Management of children with diabetes requiring surgery or fasting (ISPAD Guidelines)



Background

Children with diabetes requiring a surgical procedure

  • Must be admitted to hospital for general anaesthesia.
  • Need insulin, even if fasting, to avoid ketoacidosis.
  • Should receive a glucose infusion when fasting before an anaesthetic to prevent hypoglycaemia.

Recommendations

  1. Surgery on children and adolescents with diabetes should only be performed in centres with dedicated paediatric facilities for the care of young people with diabetes.
  2. To ensure the highest levels of safety, careful liaison is required between surgical, aesthetic and children’s diabetes care teams before admission to hospital for elective surgery and as soon as possible after admission for emergency surgery.

Elective surgery

  • Operations are best scheduled early on the list, preferably in the morning
  • Admit to hospital the afternoon prior to surgery for morning and major operations, or early morning for minor operations later in the day
  • Earlier admission is important if glycaemic control is poor
  • Admission should be to a paediatric diabetes or paediatric surgical ward

Evening prior to surgery

  • Frequent BG monitoring is important especially before meals and snacks and before bedtime (and check urinary ketones)
  • Usual evening or bedtime insulin(s) and bedtime snack should be given
  • Ketosis or severe hyperglycaemia will necessitate correction, preferably by overnight IV infusion, and might cause a delay in surgery

Morning operation

  • No solid food from midnight
  • Clear fluids may be allowed up to 4 h pre-operatively (check with anaesthetist)
  • Omit usual morning insulin dose
  • Start IV fluid and insulin infusion at 6.00–7.00 am (Table 9)
  • Hourly BG monitoring pre-operatively; half-hourly during operation and until woken from aesthetic
  • Hourly BG monitoring for 4 h postoperatively
  • Aim to maintain BG between 5 and 12 (Table 9 infusion guide)
  • Continue IV infusions until the child tolerates oral fluids and snacks (this may not be until 24–48 h following a major operation)
  • Change to usual SC insulin regimen or short/rapid-acting insulin before the first meal is taken
  • Stop insulin infusion 60 min after the SC insulin is given
  • For minor operations it may be possible to discharge from hospital after the evening meal if the child is fully recovered

Table 9 Infusion Guide for surgical procedures

1. Maintenance fluid guide
  • Glucose 10%, saline 0.18%
  • If infusion required > than 12 hrs add KCl 20 mmol to each litre and monitor U&E
  Body Weight Fluid Requirements /24hr
  3 - 9 kg 100ml/kg
For each kg between 10 - 20 kg Add 50ml/kg
For each kg over 20kg Add 20ml/kg (Max 2000ml female, 2500ml male)
2. Insulin infusion
  • Add soluble insulin 50units to 50ml 0.9% saline making solution of 1 unit/ml; attach to syringe pump and label clearly.
  • Start infusion at 0.05 ml/kg/hr (i.e. 0.05 units/kg/hr).
  • Aim to maintain BG levels between 5 and 12 mmol/l by adjusting infusion hourly.
  • Do not stop insulin infusion if BG <5 mmol/l as this will cause rebound hyperglycaemia: reduce the infusion rate.
  • The insulin infusion may be stopped if BG < 3 mmol/l but only for 15 minutes.

Afternoon operations

  • Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
  • Allow a light breakfast; clear fluids may be allowed up to 4 h pre-operatively
  • Start IV fluids and insulin infusion at midday at the latest (Table 9 above)
  • Then as for morning operations (above).
  • [Alternatively IV insulin infusion may be started at breakfast time]

Emergency surgery

  • DKA may present as an ‘acute abdomen’
  • Acute illness may precipitate DKA (with severe abdominal pain)
  • Nil by mouth
  • Secure IV access
  • Check weight, electrolytes, glucose, blood gases and urinary ketones preoperative
  • If ketoacidosis is present, follow protocol for DKA and delay surgery until circulating volume and electrolyte deficits are corrected
  • If there is no ketoacidosis, start IV fluid and insulin infusions as for elective surgery

Minor procedures requiring fasting

For short procedures (with or without sedation or anaesthesia) and when rapid recovery is anticipated, a simplified protocol may be organized by experienced diabetes/aesthetic personnel and may include either:

  • early morning procedure (e.g. 8.00–9.00 am) with delayed insulin and food until immediately after completion
    or
  • reduce (e.g. give of) usual insulin dose or give repeated small doses of short/rapid-acting insulin.

Glucose 5–10% infusion and frequent BG monitoring are recommended in all these situations.



Content by Dr Íomhar O' Sullivan 27/03/2007.   Next review 27/03/2008.