rebound

Hydralazine

0.2 to 15mg/dose IV bolus
4-6ug/kg/min IVI 

5-10 min

Direct vasodilator

Headache,
vomiting,
tachycardia

Frusemide

1-3mg/kg over 15min
0.1-1mg/kg/hr IVI

   Diuretic

Volume depletion,
electrolyte abnormalities

Editorial Information

Last reviewed: 25/11/2020

Next review date: 31/12/2023

Author(s): Ian Ramage.

Approved By: Clinical Effectiveness

Document Id: 353

References

http://www.infokid.org.uk/

Royal College of Physicians of Edinburgh. Acute kidney injury app.