CHILDREN S SERVICES Guideline for Children with Type 1 or Type 2 Diabetes on Insulin Requiring Surgery or Sedation Background Surgery places stress on the body and will alter glucose control and insulin requirements. Optimising glucose control pre-, peri- and postoperatively will improve outcomes and reduce complications. Paediatric Diabetes Team Name Grade Bleep Extension Dr Bahl Consultant 8137 2722 (secretary) Dr Baksh Consultant 8418 2546 (secretary) Anne Lyddall Diabetes Nurse Specialist 8455 3314 Paediatric SpR 5315 (on call) Key Points Liaise with Paediatric Diabetes Team Liaise with Anaesthetist All patients require insulin even if fasting to prevent DKA Try to have patients first on the list, preferably a morning list Continue long acting insulin (e.g. Lantus, Levemir ) Surgery to be delayed if DKA present until electrolyte and fluid imbalance stabilised Refer to addendum for insulin and fluid prescriptions Elective Surgery Inform the paediatric diabetes team of admission date Consider early admission if poor control Starvation Times As standard for other patients No food for 6 hours prior to operation Clear fluids until 2 hours before operation No breast milk for 4 hours before operation Guideline for Children with Diabetes on Insulin Requiring Surgery Page 1 of 5
Minor Surgery and Sedation General anaesthetic lasting less than 60 minutes with low risk of postoperative nausea, vomiting or inability to and child likely to be discharged later the same day Admit as day case Check glucose and venous blood gas when inserting cannula Check urine for ketones and glucose If evidence of DKA then manage as per DKA protocol and delay surgery until electrolyte and fluid disturbances resolved Monitor glucose levels as per addendum AM/PM List AM PM Pre or Two or Three Times Daily Regimen Basal Bolus Regimen (4 injections/day) Omit morning insulin dose Omit morning insulin dose Give ¼ of normal morning dose as Give pre lunch insulin when NovoRapid/Humalog when ready to ready to ready to Normal evening insulin to be given ready to Give ¼ of normal morning dose as NovoRapid/Humalog with breakfast at 07:30 Give ¼ of morning insulin dose as NovoRapid/Humalog when child ready to Give normal evening insulin Give normal morning insulin with breakfast at 07:30 Omit lunch time dose Give normal pre evening insulin when awake and ready to Continuous Subcutaneous Insulin Infusion (Insulin Pump) Liaise with Paediatric Diabetes Team before admission for the best approach to these patients. They can be maintained on their pumps but if there is any doubt or concern, they should be managed as per the major surgery guideline and placed on IV fluids and insulin. Allow home after evening meal if child is well, glucose 5 11 mmol/l and urine free from ketones If unwell postoperatively and unable to tolerate oral intake then tr as major surgery with IV fluids and insulin IV insulin and fluids can be started at any stage if there are concerns about glucose levels. o If IV insulin has been started, stop this 30 minutes after giving normal insulin dose Guideline for Children with Diabetes on Insulin Requiring Surgery Page 2 of 5
Major Surgery General anaesthetic lasting more than 60 minutes with high risk of postoperative nausea, vomiting or inability to and requires at least an overnight stay. Monitor glucose levels as per addendum AM/PM List AM PM Pre or ready ready to to Two or Three Times Daily Regimen Basal Bolus Regimen (4 injections/day) Continuous Subcutaneous Insulin Infusion (Insulin Pump) Give normal insulin the day before surgery Admit the afternoon before surgery Check FBC, U&E, glucose and venous blood gas at cannula insertion Check urine for ketones If evidence of DKA manage as per DKA protocol and delay surgery until electrolyte and fluid disturbances have resolved Omit morning insulin dose/bolus At 08:00 check U&E and glucose Start IV fluids and insulin Continue IV fluids and insulin until breakfast or evening meal Give normal dose of insulin with breakfast or evening meal Give normal dose of NovoRapid/Humalog with meal Restart infusion with meal and give meal bolus. Admit early morning the day of surgery Check FBC, U&E, glucose and venous blood gas at cannula insertion soon after arrival Check urine for ketones If evidence of DKA manage as per DKA protocol and delay surgery until electrolyte and fluid disturbances have resolved Give ¼ of normal morning insulin as NovoRapid/Humalog with breakfast at 07:30 Start IV fluids and insulin at 12:00 Give normal dose of insulin with breakfast or evening meal Give normal NovoRapid/Humalog with breakfast at 07:30 Miss lunchtime dose Start IV fluids and insulin at 12:00 Give normal dose of insulin with meal Continue on basal rate and give meal bolus with breakfast at 07:30 Change to IV fluids and insulin at 12:00 It is possible to maintain these children on their pumps with IV fluids. Ensure that the infusion site is well secured Restart infusion with meal and give meal bolus Guideline for Children with Diabetes on Insulin Requiring Surgery Page 3 of 5
Emergency Surgery Remember: o o DKA can present as an acute abdomen Acute illness can precipitate DKA Weigh child Secure IV access Check FBC, glucose, U&E, venous blood gas Check urine for ketones If evidence of DKA then tr this as per the DKA guidelines until electrolyte and fluid deficits are corrected before surgery If no evidence of DKA commence on IV fluids and insulin as per elective surgery Metformin The incidence of type 2 diabetes is increasing in the paediatric population. They will mostly be tred with metformin. We also have some type 1 diabetics who are also on metofrmin. For these patients: Discontinue metformin 24 hours before procedure for elective surgery For emergency surgery it is essential to maintain hydration with IV fluids before, during and after surgery If glucose > 10 mmol/l start IV insulin References: 1. ISPAD Clinical Practice Consensus Guidelines 2006-2007, Management of children with diabetes requiring surgery, Pediatric Diabetes 2007: 8; 242-247 2. Guidelines for the Management of Paediatric Surgical Patients with Insulin Dependent Diabetes Mellitus, Northampton General Hospital NHS Trust 3. UCLH Guidelines Guideline for Children with Diabetes on Insulin Requiring Surgery Page 4 of 5
Addendum Fluids to Use 5% Dextrose/0.45% NaCl with 10 mmol KCl per 500 ml should be adequate as maintenance fluids o Calculate maintenance fluids in the usual way (calculates total daily requirement) 100 ml/kg for first 10 kg 50 mlkg for next 10 kg 20 ml/kg for every subsequent kg If there are concerns about hypoglycaemia 10% dextrose can be used If the glucose level is > 15 mmol/l then use 0.9% NaCl and increase the insulin rate o Add 5% dextrose when glucose falls below 14 mmol/l Monitoring Capillary glucose levels to be monitored hourly preoperatively while fasted Capillary glucose levels to be monitored every 30 minutes during the procedure Capillary glucose levels to be monitored hourly postoperatively until ing and back onto normal insulin o If glucose levels have been stable can change to 2 hourly monitoring after 4 hours Aim for glucose level between 5 11 mmol/l Insulin Mix 50 units of Novorapid in 50 ml of 0.9% NaCl Start infusion at 0.05 units/kg/hour (0.05 ml/kg/hour) o If glucose > 12 mmol/l increase insulin to 0.075 units/kg/hour (0.075 ml/kg/hour) o If glucose < 5 mmol/l decrease insulin to 0.025 units/kg/hour (0.025 ml/kg/hour) o If glucose < 4 mmol/l contact doctor. Reduce insulin to 0.01 units/kg/hour (0.01 ml/kg/hour). May need bolus of 10% dextrose (5 ml/kg) Dr Tim Marr Paediatric SpR Presented to Paediatric Clinical Guidelines Forum on Monday 10 th November 2008 Ratified by Dr D Haddad on behalf of Children s Services Clinical Governance Committee on: Date for review: November 2011 Guideline for Children with Diabetes on Insulin Requiring Surgery Page 5 of 5