Management of children and young people with diabetes during surgery

This protocol is intended for those children with diabetes mellitus undergoing surgery. It is important to avoid the immediate complications of diabetes peri-operatively, particularly hypoglycaemia and ketoacidosis.

Background

General points:

• A child with diabetes on a pre-op fast, still needs insulin, even though they are not eating.
• A child with diabetes cannot fast without the risk of hypoglycaemia.
• Surgery is a stress and will alter insulin action.
• Children with diabetes should be scheduled first on the operating list (am or pm) to avoid unnecessarily long starvation periods.

Need to consider:

• whether elective or emergency surgery

• minor or major procedure

• surgery that will delay normal oral intake post-op, eg gastrointestinal surgery

• the usual insulin regimen of the child

Admission checklist

• inform Paediatric Diabetes team of child’s arrival

• alert anaesthetist and ward staff
• check that child has own diabetic kit eg injection materials, blood glucose strips
• check child’s current insulin regimen
• ensure that IV infusion equipment and syringe pumps are available
• clear management plan to be written in notes for the types of procedure using the outlines below, but with individualised doses clearly stated and entered on the drug chart
• state clearly who is responsible for the adjustments to the insulin regimen and how to contact

Types of insulin in use

Standard starvation times

• Food - six hours pre-op.

• Free clear fluids - up until two hours pre-op irrespective of timing of the surgery. This should avoid requirement for pre-op IV fluids at least for minor surgery.

Management for minor procedures

Definition: general anaesthetic lasting less than 30 minutes with low risk of nausea, vomiting or inability to eat, eg dental extraction, short ENT procedures, longline insertion.

(i) Children on multiple dose insulin regimen (MDI)

• admit as day case
• consult checklist

Preparation

• Give half the usual glargine/Insulatard® dose night before OR give normal evening Levemir® dose and omit morning Levemir® dose.
• Check urine for ketones and glucose on admission and treat ketoacidosis if present.

Morning operations 

• Standard starvation times as above.
• Omit usual morning bolus insulin.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10 mmol/L pre-op.

• If blood glucose stable, measure capillary blood glucose every half hour during procedure.

• Hourly capillary blood glucose measurements for four hours post-operatively.
• On return and if child well, give usual morning insulin and breakfast.
• Return to normal regimen, adjusting insulin doses if necessary. Aim to maintain blood glucose between 5-11 mmol/L.
• If unable to tolerate oral intake, set up IV infusions of insulin and five per cent dextrose 0.45 per cent saline solution, until child is taking and tolerating adequate oral fluids and snacks.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal provided blood glucose is between 5-11 mmol/L and urine is free of ketones.
• The child can return to normal insulin regimen with normal dose of glargine or Levemir® that evening.

Afternoon operations

• Usual bolus insulin with breakfast before 7.30am and omit usual lunchtime bolus insulin.
• Clear fluids may be allowed up to two hours pre-operatively and then nil by mouth.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10 mmol/L pre-op.

• If blood glucose stable measure capillary blood glucose every half hour during procedure.

• Hourly capillary blood glucose measurements for four hours post-operatively.
• On return and if child is well, give usual insulin bolus with next meal (either a late lunch or early evening meal).
• Return to normal regimen, adjusting insulin doses if necessary. Aim to maintain blood glucose between 5-11 mmol/L.
• If unable to tolerate oral intake, set up IV infusions of insulin and five per cent dextrose 0.45 per cent saline solution, until child is taking and tolerating adequate oral fluids and snacks.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal, provided blood glucose is between 5-11 mmol/L and urine is free of ketones.

• The child can return to normal insulin regimen with normal dose of glargine or Levemir® that evening.

(ii) Children on continuous subcutaneous insulin infusion (CSII)

• admit as day case
• consult checklist

Preparation

• Check urine for ketones and glucose on admission and treat ketoacidosis if present.
• Discourage family from doing a routine change of cannula site immediately prior to theatre.

Morning operations 

• Standard starvation times as above.
• Run on normal basal rates for the time of day.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10 mmol/L pre-op.

• If blood glucose stable, measure capillary blood glucose every half hour during procedure.

• Hourly capillary blood glucose measurements for four hours post-operatively. Continue to run on normal basal insulin infusion rate.
• On return and if child is well, give usual bolus insulin with breakfast.
• Aim to maintain blood glucose between 5-11mmol/L.
• Return to normal CSII regimen, using correction insulin bolus where necessary.
• If unable to tolerate oral intake, continue basal insulin infusion and set up IV infusion of five per cent dextrose 0.45 per cent saline solution, until the child is taking and tolerating adequate oral fluids. Alter basal rate accordingly.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal provided blood glucose is between 5-11 mmol/L and urine is free of ketones. Should be running on normal CSII regimen.

Afternoon operations 

• Normal CSII programme with breakfast at 7.30am.
• Clear fluids may be allowed up to two hours pre-operatively and then nil by mouth. Continue on basal insulin infusion rate.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10 mmol/L pre-op.

• If blood glucose stable, measure capillary blood glucose every half hour during procedure.

• Hourly capillary blood glucose measurements for four hours post-operatively. Continue to run on normal basal insulin infusion rate.
• On return and if child is well, give usual bolus insulin with late lunch.
• Aim to maintain blood glucose between 5-11mmol/L.
• Return to normal CSII regimen, using correction insulin bolus where necessary.
• If unable to tolerate oral intake, continue basal insulin infusion and set up IV infusion of five per cent dextrose 0.45 per cent saline solution until the child is taking and tolerating adequate oral fluids. Alter basal rate accordingly.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal provided blood glucose is between 5-11 mmol/L and urine is free of ketones. Should be running on normal CSII regimen.

(iii) Twice daily insulin mixtures

Morning operations

• Standard starvation times as above.
• Omit usual morning insulin.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10 mmol/L pre-op.

• Measure capillary blood glucose every half hour.

• Hourly capillary blood glucose measurements for four hours post-operatively.
• On return and if child is well, give NovoRapid® (one third of the total morning dose) and breakfast. For example, if usually on 12 units of Mixtard®, give four units of Novorapid®.
• Aim to maintain blood glucose between 5-11mmols/L.
• Return to normal insulin regimen in the evening.
• If unable to tolerate oral intake, set up IV infusions of insulin and five per cent dextrose 0.45 per cent saline solution until the child is taking and tolerating adequate oral fluids and snacks.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal provided blood glucose is between 5-11mmol/L and urine is free of ketones.  
• The child can return to normal insulin regimen the next day.

Afternoon operations

• Give short acting insulin (one third of total morning insulin dose) only and light breakfast before 7.30am.
• Clear fluids up to two hours pre-operatively and then nil by mouth.
• Measure capillary blood glucose hourly until operation and notify anaesthetist if <5 or >10mmol/l pre-op. 

• Measure capillary blood glucose every half hour.

• Hourly capillary blood glucose measurements for four hours post-operatively.
• On return and child is well give NovoRapid® (one third of total morning dose) and lunch.
• Aim to maintain blood glucose between 5-11mmols/L.
• Return to normal insulin regimen prior to the evening meal.
• If unable to tolerate oral intake, set up IV infusions of insulin and five per cent dextrose 0.45 per cent saline solution, until the child is taking and tolerating adequate oral fluids and snacks.
• After minor surgery and if the child has recovered, discharge may be possible after the evening meal provided blood glucose is between 5-11mmol/L and urine is free of ketones.  
• The child can return to normal insulin regimen the next day.

Management for major elective procedures

Pre-op preparation

• Liaise and notify the Paediatric Diabetes team to ensure the best blood glucose control preoperatively.
• The child should be first on the list, preferably in the morning.
• Weigh the child.
• Inform the anaesthetist that the child has diabetes.
• Admit the afternoon prior to surgery for morning operations, or early morning after 8.00am for operations later in the day.

Evening prior to surgery

• Check urine for ketones and glucose and repeat morning of surgery. Treat ketoacidosis if present.
• Measure full blood count, U&E, blood glucose and bicarbonate.
• Do pre-mealtime and pre-bedtime capillary blood glucose measurements.
• Give usual evening time insulin, if on twice daily regimen, and adequate carbohydrate for supper and bedtime snack.
• Give usual evening Levemir® dose and omit morning Levemir® dose.
• Give half the usual glargine dose if on MDI regimen.

Morning operations 

• Standard starvation times as above.
• Omit morning insulin.
• Check electrolytes and glucose pre-op and inform anaesthetist of results.
• Start IV fluid. Give five per cent dextrose and 0.45 per cent saline using the maintenance regimen.
• Commence at the same time insulin infusion.
• Measure capillary blood glucose hourly until operation.

Afternoon operations 

• For patients on MDI, give usual bolus with breakfast at 7.30am.  
• For CSII, give normal bolus with breakfast and normal basal until theatre.  
• For twice daily regimens, give 20 per cent of the usual morning insulin dose as soluble insulin eg NovoRapid®. Do not give any long acting insulin, so no insulin mixture.
• Fast after breakfast and admit to hospital.
• Clear fluids up to two hours pre-operatively.
• Start intravenous fluids and insulin by 11am at the latest. 
• Then follow protocol as for morning operations.
• Afternoon operation will require a continuation of the IV infusion regimen until the next morning, when a decision can be made about breakfast and normal insulin regimen if clinically appropriate.

Morning and afternoon operations

• Measure capillary blood glucose every half hour.
• Intraoperative replacement fluid must be as Hartmann’s/blood etc as indicated.
• Adjust insulin infusion according to blood glucose concentrations.
• Suggested insulin infusion rates (blood glucose, insulin infusion rate)
  • >12 mmol/l - 0.05 units/kg/hr
  • 9 to 12mmol/l - 0.04 units/kg/hr
  • 7 to 8.9mmol/l - 0.03 units/kg/hr
  • 4 to 6.9mmol/l - 0.02 units/kg/hr  
  • <4mmol/l - 0.01units/kg/hr with 2ml/kg of 10 per cent glucose
• These doses may need to be revised in severely ill patients and children who were on high doses of insulin or receiving steroids.
• Do not stop the insulin infusion if the blood glucose is lower than four, as this will cause hyperglycaemia. Reduce the rate of the insulin infusion further. Continue with glucose infusion and increase the rate if required.

• Hourly capillary blood glucose measurements for four hours post-operatively.
• Six hourly U&E measurements until stable, daily U&E measurements and accurate fluid balance thereafter.
• If no change in insulin infusion rate is required, do two hourly capillary blood glucose measurements until the usual insulin is restarted.
• Aim to maintain blood glucose between 5-11mmols/L.
• Continue IV infusions of insulin and five per cent dextrose 0.45 per cent saline, until the child is taking adequate oral fluids and snacks.
• Once the child is drinking and eating, the return to standard insulin regimen can be contemplated.
• If on MDI, then stop infusions and give the normal ultra short-acting insulin dose subcutaneously, immediately. Then follow with normal regimen.  
• If on CSII, start on normal basal rate and switch off IV insulin infusion after 15 mins.
• For those patients on a twice daily insulin regimen, the normal insulin dose can be given with breakfast or the evening meal. 

Emergency surgery

• Remember that diabetic ketoacidosis may present as an acute abdomen.
• Acute illness may precipitate diabetic ketoacidosis.
• Do not overlook established diabetes
• Stress, trauma or surgery may unmask impending diabetes.
• It is always wise to check blood glucose and ketonuria in all emergencies.
• Inform diabetes team.
• Keep nil by mouth.
• Check weight, electrolytes, glucose, venous pH/bicarbonate and urine for ketones pre-operatively.
• If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery until circulating volume and electrolyte deficit are corrected. Operate only when rehydrated and blood pressure stable.
• If there is no ketoacidosis, start insulin and maintenance fluid regimen as for elective surgery.

Contact numbers

• SpR Endocrinology GOSH: 020 7405 9200 bleep 0281
• SpR Paediatric Endocrinology UCLH: 0845 1555 000 bleep 2064

Endocrine consultants

• All via GOSH switchboard.
• Diabetes nurse specialists based at UCLH: 020 7380 9364
• Endocrine nurse specialists based at GOSH: 020 7813 8214

Appendix 1 - Maintenance fluid guide

Appendix 2 - Insulin infusion regimen for patients with diabetes undergoing surgery

1. Draw up 50mls 0.9 per cent saline into 50ml syringe.
2. Draw up actrapid 50 units into insulin syringe.
3. Add actrapid insulin to the 50mls of saline in the syringe and attach to syringe pump (1ml solution = 1 unit soluble insulin).
4. Label syringe clearly.
5. Give the insulin along with the IV dextrose infusion at a rate of 0.05 unit/kg/hour (0.05ml/kg/hour) via the same cannula with non-return valve.
6. Monitor blood glucose hourly and adjust insulin infusion rate to maintain blood glucose between 5-11 mmol/L.

• check cannulae patency
• check infusion equipment
• make up fresh insulin infusion solution
• discuss with Diabetic team

References

Document control information

Peter Hindmarsh, Professor of Paediatric Endocrinology, Endocrinology

Additional authors
Rebecca Thompson, Nurse Consultant, UCLH, Diabetes

Document owner
Catherine Peters Consultant, Endocrinology

Approved by
Clinical Practice Committee

First introduced: 5 October 2011
Date approved: 19 October 2011
Review schedule: Two years
Next review: 21 October 2013
Document version: 2.0
Replaces version: 1.0