Management of children with diabetes requiring surgery or fasting (ISPAD Guidelines)
Background
Children with diabetes requiring a surgical procedure
- Must be admitted to hospital for general anesthesia
- Need insulin, even if fasting, to avoid ketoacidosis
- Should receive a glucose infusion when fasting before an anesthetic to prevent hypoglycemia
Recommendations
- Surgery on children and adolescents with diabetes should only be performed in centers with dedicated pediatric facilities for the care of young people with diabetes.
- To ensure the highest levels of safety, careful liaison is required between surgical, anesthetic and children’s diabetes care teams before admission to hospital for elective surgery and as soon as possible after admission for emergency surgery
Elective surgery
- Operations are best scheduled early on the list, preferably in the morning
- Admit to hospital the afternoon prior to surgery for morning and major operations, or early morning for minor operations later in the day
- Earlier admission is important if glycemic control is poor
- Admission should be to a pediatric diabetes or pediatric surgical ward
Evening prior to surgery
- Frequent BG monitoring is important especially before meals and snacks and before bedtime (and check urinary ketones)
- Usual evening or bedtime insulin(s) and bedtime snack should be given
- Ketosis or severe hyperglycemia will necessitate correction, preferably by overnight IV infusion, and might cause a delay in surgery
Morning operations
- No solid food from midnight
- Clear fluids may be allowed up to 4 h preoperatively (check with anesthetist)
- Omit usual morning insulin dose
- Start IV fluid and insulin infusion at 6.00–7.00 am (Table 9)
- Hourly BG monitoring preoperatively; half-hourly during operation and until woken from anesthetic
- Hourly BG monitoring for 4 h postoperatively
- Aim to maintain BG between 5 and 12 (Table 9 infusion guide)
- Continue IV infusions until the child tolerates oral fluids and snacks (this may not be until 24–48 h following a major operation)
- Change to usual SC insulin regimen or short/rapid-acting insulin before the first meal is taken
- Stop insulin infusion 60 min after the SC insulin is given
- For minor operations it may be possible to discharge from hospital after the evening meal if the child is fully recovered
Table 9 Infusin Guide for surgical procedures
1. Maintenance fluid guide |
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| Body Weight | Fluid Requirements /24hr | |
| 3 - 9 kg | 100ml/kg | |
| For each kg between | 10 - 20 kg | Add 50ml/kg |
| For each kg over | 20kg | Add 20ml/kg (Max 2000ml female, 2500ml male) |
2. Insulin infusion |
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Afternoon operations
- Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
- Allow a light breakfast; clear fluids may be allowed up to 4 h preoperatively
- Start IV fluids and insulin infusion at midday at the latest (Table 9 above)
- Then as for morning operations (above).
- [Alternatively IV insulin infusion may be started at breakfast time]
Emergency surgery
- DKA may present as an ‘acute abdomen’
- Acute illness may precipitate DKA (with severe abdominal pain)
- Nil by mouth
- Secure IV access
- Check weight, electrolytes, glucose, blood gases and urinary ketones preoperatively
- If ketoacidosis is present, follow protocol for DKA and delay surgery until circulating volume and electrolyte deficits are corrected
- If there is no ketoacidosis, start IV fluid and insulin infusions as for elective surgery
Minor procedures requiring fasting
For short procedures (with or without sedation or anesthesia) and when rapid recovery is anticipated, a simplified protocol may be organized by experienced diabetes/anesthetic personnel and may include either
- early morning procedure (e.g. 8.00–9.00 am) with delayed insulin
and food until immediately after completion
or - reduce (e.g. give of) usual insulin dose or give repeated small doses of short/rapid-acting insulin
Glucose 5–10% infusion and frequent BG monitoring are recommended in all these situations.
ISPAD Consensus Guidelines
