Mx of diabetes in children going to theatre for surgery

see also:

• paediatric emergency medicine
• endocrinology
• diabetes mellitus
• insulin
• hypoglycaemia
• diabetes in children
• RCH guideline - diabetes mellitus
• RCH guideline - diabetes and surgery

• primary aims for Mx of diabetic children going to theatre for surgery and who are thus fasting are:
  • maintainence of euglycaemia, and,
  • avoidance of diabetic ketoacidosis (DKA), and,
  • avoidance of hypoglycaemia
• in general, peri-operative insulin orders should be confirmed by a paediatric endocrinologist
• see hospital guidelines for hospital-specific policies:
  • RCH guideline - diabetes and surgery
  • Western Health policy and procedure for diabetic children going to theatre (docx) - intranet only

• normal diet and insulin Rx on day prior to theatre
• finger-prick blood glucose levels every hour starting at 6am, aiming to maintain BGL between 5-10 mmol/L, and every 2 hours post-operatively for 12-24hrs post-surgery
• fast prior to theatre as per anaesthetist instructions
  • minimise the time patients with diabetes are fasted before theatre
  • can usually give clear fluids including glucose orally for Rx of hypoglycaemia, up until 2 hours prior to theatre
    • if BGL < 5mmol/L and delay in iv access, give 5-10mL/kg (max 200mL) of lemonade or other clear sugar-containing, non-particulate fluid (10% sugar)
• commence IV infusion of 5% glucose and 0.45% sodium chloride at usual fluid maintenance rates if either:
  • on continuous S/C insulin infusion pump and one hour before induction of anaesthesia, or,
  • pre-op and BGL < 6mmol/L,
  • < 2 hours post-op and BGL < 4mmol/L
  • NB. discontinue iv fluids once patient is eating and drinking normally
  • NB. if extended fasting post-op, use intravenous infusion 5% glucose, 0.45% sodium chloride and 20mmol/L potassium chloride at the required maintenance rate as long as required and give reduced doses of long acting and short acting insulins, or use an iv insulin infusion
• for type 1 diabetics, a basal insulin dose must be maintained:
  • patients on bd mixed insulin Rx:
    • omit morning short acting insulin and give usual dose of long acting unless otherwise directed
    • post-op, consider giving a stat dose of short acting insulin (0.1-0.25 units/kg) if BGL > 15mmol/L before lunch, check for ketones!
  • patients on basal bolus insulin Rx:
    • give the usual long acting insulin and omit the morning short acting insulin
    • continue to omit the usual short acting doses until eating normally, or BGL > 10mmol/L
  • patients with continuous S/C insulin infusion pump:
    • pre-op:
      • keep the pump on usual basal rates, giving correctional boluses (using the insulin pump bolus advisor facility) as usual if required.
    • during procedure, consider either:
      • disconnecting insulin pump just prior to starting theatre, give pump to parant, and reconnect when patient is in recovery, preferably in presence of paraent or guardian, or,
      • setting it to a temporary 80% of basal dose rate during procedure

• assess for ketoacidosis and dehydration
• if not ketotic:
  • consider iv insulin infusion at 0.02-0.04 units/kg/kr and adjust as needed according to hourly BGL, ketones/acidosis
  • ensure intravenous infusion of 5% glucose, 0.45% sodium chloride with 20mmol/L potassium chloride at required maintenance rate (with or without an insulin infusion) is running before, during and after surgery.
• if dehydrated or ketotic:
  • call paediatric endocrinologist ASAP
  • if ketoacidotic, Rx as per diabetic ketoacidosis (DKA)

• maintenance intravenous fluids (5% glucose, 0.45% sodium chloride with 20mmol/L potassium chloride) at required rate, until diet is re-introduced
• discuss insulin Rx with paediatric endocrinologist
  • consider, intravenous insulin infusion at 0.02-0.04 units/kg/hr (usual total daily insulin in systemically well children and teenagers is 0.5 – 1 units/kg/day), and adjust according to hourly blood glucose concentrations and the presence of acidosis/ketones.