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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

 

 

Hypertension Eclampsia Management (402)

Please report any inaccuracies or issues with this guideline using our online form

Eclampsia is a life threatening complication of pregnancy. 

UK incidence is about 1 per 2000 maternities.

Seizure incidence: 38% pre-labour, 18% during labour, 44% postnatal

Pathophysiology is thought to involve cerebral vasospasm leading to ischaemia, disruption of the blood brain barrier and cerebral oedema. 

Neurological complications may include coma, focal motor defects and cortical blindness. Cerebrovascular haemorrhage is a complicating factor in 1- 2 % of cases.

Eclampsia is usually part of a multisystem disorder. There may be little or no warning that a seizure is imminent and no evidence of existing "pre-eclampsia". All pregnant women regardless of parity are at risk. There is a significant increased risk in women in the 15-19 year age group and women with previous eclampsia. 

Acute management of eclampsia

A

AIRWAY

(Jaw thrust, High flow O2)

& LATERAL TILT & CALL FOR HELP 2222 

B

BREATHING

Assess, ventilate as required.

C

CIRCULATION

Assess (BP, pulse, O2 saturation) & Access

  • Site 2 large bore cannulae (14g ideally, minimum 16g)
  • Obtain blood FBC,U&E, LFT, urate, coagulation screen
  • G&S

C1: CONTROL SEIZURE

C2: CONTROL BLOOD PRESSURE

C3: CONTROL FLUID BALANCE

*** The “Eclampsia” box contains all the necessary drugs, antidotes and instructions ***

D

DELIVERY PLAN

E

EVALUATE

Reassess monitoring and Investigations

C1: CONTROL SEIZURE

Magnesium Sulphate is the drug of choice unless there are specific contra indications to its use.

Magnesium Sulphate:

Loading Dose (by hand):                      

  • 4 grams IV over 5 minutes
    (Add 4 grams (8 mls of 50%) Magnesium Sulphate to 12 mls Normal Saline)          

Maintenance Infusion Dose:

  • IV infusion 1 gram Magnesium Sulphate per hour                 

Maintenance Infusion Preparation:

  • 10 grams (20 mls of 50%) Magnesium Sulphate made up to 50 mls by adding to 30 mls normal saline in a 60 ml luer lock syringe
  • Infusion rate is 1 gram (5 mls) per hour via an syringe driver

Infusion is maintained at 1 gram/hr for 24 hours provided:

  • Respiratory rate > 14 per minute
  • Urine output > 25mls/hour, and
  • Patellar reflexes are present

NB:  The volume of the Magnesium Sulphate infusion must be included as part of  the total fluid maintenance infusion for the patient of 85ml/hour

Recurrent Seizures on Treatment:

  • Give a 2nd bolus dose of Magnesium Sulphate 2 grams over 5 minutes by hand (do not stop infusion)
  • add 2 grams (4 mls of 50%) Magnesium Sulphate to 6 mls of Normal Saline
  • One dose only

If further seizures despite 2nd bolus give Diazepam 10mg IV.  Intubation may be required to protect airway and ensure adequate oxygenation.

Magnesium Sulphate – Patient Monitoring:

Reflexes:

  • Patellar reflexes after completion of loading dose and hourly whilst on maintenance dose (use arm reflexes if functional regional anaesthesia).
  • If reflexes are absent stop infusion until reflexes return and check Magnesium level.

Oxygen Saturation / Respiratory Rate:

  • Continuous O2 saturation should be assessed.
  • Perform respiratory rate every 15 minutes
  • If O2 saturation < 94% or respiratory rate < 14 / min, administer O2 (4 L/min via Hudson mask), stop Magnesium Sulphate infusion and call anaesthetist. Check Magnesium level. Consider antidote

Urine Output:

Monitor hourly.

If >20 ml/h - continue Magnesium Sulphate infusion.

If 10 - 20 ml/h & creatinine <150mmol/l - continue as protocol and recheck Magnesium level every 2 hours.

If 10 - 20 ml/h & creatinine > 150mmol/l (or urea >10) - recheck Magnesium levels immediately and every 2 hours. Decrease infusion rate to 0.5gram/hour.

If < 10 ml/h - stop infusion and check Magnesium level.

Biochemical Monitoring (Magnesium levels):  This is not routine. If required then see below.

The Therapeutic range is 2-4 mmol/l.

Low If < 2 mmol/l - Maintain infusion at current rate.  Recheck in 2 hours.

Therapeutic If 2 -3.5 mmol/l - Continue infusion at current rate. Recheck in 2 hours if clinical indication remains.

High If 3.55 - 5 mmol/l - STOP INFUSION for 15 min and then recommence at half previous infusion rate and recheck in 1 hour.

Very High If > 5mmol/l - STOP INFUSION and consider antidote. See below for further details.

Magnesium Sulphate toxicity and management:

Clinical Features

   Mg level

Action

Loss of Patellar reflexes
Weakness
Nausea, Flushing
Double vision
Slurred speech
Somnolence 

circa 5 mmol/l

STOP INFUSION

GIVE ANTIDOTE
10 ml of 10% Calcium Gluconate (1gram)
Slow IV inject over 10 mins. 
CHECK Magnesium level.  

Muscle Paralysis

circa 6-7.5 mmol/l

STOP INFUSION

GIVE ANTIDOTEAS ABOVECHECK
Magnesium level.  

Respiratory Arrest
Cardiac Arrest 

circa 12 mmol/l

STOP INFUSION

INSTITUTE CPR 
2222 CALL Obstetric and cardiac arrest team INTUBATE AND VENTILATE
GIVE ANTIDOTE AS ABOVE 
CHECK Magnesium level

C2: CONTROL BLOOD PRESSURE

  • MAP > 140 mm Hg is an obstetric emergency

  • No evidence that one particular drug is superior for treatment. Labetalol tends to be the first line drug of choice in this locality.

  • Continuous fetal monitoring is necessary because lowering of maternal BP may lead to fetal distress, particularly if there is associated IUGR

  • Automated oscillometric devices may underestimate BP

  • Commence MEWS chart (one large bold box per hour)

  • MAP >140 mm Hg - measure BP every 5 minutes

  • MAP 125 -140 mm Hg - measure BP every 15 minutes

  • Aim for gradual reduction in BP to around 130-140 / 90 - 100 mmHg (MAP < 125)

  • Site 2 x wide bore IV cannula & check BP bloods (U+E, LFT, urate, FBC +/- coagulation if platelet count is < 150 or previous abnormality) 6 hourly if patient stable, X-match 2 units blood

  • Foley catheter inserted and hourly urine volumes commenced

  • Continuous pulse oximetry

Antihypertensive treatment for hypertensive crisis (flowchart)

If Labetalol contraindicated or above labetalol regime has failed to control blood pressure - Second Line Agent (Hydralazine OR Nifedipine) (flowchart)

Antihypertensive drugs

Labetalol:

Contraindications including:

Asthma, Bronchospasm, Uncontrolled heart failure

IV bolus:    

50 mg over 5 minutes
i.e. 10 mls of 5 mg/ml
Can be repeated; and/or followed by infusion (see chart)

Infusion preparation: 

Prepare 5 mg/ml infusion
i.e.  300 mg Labetalol in 60mls
Commence infusion at 50 mg (10 mls) per hour.

Nifedipine:

Contraindications including: Hypersensitivity to nifedipine, or to other dihydropyridines because of the theoretical risk of cross-reactivity, or to any of the excipients, Angina, Recent MI, Aortic Stenosis
  (Care with Magnesium Sulphate – see note below*)
Preparation:  10 mg capsule orally (swallowed whole)Repeated doses of 10 mg can be given at 6 hourly intervals

Hydralazine:

Contraindications: Hypersensitivity to hydralazine or dihydralazine
Connective tissue disorders
Severe tachycardia and heart failure with high output cardiac failure (e.g. in thyrotoxicosis)
Myocardial insufficiency due to mechanical obstruction (e.g. in the presence of aortic or mitral stenosis or constructive pericarditis)
Isolated right ventricular failure due to pulmonary hypertension (cor pulmonale)
Dissecting aortic aneurysm
IV bolus: 5 mg slowly over 5 minutes
Boluses can be repeated at 20 minute intervals, but may be simpler to start infusion(
A 5 mg dose can be effective for 6 hours)
Infusion preparation:   Prepare 1 mg/ml infusion i.e.  40 mg Hydralazine made to 40mls with normal saline.
Infuse at 10 mg (10 mls) per hour

*Note

There are 2 case reports of neuromuscular blockade resulting from simultaneous use of Nifedipine and Magnesium Sulphate.  However, 1,469 women were assigned to receive Magnesium Sulphate and Nifedipine in the Magpie trial, and no such blockade was reported.  Similarly, no adverse events were reported in RCTs comparing Hydralazine with Nifedipine in which all, or some, women received magnesium sulphate.  The risk of neuromuscular blockade is therefore likely to below. MAP > 140 mm Hg is an obstetric emergency.

C3: CONTROL FLUID BALANCE

  • The main risk is of pulmonary oedema to iatrogenic fluid overload.
  • Patients should be fluid restricted (85mls per hour of total input).
  • Document hourly urine output on MEWS chart
  • Oliguria is common in severe pre-eclampsia.
  • The natural diuresis may not occur for at least 12 hours post delivery.
  • Renal failure is uncommon.

  • Furosemide should be reserved for pulmonary oedema and prescription must be discussed with consultant obstetrician.

  • In persisting oliguria U&Es should be checked 6 hourly.
  • In persisting oliguria: urine osmolality that is not concentrated, or high potassium levels indicates renal failure and renal physicians should be contacted.

  • CVP monitoring can be misleading.
  • Consultant obstetrician on-call must be informed if CVP line is considered.

Delivery

  • Delivery is the definitive treatment for severe pre-eclampsia/eclampsia
  • Mother MUST be stabilised prior to delivery irrespective of circumstances (e.g. fetal distress)
  • HDU support is required post delivery
  • ITU if ventilated

N.B.  Avoid ergometrine use. Skip to next medical treatment if uterine atony (PPH guideline). 

Editorial Information

Last reviewed: 22/12/2015

Next review date: 15/02/2021

Author(s): Janet Brennand.

Approved By: Obstetrics Clinical Governance Group

Document Id: 402