Diabetes and Surgery Title of Guideline Contact Name and Job Title (author) Guideline for the management of children and young people with diabetes aged 18 or under requiring surgery Dr Priyha Santhanam, Paediatric Registrar, Dr Tabitha Randell, Consultant in Paediatric Endocrinology and Diabetes Directorate & Speciality Directorate: Family Health Children Speciality: Endocrine Date of submission October 2017 Date when guideline reviewed October 2022 Guideline Number 1930 version 3 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Children and young people with diabetes aged 18 and under admitted for surgical procedures (or procedures under GA) Abstract This guideline describes diabetes management in children and young people undergoing surgery (whether elective or emergency) or general anaesthetic for other reasons Key Words Paediatrics. Children. Diabetes. Surgery Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? 1a meta analysis of randomised controlled Put a cross (X) in the highest level of evidence. trials 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the X clinical experience of the guideline developer Consultation Process Staff at Nottingham Children s Hospital via the Guidelines E-mail process. Target audience Staff at the Nottingham Children s Hospital This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Dr Tabitha Randell Page 1 of 7 November 2014
Document Control Document Amendment Record Version Issue Date Author V1 November 2011 Dr Tabitha Randell V2 November 2014 Dr Priyha Santhanam Dr Tabitha Randell V3 October 2017 Dr Tabitha Randell Summary of changes for new version: Oct 2017 - Lucozade no longer used to treat hypoglycaemia now use Glucojuice. Wording updated to reflect this Statement of Compliance with Child Health Guidelines SOP This guideline has had only minor changes made and therefore this version has not been circulated to all for review. A previous version had been approved by circulation to senior team members. Maria Moran Clinical Guideline Lead October 2017 Dr Tabitha Randell Page 2 of 7 November 2014
This guideline is aimed at all staff managing children and young people with diabetes who are undergoing surgery, general anaesthetic or sedation requiring a period of fasting. Hospital admission, preparation for anaesthesia and surgery inevitably disrupt the structured management that is the basis of satisfactory diabetes control. This disruption can be minimised by careful planning and by following established guidelines. Aims of diabetes management during surgery: Avoid hypoglycaemia Avoid ketoacidosis Normoglycaemia is not essential in the short term and it is acceptable to maintain blood glucose levels in the range 5-11mmol/l. Minimise duration of hospital stay, the majority of children are better controlled by their parents in their own homes. Section A - PLANNED MAJOR SURGERY Pre-admission checklist 1. Please select morning (preferably first on the list) theatre session. 2. Inform Nottingham Children s Hospital Diabetes Team of planned date for admission (group email PAEDIATRIC DIABETES TEAM). For the majority of children with diabetes who need major surgical procedures, it is appropriate to admit them the evening before. Children having minor procedures or procedures likely to take less than 1 hr can be admitted on the day of procedure (see section B) 3. Check that a current copy of the Surgery and Childhood Diabetes protocol is available on the ward. Diabetes Teams Drs Denvir, Drew and Randell s Secretary 62336 Dr Randell/Denvir s registrar (bleep 7841411) Diabetes Specialist Nurse (8.00am 6.00pm, Mon-Fri. Page via switch. 24 hour answerphone available, tel 0115 924 9924 x 61731/62208 E-mail Paediatric Diabetes Team via Outlook The admission will be placed in the team diary so that medical staff are alerted to visit the child. The diabetes specialist nurses will advise the families on insulin management in preparation for admission. The paediatric dietitian will be alerted. Admission Checklist 1. Alert Children s Diabetes Team of child s arrival (see above) or Paediatric Registrar on call if admitted at weekend 2. Alert Anaesthetist 3. Check that the child has her/his own diabetes kit eg Insulin injection pen, capillary blood sampler and glucose monitor 4. Check child s current insulin regimen from family held record 5. Check availability of IV infusion equipment and syringe infusion pump (see below) Dr Tabitha Randell Page 3 of 7 November 2014
1.Insulin Regimen on Day Before Planned Surgery (a) The usual regimen will be continued up to bedtime of the evening before surgery. (b) Capillary blood sugar measurements need to be performed before meals and at bedtime. (c) Check admission urine or blood for ketones. (d) Contact the Diabetes team if blood sugars are elevated (above 15mmol/l) or more than slight ketonuria/blood ketones >1.5 is present. 2.Insulin Regimen on Day of Surgery for procedures expected to take >1 hour (a) Guidance from anaesthetist regarding oral intake. NB if patient is on insulin pump therapy, continue with insulin pump at normal background rate and do not start IV insulin without discussing with diabetes team first. (See guideline: Pre-operative fasting in children). MORNING LIST: Follow current pre-operative fasting guidelines for timing of last food and fluid intake. If on basal bolus regimen, give basal insulin at the same time as is normally given. Do not give morning short acting or mixed insulin and set up IV fluids and insulin infusion as in Table-1. AFTERNOON LIST: Follow current pre-operative fasting guidelines for timing of last food and fluid intake. Pre-breakfast subcutaneous insulin will depend on insulin regimen If on twice daily mixed insulin: give approximately the short acting component of the morning insulin dose but no medium duration insulin. Example: usual morning insulin is 10 units of Humulin M3 or Novomix 30 Therefore usual short-acting component is 3/10 x 10 = 3 unit of Novorapid via pen device If on a basal bolus regimen: give normal doses of short acting insulin (Usually Novorapid) and the full dose of basal insulin.omit lunchtime dose of Novorapid. Continue basal insulin (Lantus or Levemir) throughout hospital stay, even whilst on IV insulin infusion. IF IN DOUBT, DISCUSS WITH PAEDIATRIC DIABETES TEAM OR PAEDIATRIC ENDOCRINOLOGIST ON-CALL. (b)commence intravenous infusion pre-operatively, by 07.00 for morning list (consider option of inserting IV cannula on the previous evening) and by 12.00 for afternoon list. (c)fluids: 0.9% sodium chloride /5% glucose plus potassium, 10mmol per 500 ml. Calculate rate using weight and current IV fluid guidelines. (d)insulin: Human Actrapid via syringe infusion pump connected to infusion line. Mix 50 units of Actrapid, drawn up using an insulin syringe, with 49.5ml 0.9% sodium chloride to give 1 unit/ml solution. Flush tubing with solution and commence Actrapid infusion as detailed below (Table 1) (e)start Hourly BM monitoring once Nil by mouth and ½ hrly BM during surgery. Dr Tabitha Randell Page 4 of 7 November 2014
Table 1. Insulin infusion rate guided by serial blood glucose measurement Standard insulin infusion rate will depend on the blood glucose. Monitor blood glucose at hourly intervals. Blood glucose above 15 mmol / l 0.1units / kg / hr Blood glucose 12-14.9 mmol/l Blood glucose 8-11.9 mmol/l Blood glucose 5-7.9 mmol/l Blood glucose < 5 mmol 0.075 units/kg/hr 0.05units/kg/hr 0.025 units/kg/hr Do not stop insulin infusion. If NBM Give 2ml/kg 10% glucose and recheck capillary glucose or treat with Glucojuice or glucose tablets as per hypoglycaemia guidelines if allowed oral intake. Continue sodium chloride/glucose infusion and add additional glucose as needed. To increase glucose concentration in 0.9% sodium chloride/5% glucose 500ml bag to 10% glucose, add 50 ml 50% glucose to the bag and mix well. Inform diabetes team. If blood glucose levels are not returned to target range after one adjustment of insulin infusion rate: a) Check infusion equipment b) Make up fresh insulin infusion solution c) Discuss with Diabetes Team 3. Insulin and fluid Regimen After Surgery (a) If normally on basal bolus regimen, continue with basal insulin (Lantus or Levemir) at normal doses throughout the hospital stay (b) If on insulin pump therapy, discuss with Paediatric Diabetes Team or Paediatric Endocrinologist on call (c) Continue IV fluids and insulin infusion with hourly blood glucose monitoring until regular oral drinks and snacks are tolerated, and the child has not vomited for 2 hours following food or drink. Discontinue IV insulin 10 mins after giving Novorapid, Novomix 30 or Humalog, discontinue after 1 hour after giving Humulin M3. Discuss with paediatric endocrinologist oncall if any queries. (d) Prolonged dependence on intravenous infusion such as after GIT surgery will require adjustments to the fluid replacement. Serum urea and electrolytes should be checked 24 hourly whilst on IV fluids. (e) Minor surgery and return to full diet. Plan normal evening insulin with evening main meal with additional monitoring of blood sugars. Return to usual regimen on the next day. (f) Major surgery or gradual return to full diet. Plan s/c NovoRapid insulin before meals after discussion with the Paediatric Diabetes Team. Dr Tabitha Randell Page 5 of 7 November 2014
Section B- PLANNED MINOR PROCEDURE A simplified approach may be used if a child with satisfactory diabetes control is to have a minor procedure e.g. simple dental extraction under sedation or general anaesthesia, upper GI endoscopy. This needs to be agreed and planned before admission, and is dependent on patient being able to tolerate oral intake shortly after the procedure. Insulin Regimen on Day of Surgery Plan morning procedure wherever possible (if only afternoon list available, see below) and follow preparatory steps listed in section A.2.(a) above. If first on this list and the child is expected to make a rapid recovery (eg upper GI endoscopy), then withhold morning dose of insulin and give normal dose of morning insulin with food once back on ward after completion of procedure. If basal insulin is given in the morning, continue to give it as usual. If afternoon procedure and child/young person is expected to make a rapid recovery allowing normal food consumption immediately afterwards, they will require some insulin in the morning to cover breakfast. If on basal bolus regime, give full dose of rapid acting insulin according to carbohydrate content. PLEASE LIAISE WITH THE DIABETES TEAM SEVERAL DAYS BEFOREHAND SO THE FAMILY CAN BE ADVISED ABOUT INSULIN ADJUSTMENT. Delayed reintroduction of oral intake may require intravenous fluids and insulin. If on insulin pump, run the pump at the usual basal settings and blood sugar should be checked hourly once nil by mouth.aim to keep the blood sugar between 5-11mmol/l. If at any time the blood glucose <5 mmol/l,give IV bolus of 10% glucose 2ml/kg, recheck blood glucose 15 min later. If at any time blood glucose is >12 mmol/l, start IV insulin and IV fluids as per table 1 If for some reason procedure is delayed for a further 2 hours or child has had repeated low BGs, start on maintenance IV fluids. Section C - EMERGENCY SURGERY Acute illness commonly precipitates diabetic ketoacidosis Ketoacidosis may manifest as an acute abdomen Established diabetes must not be overlooked in a child-victim of severe trauma. The stress of trauma or surgery may unmask impending diabetes. Measurement of blood glucose and ketones are essential in children with diabetes and a wise precaution in all emergencies. Checklist for Emergency Surgery 1) Alert the Paediatric Diabetes Team or Paediatric Endocrinologist on-call if out of hours. 2) Commence regular blood glucose monitoring, 1 hourly until stable and then 2 hourly. 3) Perform baseline investigations including: FBC Electrolytes, urea and osmolality, lab glucose Blood / Urine ketones Venous blood gas analysis 4) Discuss intravenous strategy with Surgeons, Anaesthetists and Paediatric Diabetes Team. Consider priorities: Correction of circulating volume Correction of electrolyte deficit Correction of ketoacidosis Dr Tabitha Randell Page 6 of 7 November 2014
5) Diabetic ketoacidosis: plan to correct before surgery if possible. See protocol DIABETIC KETOACIDOSIS 6) Diabetes without ketoacidosis: plan to use IV fluids and insulin infusion as detailed under Section A - planned surgery. REFERENCES ACDC: Guidelines on the care of children under 18yrs of age with diabetes mellitus undergoing surgery. - J Chizo Agwu, M Ng, JA Edge, J H Drew, C Moudiotis, NP Wright, M. Kershaw, N Trevelyan, RGoonetilleke. Version 1, Oct 2013. ISPAD 2009 Clinical Practice Consensus Guideline: Management of children and adolescents with diabetes requiring surgery. Paediatric Diabetes 2009: 10 (suppl 12); 169-174 Dr Tabitha Randell Page 7 of 7 November 2014