High regional or total spinal block | Right Decisions

Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26^th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

2.National IV fluid prescribing calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

New toolkits

The following toolkits are now live;

Gender identity healthcare: adults and young people standards. (https://rightdecisions.scot.nhs.uk/genderidentity ) Note that this toolkit includes self-evaluation forms for each standard. A Scottish Government launch of these standards, together with the toolkit and NES educational resources, is planned for 3^rd September.
Care Inspectorate staffing method framework.
Vascular surgery pathways from the Modernising Patient Pathways Programme within the Centre for Sustainable Healthcare Delivery.

Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

Thursday 5 September 1-2 pm
Wednesday 24 September 4-5 pm
Friday 27 September 12-1 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.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

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

The incidence is 1 in 27,000 obstetric epidurals. Strictly, total spinal is the subarachnoid injection of a large (epidural) dose of local anaesthetic, resulting in severe hypotension, profound bradycardia, respiratory arrest and loss of consciousness. However, a similar result can follow epidural or subdural injection of local anaesthetic: high regional block is defined as an excessively high block requiring tracheal intubation.

Although the features (weakness of upper limbs, difficult breathing, slurred speech, sedation and high level of numbness) are typically rapidly ascending, these may develop late and insidiously.

Management

Call immediately for an ODP and a second anaesthetist.

Equipment immediately required

Cardiac arrest trolley (kept in resuscitation equipment bay by baby resuscitation room) with laryngoscope, endotracheal tubes and suction pump.

Management technique

Position patient on her left side (or other method of uterine displacement). The patient must be positioned to eliminate aortocaval compression at all times.
Oxygen should be administered with a mask and bag as necessary.
500 - 1000 mL of Plasmalyte 148/Ringer’s lactate rapidly intravenously.
Ephedrine 15 mg intravenously. Repeat as necessary. Consider phenylephrine, adrenaline and atropine administration. Maintain the blood pressure with ephedrine or a phenylephrine infusion plusglycopyrrolate or atropine and an intravenous infusion as required.
If breathing is inadequate, perform rapid sequence induction with cricoid pressure. The patient should be intubated and kept ventilated and anaesthetised.
If intubation is difficult or fails, do not wait for the return of spontaneous ventilation – it may not occur. Proceed with emergency airway management and IPPV (see failed intubation drill).
Move the patient to the operating theatre for full monitoring including blood pressure, SpO2, EtCO2 and ECG.
In the event of fetal distress, caesarean section is advised.
The patient and her relative(s) should be reassured; allocate a team member to escort the
partner/relative out of the room as soon as possible.

Consider alternative diagnoses, e.g. subarachnoid haemorrhage.

Post-event

A post delivery visit is vital to explain what has happened and why. Further follow up may be needed to deal with psychological issues.

Author(s): NHS Lothian.

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