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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

 

 

Adrenal Crisis: Avoidance in Pregnant Women at Risk (520)

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

Glucocorticoid dependent obstetric patients are not encountered commonly, however appropriate care is crucial to avoid potentially life threatening acute adrenal crisis. In order to avoid a precipitous fall in BP during anaesthesia or in the immediate postoperative period, anaesthetists must know whether a patient is taking or has been taking glucocorticoids. 

Signs of acute adrenal crisis include severe dehydration, pale clammy skin, sweating, rapid and shallow breathing, hypotension, dizziness, vomiting and diarrhoea and severe drowsiness or loss of consciousness.

Women at risk [1]

  1. All women requiring long term glucocorticoid replacement (for example as a result of pituitary disease or congenital adrenal hyperplasia, or women with Addison’s disease). These women will usually be receiving the equivalent of 20-25mg hydrocortisone per day and are likely to be dependent on this replacement.1
  2. Women receiving exogenous glucocorticoid may now be dependent on this and develop adrenal crisis if they are stopped suddenly. This group of women includes:
    1. Patients taking the equivalent of 5mg prednisolone per day for more than FOUR See Appendix 1 for more detail.2
    2. Patients on more than the equivalent of 40mg prednisolone per day for more than 7 days2
    3. Patients on long term high dose inhaled steroids. See Appendix 2 for more detail.2
    4. High doses of topical steroids (e.g. ≥200g per week of potent or very potent steroids). See Appendix 3 for more detail. 2

Mineralocorticoids

Note that women with adrenal disease (e.g. Addisons disease or previous bilateral adrenalectomy) may also be receiving mineralocorticoid replacement, usually in the form of fludrocortisone. This also needs to be considered and likely continued.

Factors which can precipitate Adrenal Crisis

  • Infection.
  • Major surgery (e.g. caesarean section).
  • Malabsorption of oral steroids (e.g. due to vomiting).
  • Major stress (e.g. labour).
  • Discontinuation of glucocorticoids (hydrocortisone, prednisolone, dexamethasone).

Peripartum Steroid Management [4]

Caesarean Section

On day of surgery

  • Normal morning dose of steroid.
  • 100 mg hydrocortisone IV just before anaesthesia. Then:
  • Double oral glucocorticoid dose for 48 hours.

Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case:

  • 50 mg hydrocortisone IM 6 hours until eating and drinking normally.
  • Once well, return to oral dose as above. After 48 hours:
  • If well, return to patient’s normal dose.

Induction of Labour

  • Continue normal dose of steroid until labour diagnosed.

Labour

When labour is diagnosed:

  • 100 mg hydrocortisone IV at onset of labour.

Then:

  • Commence infusion of hydrocortisone at 200mg IV over 24hr

OR

  • 50mg hydrocortisone every 6hrs IM.

Then:

  • Double oral glucocorticoid dose for 48 hours postpartum.
  • Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case use the IM route as above.

After 48 hours:

  • If well, return to patient’s normal dose.

Special Points

All women at risk of adrenal crisis should consider carrying a Steroid Emergency Card to alert healthcare professionals.

Women who are deficient in glucocorticoids are also at risk of hypoglycaemia. 

  • Check capillary blood glucose and a formal laboratory glucose when first assessed and if the patient develops any symptoms of hypoglycaemia. 

If patient becomes hypotensive, drowsy or peripherally shut down, give 100mg hydrocortisone IM or

IV immediately. (Intravenous doses should be administered over 10 minutes.) 

IM hydrocortisone is preferable to IV since it has a more sustained release. 

Use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, not hydrocortisone acetate. 

If the patient is unwell postpartum (e.g. vomiting or fever), delay return to normal dose beyond the 48 hour period stated above. If the patient is nil by mouth, ensure adequate intravenous fluid replacement (e.g. 0.9% sodium chloride or Hartmann’s solution). 

Monitor electrolytes and BP post-partum: 

  • BP every 4 hours.
  • U&Es daily for 2-3 days.

Appendix 1 Long-term oral glucocorticoids (ie 4 weeks or longer)

Long-term oral glucocorticoids (ie 4 weeks or longer) – Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

MedicineDose (*) 
Beclometasone 625 microgram per day or more 
Betamethasone750 microgram per day or more 
Budesonide1.5mg per day or more (***) 
Deflazacort 6mg per day or more 
Dexamethasone 500 microgram per day or more (**)4
Hydrocortisone 15mg per day or more (**)
Methylprednisolone4mg per day or more 
Prednisone5mg per day or more 
Prednisolone5mg per day or more  

(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020)4 and (***) based on best estimate

Appendix 2 Inhaled glucocorticoid doses

Inhaled glucocorticoid doses - Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine

Dose (*)5

Beclometasone          

(as non-proprietary, Clenil, Easihaler, or Soprobec)

More than 1000 microgram per day 

Beclometasone         

(as Qvar, Kelhale or Fostair )       

More than 500 microgram per day

(check if using combination inhaler and MART regimen) 

Budesonide      

More than 1000 microgram per day 

(check if using combination inhaler and MART regimen) 

Ciclesonide                          

More than 480 microgram per day 

Fluticasone propionate  

More than 500 microgram per day 

Fluticasone furoate          

(as Trelegy and Relvar)

More than 200 microgram per day 

Mometasone                     

More than 800 microgram per day 

(*) dose equivalent - NICE Inhaled corticosteroid doses for NICE’s asthma guideline (2018)

Appendix 3 Topical glucocorticoids

Topical glucocorticoids. 2

Topical steroid treatments

Potency of steroid 

Beclometasone dipropionate 0.025%

Potent 

Betamethasone dipropionate 0.05% and higher

Potent 

Betamethasone valerate 0.1% and higher

Potent 

Clobetasol propionate 0.05% and higher

Very potent 

Diflucortolone valerate 0.1%

Potent 

Diflucortolone valerate 0.3%

Very Potent 

Fluocinonide 0.05%

Potent 

Fluocinolone acetonide 0.025%

Potent 

Fluticasone propionate 0.05%

 Potent 

Hydrocortisone butyrate 0.1%

Potent 

Mometasone 0.1%

Potent

Triamcinolone acetonide 0.1%

Potent

All other topical glucocorticoids available in the UK are either mild or moderate potency.

Editorial Information

Last reviewed: 22/04/2022

Next review date: 01/04/2027

Author(s): Andrew Thomson.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 520

References
  1. Wass JAH, Arlt W. How to Avoid precipitating an acute adrenal crisis. BMJ. 2012; 345: e6333
  2. Erskine D, Simpson H. Exogenous Steroids Treatment in Adults. Adrenal Insufficiency and Adrenal Crisis – Who is at risk and how should they be managed safely. Society for Endocrinology and the British Association of Dermatologists.
  3. Woodcock et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia. 2020; 75: 654-663.
  4. Simpson H, Tomlinson J, Wass J, Bean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London). 2020; 20 (4): 371-378.
  5. Inhaled corticosteroid doses for NICE’s asthma Guideline. July 2018.