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Announcements and latest updates

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

  1. 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 26th 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.

 

  1. New toolkits

The following toolkits are now live;

  1. 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.

 

  1. 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.

 

  1. 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

Seizures

Introduction

Seizures (generalised or partial) occur most often in 10 to 15% of patients with palliative care needs due to primary or secondary brain tumours, cerebrovascular disease, epilepsy or biochemical abnormalities, for example low sodium, hypercalcaemia or uraemia. 70% of patients with brain tumours have seizures during the course of their illness. An advance care plan is particularly important for people at risk of seizures and may help to avoid unnecessary hospital admission.

 

Assessment

  • Eliminate other causes of loss of consciousness or abnormal limb or facial movement, for example vasovagal episode, postural hypotension, arrhythmia, hypoglycaemia, extrapyramidal side effects from dopamine antagonists.
  • Find out if the patient has had previous seizures or is at risk. Exclude history of epilepsy, previous secondary seizure, known cerebral disease and dementia.
  • Ensure there are no problems with usual anti-epileptic drug therapy – check patient is able to take oral medication. Drug interactions are common (for example corticosteroids reduce the effect of carbamazepine and phenytoin). Please check the British National Formulary (BNF).

 

Management

The management advice below is intended for situations where the standard medical protocols are unavailable or not assessed to be in the patient’s best interest.   

  • Choice of anti-epileptic drug is guided by seizure type, potential for drug interactions and co-morbidities. Consider discussion with epilepsy specialist when identifying seizure type and management plan for patient. The adverse effects and interactions profiles of these medications should be key in deciding management of individuals. Levetiracetam is better tolerated in patients aged 60 years and over.
  • Dying patients unable to take oral medication: anti-epileptic drugs have a long half-life, however ongoing management should be considered:
    • †Midazolam 5mg subcutaneously (SC). Buccal midazolam is another option and can be acceptable for patients. 
    • †Midazolam 20mg to 30mg via continuous subcutaneous infusion (CSCI) over 24 hours can be used as maintenance therapy.
    • †Subcutaneous levetiracetam via CSCI over 24 hours is an option to be considered. Conversion of oral to CSCI of levetiracetam is 1:1.

 

 Seizure management in patients unsuitable for standard medical management

Seizures flowchart

 

Tables are best viewed in landscape mode on mobile devices

Drug

Experience of use in syringe pump

Oral to CSCI conversion

Starting dose for seizures (over
24 hours)

Sedating effect

Guide dose titration

Midazolam

Extensive

NA

20mg to 30mg

Often

Increase by 5mg to 10mg every 24 hours

Levetiracetam*

Some

1:1

1g (or equivalent to current oral dose)

No

Increase by 500mg every 2 weeks (max 3g may need 2 syringe pumps)

Sodium Valproate*

Very limited (specialist advice)

1:1

1g

No

Increase by 200mg every 3 days (max 2.5g)

Phenobarbital*

Extensive (under specialist advice only)

Not applicable

200mg to 400mg (stat bolus of 100mg to 200mg IM/IV may also be needed)

Yes

Increase by 200mg every 24 to 48 hours

* Only for use in conjunction with advice from specialist palliative care.

If necessary, a combination of the above medications may be used. Seek advice from specialist palliative care.

 

Practice points

  • Midazolam injection is licensed for intravenous (IV), intramuscular (IM) and rectal use but it can also be given (unlicensed) via SC, CSCI, intranasal and buccal routes. There are newer buccal preparations available and these may be easier and maintain more dignity for the patient than rectal diazepam.
  • Although first seizures are not usually treated, for those with intracranial tumours, anti‑epileptic drugs are normally commenced following first seizure. There is no evidence of benefit of prophylactic anti-epileptic drugs (before any seizure occurs). 30% of patients with primary brain tumours have a seizure in the last week of life.
  • Consider commencement of (or review dose of) corticosteroid in those with intracranial tumour and seizure.
  • Levetiracetam and lamotrigine do not significantly induce enzymes and will have minimal interactions with other medications such as chemotherapy.
  • Monitor effect of medication which can lower seizure threshold such as QThaloperidol or levomepromazine; review need and dose if there is definite exacerbation of seizure activity as a result.
  • In patients with moderate to severe renal impairment defined by a creatinine clearance of less than 30ml/min/1.73m2, consider reducing levetiracetam dose to 250mg twice daily or 500mg/24 hours via syringe pump.
  • Seizures are frightening for patients and their families. Educate and address any concerns such as desired management of further seizures, management of risk of seizure recurrence if stopping anti-epileptic drugs, for example due to swallowing difficulties.
  • If relevant, it is important to remind patients that anti-epileptic drug treatment would be life-long and that there are implications for driving following seizures.
  • Buccolam® (midazolam 5mg/ml) is unlicensed for use in adults. Epistatus® (midazolam 10mg/ml) is unlicensed for use in adults. Check local policy for product choice.

 

References

Scottish Palliative Care Guidelines - Levetiracetam (Subcutaneous Infusion). 2018 [cited 2019 February 08]; Available from https://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/levetiracetam-(subcutaneous-infusion).aspx

British National Formulary.2017. Available from https://www.medicinescomplete.com/mc/bnf/current/PHP-bnf-interactions-list.htm

BMJ Best Practice. Focal seizures. 2018 [cited 2018 Oct 04]; Available from: https://bestpractice.bmj.com/topics/en-gb/544.

BMJ Best Practice. Generalised seizures. 2018 [cited 2018 Oct 04]; Available from:https://bestpractice.bmj.com/topics/en-gb/543.

Dickman A, Schneider J. The Syringe Driver. 4th ed: Oxford University Press; 2016.

Freiherr von Hornstein W, editor. Levetiracetam continuous subcutaneous infusion in the management of seizures. First experience. Poster presentation IAPC Education & Research Seminar 2014.

Freiherr von Hornstein W, O'Gorman A, Richardson J, Wilson M, Carroll M, editors. Successful Management of Seizures until the End of Life using Levetiracetam Continuous Subcutaneous Infusion. Poster presentation NCRI Cancer Conference Abstracts; 2014.

Kerrigan S, Grant R. Antiepileptic drugs for treating seizures in adults with brain tumours. 2011 [cited 2018 Oct 04]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008586.pub2/epdf/standard.

Lopez-Saca JM, Vaquero J, Larumbe A, Urdiroz J, Centeno C. Repeated use of subcutaneous levetiracetam in a palliative care patient. J Pain Symptom Manage. 2013;45(5):e7-8.

NICE. Epilepsies: diagnosis and management CG137. 2018 [cited 2018 Oct 04]; Available from: https://www.nice.org.uk/guidance/cg137.

Pruitt AA. Medical management of patients with brain tumors. Continuum (Minneap Minn). 2015;21(2 Neuro-oncology):314-31.

Remi C, Lorenzl S, Vyhnalek B, Rastorfer K, Feddersen B. Continuous subcutaneous use of levetiracetam: a retrospective review of tolerability and clinical effects. J Pain Palliat Care Pharmacother. 2014;28(4):371-7.

Royal Pharmaceutical Society. BNF - Levetiracetam. 2018 [cited 2018 Oct 04]; Available from: https://www.medicinescomplete.com/#/content/bnf/_695768521.

SIGN. Diagnosis and management of epilepsy in adults No143. 2015 [cited 2018 Oct 04]; Available from: https://www.sign.ac.uk/our-guidelines/diagnosis-and-management-of-epilepsy-in-adults/.

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.