Arginine stimulation test | Right Decisions

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Arginine stimulation test

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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.

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With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Indications for the procedure

Short stature.

Consistent abnormally low growth velocity.

Assessment of possible growth hormone deficiency.

Where the ITT is not recommended or not suitable.

Preparation for the test

Patient to have water only for 8 hours prior to the test.
Arginine may cause nausea and some irritation at the infusion site. A cannula of at least 22g should be used.
In children with suspected hypopituitarism prolonged fasting may induce hypoglycaemia. Blood glucose should be checked by ward meter with each sample in these patients whenever a sample is taken.
This test can be combined with synacthen test to assess adrenal cortisol production (but not ACTH deficiency), in addition to growth hormone deficiency.

Drug administration

Drug(s) Given

Arginine monochloride 0.5g/kg
Up to a maximum of 30g.

How Given

Dilute Arginine in equal quantities of 0.9% saline and infuse over 30 minutes.

For example, dose 0.5gms per kilo
20kg child = 10gms of arginine= 20mls of arginine solution (5gms in 10mls).

Add 20mls of arginine solution to 20mls of 0.9% saline.

Timing of Administration

Give after the first basal blood sample has been taken and the Capillary Blood Glucose is known.

Procedure

Time (minutes)	Action
-30	Insert a reliable cannula (at least 22g). Take venous blood sample. Measure capillary blood glucose (CBG) using ward meter. Start the arginine infusion and give over 30 minutes.
0	Take venous blood sample. Measure CBG
15	Take venous blood sample. Measure CBG
30	Take venous blood sample. Measure CBG
60	Take venous blood sample. Measure CBG
90	Take venous blood sample. Measure CBG
120	Take venous blood sample. Measure CBG

Samples required

	Time (minutes)
	-30	0	15	30	60	95	120
Glucose
GH
Cortisol ¹
IGF₁
T₄, TSH

1 If synacthen test is performed at the same time.

Interpretation

If the plasma GH concentration reaches 6.7 micrograms/L or more, further investigations are not indicated.

If the response is below this level, then an insulin hypoglycaemia test may be necessary.