Treatment of Children with Diabetes Undergoing Surgery
Introduction
This guideline is intended for use in managing all children and young people up to the age of 18 years with diabetes mellitus who require surgery.
Children with diabetes mellitus are at risk of blood glucose (BG) alterations when undergoing surgery. This risk results from a change in routine, change in or lack of perioperative insulin, physical and emotional stress related to the surgical procedure, surroundings, parental anxiety, and surgical pain.
Adverse events to watch for include:
These can result from
For the above reasons, it is very important that there should be close liaison between the surgeon, the anaesthetist and the local paediatric diabetes team. Children with diabetes undergoing surgical procedures should not have to spend longer in hospital because their diabetes management has been unduly complicated.
This guideline is intended for use in managing all children and young people up to the age of 18 years with diabetes mellitus who require surgery.
Children with diabetes mellitus are at risk of blood glucose (BG) alterations when undergoing surgery. This risk results from a change in routine, change in or lack of perioperative insulin, physical and emotional stress related to the surgical procedure, surroundings, parental anxiety, and surgical pain.
Adverse events to watch for include:
- Hypoglycaemia
- Hyperglycaemia
- Diabetic ketoacidosis
These can result from
- Inappropriate use of intravenous insulin infusion
- Medication errors when converting from the intravenous insulin infusion to usual medication
For the above reasons, it is very important that there should be close liaison between the surgeon, the anaesthetist and the local paediatric diabetes team. Children with diabetes undergoing surgical procedures should not have to spend longer in hospital because their diabetes management has been unduly complicated.
Definitions
MINOR SURGERY
Short procedures (usually less than 30 minutes) with or without sedation or anaesthesia where rapid recovery is anticipated and child is expected to be able to eat by the next meal. Examples include endoscopic biopsies, myringotomy, incision and drainage of an abscess and long line insertion.
MAJOR SURGERY
Includes all surgery requiring more prolonged general anaesthesia lasting >30 minutes or procedures which are likely to cause post-operative nausea, vomiting or inability to feed adequately.
If you are unsure about the length of anaesthetic or risk of slow post-operative recovery from anaesthesia please discuss with anaesthetist and surgeon.
Short procedures (usually less than 30 minutes) with or without sedation or anaesthesia where rapid recovery is anticipated and child is expected to be able to eat by the next meal. Examples include endoscopic biopsies, myringotomy, incision and drainage of an abscess and long line insertion.
MAJOR SURGERY
Includes all surgery requiring more prolonged general anaesthesia lasting >30 minutes or procedures which are likely to cause post-operative nausea, vomiting or inability to feed adequately.
If you are unsure about the length of anaesthetic or risk of slow post-operative recovery from anaesthesia please discuss with anaesthetist and surgeon.
Glycaemic Targets Prior to Elective Surgery
Elective surgery should be postponed, if possible, if glycaemic control is very poor (HBA1c >75mmol/mol [9.0%])
Consider admission to hospital prior to elective surgery for assessment and stabilisation if glycaemic control is poor. If control remains problematic, due consideration should be given to cancelling surgery and re-scheduling at a time when diabetes is less problematic and likely to cause less complications peri-operatively.
There are currently no published data in children on the impact of pre-operative glycaemic control on post-operative outcomes. However Dronge et al found that in adults, an HbA1c ≥ 7% (53 mmol/mol) more than doubles the risk of post-operative wound infection [1])
Consider admission to hospital prior to elective surgery for assessment and stabilisation if glycaemic control is poor. If control remains problematic, due consideration should be given to cancelling surgery and re-scheduling at a time when diabetes is less problematic and likely to cause less complications peri-operatively.
There are currently no published data in children on the impact of pre-operative glycaemic control on post-operative outcomes. However Dronge et al found that in adults, an HbA1c ≥ 7% (53 mmol/mol) more than doubles the risk of post-operative wound infection [1])
Pre-operative Assessment for Elective Surgery
Role of surgeon carrying out surgery/procedure:
As soon as the decision is made to undertake surgery, the surgeon needs to liaise with the local diabetes team and anaesthetist about the date & timing of planned procedure; the type of procedure and whether it is judged to be major or minor surgery (as defined above).
Once date & timing of procedure is decided the local paediatric diabetes team will be able to help formulate a peri-operative diabetes management plan for the patient.
Role of the paediatric diabetes team:
As soon as the decision is made to undertake surgery, the surgeon needs to liaise with the local diabetes team and anaesthetist about the date & timing of planned procedure; the type of procedure and whether it is judged to be major or minor surgery (as defined above).
Once date & timing of procedure is decided the local paediatric diabetes team will be able to help formulate a peri-operative diabetes management plan for the patient.
Role of the paediatric diabetes team:
- Try to optimise glycaemic control prior to planned surgery
- Ensure patients and ward staff have clear written instructions regarding the management of the child’s diabetes (including any medication adjustments) prior to surgery.
- Basic information to be considered:
- Recent weight
- Current diabetes treatment or insulin regimen and most recent recorded doses of insulin
- Most recent HbA1c & date measured
- Hypoglycaemia awareness and any current issues with severe hypoglycaemia
- Any co-morbidities (thyroid disorders/ Addison’s disease/ Coeliac Disease)
Pre-operative Fasting if Undergoing Elective Surgery - the '1-4-6 rule'
‘1’ – Intake of clear fluids (including. water, low-sugar squash and, if needed, clear sugar containing juice such as apple juice, up to one hour before induction of anaesthesia [16]
‘4’ – Breast milk up to four hours before
‘6’ – Formula milk, cows’ milk or solids up to six hours before
‘4’ – Breast milk up to four hours before
‘6’ – Formula milk, cows’ milk or solids up to six hours before
- Children should be encouraged to drink clear fluids (including. water, low-sugar squash) up to 1 hour before elective surgery.16 Where this is not possible, then an intravenous fluid (IV) may be necessary, especially if the time of operation is uncertain or postponed (see section 9 below).
Peri-operative Blood Glucose Targets
- BG should be kept between 5-11 mmol/l during the peri-operative period
- BG should be checked at least hourly for 2 to 3 hours before surgery, during and after surgery until the patient is alert and able to tolerate eating and drinking.
- If the patient is using a continuous glucose monitoring device e.g Dexcom, Libre, Medtronic Guardian, this can be used to measure sugar levels perioperatively instead of finger prick. The benefit of these devices is that they will provide a glucose level as well as direction of change of glucose by means of trend arrows. This can be useful, for example if the sugar level is in the normal range but dropping rapidly. However, it is important to note that glucose levels displayed on these devices are the interstitial glucose level and so can lag by up to 10 mins behind true blood glucose levels. Therefore blood sugar results that need actioning e.g low blood sugar( 4mmol/l or below ) or high blood sugars (14 mmol or above) need to be double checked on a finger prick test. The current advice from the companies making continuous glucose monitors, is that there is a theoretical risk of interference with glucose monitoring on these devices, when the glucose monitors are in close proximity with diathermy. This risk is greatest when uni-polar diathermy is being used. There are currently no reports in the literature that this theoretical risk has been seen in practice.
Pre-operative Hypoglycaemia - Blood Glucose <4mmol/L
- If more than 1 hour prior to surgery
- Give clear glucose containing fluids (e.g 60-100 mls apple juice)16 or glucogel (10 to 15g dextrose i.e. roughly 1/3 to 2/3 of a tube of glucogel). Then establish intravenous access and commence maintenance IV fluids containing 5% Dextrose, as there is a high probability of further hypoglycaemia.
- Give clear glucose containing fluids (e.g 60-100 mls apple juice)16 or glucogel (10 to 15g dextrose i.e. roughly 1/3 to 2/3 of a tube of glucogel). Then establish intravenous access and commence maintenance IV fluids containing 5% Dextrose, as there is a high probability of further hypoglycaemia.
- If less than 1 hour to surgery
- Treat hypoglycaemia with glucogel (as this is smaller volume and safer preoperatively) and establish intravenous access and commence maintenance fluids containing 5% Dextrose
If IV access already available Treat hypoglycaemia wih 2 ml/kg of 10%Dextrose followed by maintenance IV fluids containing 5%Dextrose
- Treat hypoglycaemia with glucogel (as this is smaller volume and safer preoperatively) and establish intravenous access and commence maintenance fluids containing 5% Dextrose
The Anaesthetist must be informed of any preoperative hypoglycaemia and its treatment, as this may affect the patient’s suitability for anesthesia and /or the surgery
There are no Paediatric studies on the ideal BG targets to aim for peri-operatively. In adults, the implementation of intensive glucose control was associated with a higher number of patients experiencing hypoglycaemic episodes4
The following guidelines are divided into minor procedures, major procedures and emergency surgery. The management depends on the insulin regimen the child is on and varies whether the child is on a morning or afternoon list.
It is impossible to write guidance for every eventuality that may occur for a child with diabetes undergoing surgery. For any concerns regarding the child’s blood sugar or diabetes management peri-operatively outside the scope of this guideline, contact the local paediatric diabetes team if possible, but failing this early involvement of a senior general paediatrician is advised.
Guideline for Children with Diabetes on Insulin Therapy
General Advice:
- Liaise with the paediatric diabetes team and anaesthetist as soon as possible once it is known that the child will need to go to theatre.
- Children on Multiple Daily Injections(MDI) which invoves taking long acting insulin (Glargine, Levemir or Tresiba) once a day and fast acting insulin before meals, should never stop or omit a dose of their basal insulin (Glargine/ Levemir /Tresiba)
Minor Elective Morning Surgery
Minor Elective Afternoon Surgery
- Patient should be admitted by 7am on the morning of surgery with an anticipation that they will be going down to theatre between 8.30 & 9am
Minor Elective Afternoon Surgery
- Advise the child to have a normal breakfast no later than 7.30am and to take normal bolus dose (+/- correction dose if needed) of insulin with this.
- Basal insulin (Glargine / Tresiba/ Levemir), if given in the morning should also be given in FULL.
Major Elective Morning Surgery
Major Elective Afternoon Surgery
Emergency Surgery
Intravenous Maintance Fluid Guide [6, 7, 8, 9, 10]
Fluid of choice - 0.9% sodium chloride/5% glucose with 20mmol/L KCl
Alternatively Plasmalyte with 5% dextrose can be used; however please note that this only contains 5mmol/L KCl and so risk of hypokalaemia is greater when using this alongside IV insulin. If using Plasmalyte with 5% dextrose K+ levels should be carefully monitored (this can be done from a blood gas) and additional KCl may need to be added to the IV infusion.
Maintance Fluid Calculation
Alternatively Plasmalyte with 5% dextrose can be used; however please note that this only contains 5mmol/L KCl and so risk of hypokalaemia is greater when using this alongside IV insulin. If using Plasmalyte with 5% dextrose K+ levels should be carefully monitored (this can be done from a blood gas) and additional KCl may need to be added to the IV infusion.
Maintance Fluid Calculation
Insulin Treatment
Intravenous Insulin infusion sliding scale [11,12]
To make up insulin infusion dilute 50 units soluble insulin (Actrapid) in 50 ml 0.9% sodium choride to give a 1 unit/ml solution.
Variable rate Insulin Infusion (VRII)
To make up insulin infusion dilute 50 units soluble insulin (Actrapid) in 50 ml 0.9% sodium choride to give a 1 unit/ml solution.
Variable rate Insulin Infusion (VRII)
Monitor BG hourly before surgery & until the child is off sliding insulin scale. Adjust IV insulin infusion rate according to BG reading.
Ensure at all times that when IV insulin is running there is also IV dextrose containing fluids running.
How to restart subcutaneous insulin after being on intravenous insulin
Once the child feels ready to try to eat, let them have a small drink and snack (e.g. cup of sugar free juice and a piece of toast or a biscuit) to ensure that they are ready to eat prior to stopping the IV infusions.
Once patient is ready to eat a meal give the following insulin:
IV insulin can be stopped at the same time the insulin pump is restarted. IV fluids can be stopped once the child is tolerating oral fluids / food. If the child has been off their insulin pump for more than 4 hours they should have a new pump cannula inserted prior to re-commencing pump therapy. Parents will be able to do this and will have the required equipment.
Ensure at all times that when IV insulin is running there is also IV dextrose containing fluids running.
How to restart subcutaneous insulin after being on intravenous insulin
Once the child feels ready to try to eat, let them have a small drink and snack (e.g. cup of sugar free juice and a piece of toast or a biscuit) to ensure that they are ready to eat prior to stopping the IV infusions.
Once patient is ready to eat a meal give the following insulin:
- For those patients on Multiple daily injection / basal bolus regimens, give rapid acting insulin (e.g. Novorapid; Humalog; Apidra) with their first meal. Check that long-acting insulin (Glargine / Tresiba / Levemir) has been given at usual time for patient throughout their stay. If they have missed a dose of basal insulin, consider delaying taking them off their IV insulin & IV fluids until they have had their long-acting insulin.
- For those patients on insulin pumps – the parents can re-start the insulin pump at the usual basal rate once the child is feeling better and capillary BG levels are stable with blood ketones less than 0.6mmol/L. Parents should be allowed to manage the insulin pump according to their usual practice.
IV insulin can be stopped at the same time the insulin pump is restarted. IV fluids can be stopped once the child is tolerating oral fluids / food. If the child has been off their insulin pump for more than 4 hours they should have a new pump cannula inserted prior to re-commencing pump therapy. Parents will be able to do this and will have the required equipment.
Guideline for Children on Other Diabetes Medications (Hypoglycaemic Agents)
Metformin
The main concern regarding Metformin therapy during surgery relates to the rare complication of lactic acidosis. Metformin has a long biological half-life (17-31 hours) hence the need to stop it at least 24 hours prior to surgery13,14.
Sulphonylureas (e.g. Gliclazide, Glibenclamide)
Liraglutide
The main concern regarding Metformin therapy during surgery relates to the rare complication of lactic acidosis. Metformin has a long biological half-life (17-31 hours) hence the need to stop it at least 24 hours prior to surgery13,14.
- Discontinue at least 24 hours before procedure for elective surgery.
- In emergency surgery and when metformin is stopped < 24 hours, ensure optimal hydration to prevent risk of lactic acidosis and monitor lactate levels on regular blood gases
- Restart Metformin once the patient is able to tolerate medication and food orally.
Sulphonylureas (e.g. Gliclazide, Glibenclamide)
- Give as normal the day before theatre.
- Omit the morning of theatre, but if able to eat and drink later that day restart the Sulphonyurea then.
- If not eating & drinking omit until the following morning
Liraglutide
- Give as normal the day before theatre.
- Omit dose on the day of theatre.
- Restart the following morning with breakfast at usual time. However if still feeling nauseous on day 1 post op and not wanting to eat then it is safe & advisable to omit for a further 24 hours.
References
- Dronge, A. S., Perkal, M. F., Kancir, S. Concato, J., Aslan, M., Rosenthal, R. A. (2006) "Long-term glycemic control and postoperative infectious complications." Arch Surg 141, 375-380.
- Brady M, Kinn S, Ness V, et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev 2009;(4):CD005285.
- Perioperative fasting in adults and children – an RCN guideline for the multidisciplinaryteam. RCN publications November 2005. http://www.rcn.org.uk/publications/pdf/guidelines/perioperative_fasting_adults_children _full.pdf
- Buchleitner AM, Martínez-Alonso M, Hernández M, Solà I, Mauricio D. Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007315. DOI: 10.1002/14651858.CD007315.pub2
- British Society for Paediatric Endocrinology and Diabetes (BSPED) guidelines for the management of DKA. http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf accessed 2nd Sept 2013
- UK National Patient Safety Agency Alert NPSA/2007/22 accessed at: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59809 webcite
- Montanana PA, Modesto I Alapont V, Ocon AP, Lopez PO, Lopez Prats JL, ToledoParreno JD: The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: a randomized, controlled open study. Pediatric Critical Care Med 2008, 9(6):589-597.
- Choong K, Arora S, Cheng J, et al. Hypotonicversus isotonic maintenance fluids aftersurgery for children: a randomized controlledtrial. Pediatrics. 2011;128(5):857–866.
- Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL. Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. Journal of Paediatrics 2010; 156(2) 313-319.e2
- Brazel PW, McPhee IB: Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: The role of fluid management.Spine 1996; 21 (6) 724–727.
- Kannan L, Lodha R, Vivekanandhan S, Bagga A, Kabra SK, Kabra M: Intravenous fluid regimen and hyponatraemia among children: a randomized controlled trial. Pediatric Nephrology 2010, 25(11):2303-2309.
- Betts P, Brink S, SilinkM, Swift PGF, Wolfsdor J,Hanas R. Management of children and adolescents withdiabetes requiring surgery.Pediatric Diabetes 2009: 10 (Suppl. 12): 169–174.
- IDF/ISPAD 2011 Global Guideline for Diabetes in Childhood and Adolescence http://www.ispad.org/resource-type/idfispad-2011-global-guideline-diabetes-childhood-and-adolescence. Accessed 28th Sept 2013.
- Sirvinskas E, Kinduris S, Kapturauskas J, Samalavičius R. Perioperative use of metformin in cardiac surgery. Medicina (Kaunas). 2010;46(11):723-9.
- Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD002967. DOI: 10.1002/14651858.CD002967.pub4.
- Gastric Emptying Is More Rapid in Adolescents With Type 1 Diabetes and Impacts on Postprandial Glycemia. Shiree J. Perano Chris K. Rayner Stamatiki Kritas Michael Horowitz Kim DonaghueChristine Mpundu-Kaambwa Lynne Giles Jenny J. Couper. Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 6, 1 June 2015, Pages 2248–2253,https://doi.org/10.1210/jc.2015-1055
Appendix 1 - Insulin Infusion Calculator
Please complete table below based on patient’s weight; print off & insert in patient’s notes.
General points regarding IV sliding scales
- All patients must have daily U&Es whilst on IV insulin & IV fluids.
- Consider 10% Dextrose and 0.9% sodium chloride with 20 mmol added potassium chloride per 500ml bag if BG <4.0mmol/L despite switching off IV insulin
- If BG levels are high and are not starting to respond after one adjustment of insulin infusion rate:
- Check cannula patency and infusion equipment
- Make up fresh insulin infusion solution
NOTE: Insulin should be considered in the same manner as a controlled drug. The infusion system that is set up, the dosing schedule used and each change of infusion rate needs to be checked by 2 people.
Sliding scales of IV insulin are in widespread use but often give sub-optimal diabetic control because of variations in insulin requirements between individuals. The insulin sliding scale should be reviewed and re-written at least daily, adjusted according to the insulin requirements of the individual. Please contact a member of the local paediatric diabetes team for advice if glucose levels are difficult to control.
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Document Version:
2.0 Lead Authors: Nicola Trevelyan, Southampton Children's Hospital |
Approving Network:
Wessex Children and Young People's Diabetes Network Date of Approval: June 2023 Review Due: June 2026 |
PIER Contact |
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