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Great Ormond Street Hospital for Children NHS Trust UCL Institute of Child Health
 

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Diabetic children undergoing surgery NEEDS REVIEW

This clinical guideline was due to for review on July 31, 2009 and therefore may not reflect current practice at Great Ormond Street Hospital. This guideline is for reference only. For advice on current practice please contact Peter Hindmarsh.

Background

This guideline has been prepared by the North Central London (NCL) Paediatric Diabetes Network.

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.

Need to consider:

  1. Whether elective or emergency surgery
  2. Minor or major procedure
  3. Surgery that will delay normal oral intake post-op, eg. Gastrointestinal surgery
  4. The usual insulin regimen of the child

    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

       

      Types of insulin in use:

       Insulin type  

      Onset (hr) 

      Peak (hr)

      Duration (hr) 

       Ultra short

      Novorapid, Humalog

       < 0.5

      1

      3-4

       Short

      Humulin S, Velosulin

       0.5 - 1

      2 - 6

      3 - 8

       Long acting

      Insulatard/Humulin I

       3 - 4

      4 - 12 

      10 - 20

       

      		 Glargine/Demetir

       1

      none 

      24

      Standard starvation times:

      Food- 6 hours preop Free clear fluids- up until 2 hours pre-op irrespective of timing of the surgery. This should avoid requirement for preop IV fluids at least for minor surgery

Management

Management is divided into three sections- minor procedures, major elective procedures and emergency surgery.

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)

These children will usually have short or rapid acting insulin three times daily with main meals. Once daily (usually at bedtime) long acting insulin such as glargine.

  • Admit as day case.
  • Consult checklist

Preparation

  • Give half the usual glargine/insulatard dose night before.
  • Check urine for ketones and glucose on admission and treat ketoacidosis if present.

 Morning operations  Afternoon operations

Prior to Surgery:

  • 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

Prior to Surgery:

  • Usual bolus insulin with breakfast before 07.30h and omit usual lunchtime bolus insulin
  • Clear fluids may be allowed up to 2 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

During surgery:

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

During surgery:

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

After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively
  • On return and child is well give usual morning insulin and breakfast
  • Aim to maintain blood glucose between 5 and 11 mmol/L
  • Return to normal regimen, adjusting insulin doses if necessary
  • If unable to tolerate oral intake set up IV infusions of insulin and 5% dextrose 0.45% 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 5-11 mmol/L and urine is free of ketones
  • The child can return to normal insulin regimen that evening with normal dose of glargine

After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively
  • On return and child is well give usual insulin bolus with next meal (either a late lunch or early evening meal)
  • Aim to maintain blood glucose between 5 and 11 mmols/L
  • Return to normal regimen, adjusting insulin doses if necessary
  • If unable to tolerate oral intake set up IV infusions of insulin and 5% dextrose 0.45% 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 5-11 mmol/L and urine is free of ketones
  • The child can return to normal insulin regimen with glargine that evening

(ii) Children On Continuous Subcutaneous Insulin Infusion (CSII)

 As these systems deliver basal insulin separate from any bolus insulin all that is required is to run the pump on the normal basal setting for the duration of the procedure.

Blood glucose should be checked on hourly basis and carer/patient asked to alter infusion rate accordingly. Basal rate can be suspended temporarily to correct any episodes of mild hypoglycaemia.

  • 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  Afternoon operations

 Prior to Surgery:

  • 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 >10mmol/l pre-op.

 Prior to Surgery:

  • Normal CSII programme with breakfast at 07.30h.
  • Clear fluids may be allowed up to 2 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 >10mmol/l pre-op.

 During surgery:

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

  During surgery:

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

 After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively. Continue to run on normal basal insulin infusion rate.
  • On return and 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 boluses where necessary
  • If unable to tolerate oral intake continue basal insulin infusion and set up IV infusion of 5% dextrose 0.45% 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.

 After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively
  • On return and child is well give usual bolus insulin with late lunch
  • Aim to maintain blood glucose between 5-11mmols/L
  • Return to normal CSII regimen, using correction insulin boluses where necessary
  • If unable to tolerate oral intake continue basal insulin infusion and set up IV infusion of 5% dextrose 0.45% saline solution until the child is taking and tolerating adequate oral fluids
  • 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. Should be running on normal CSII regimen.

(iii) Twice Daily  Insulin Mixtures

For example, children on Mixtard 30 or HumalogMix 25

 Morning operations  Afternoon operations

 Prior to Surgery:

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

 Prior to Surgery:

  • Give short acting insulin (1/3rd of total morning insulin dose) only and light breakfast before 07.30h.
  • Clear fluids up to 2 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.

 During surgery:

  • Measure capillary blood glucose every half hour.

 During surgery:

  • Measure capillary blood glucose every half hour.

 After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively
  • On return and child is well give Novorapid (1/3rd of the total morning dose) and breakfast for example, if usually on 12 units of Mixtard give 4 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 5% dextrose 0.45% 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

 After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively
  • On return and child is well give Novorapid (1/3rd 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 5% dextrose 0.45% 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

 

Major elective procedures

Definition: General anaesthetic lasting more than 30 minutes, likely to cause post-operative nausea, vomiting or inability to feed adequately.

Preop-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 08.00h 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 half the usual glargine dose if on MDI regimen.

 

 Morning Operations  Afternoon Operations

 Prior to Surgery:

  • Standard starvation times as above.
  • Omit morning insulin
  • Check electrolytes and glucose pre-op and inform anaesthetist of results
  • Start IV fluid. Give 5% Dextrose and 0.45% saline using the maintenance regimen.
  • Commence at the same time insulin infusion.
  • Measure capillary blood glucose hourly until operation.
  • For patients on MDI give usual bolus with breakfast at 07.30. 
  • For CSII normal bolus with breakfast and normal basal until theatre. 
  • For twice daily regimens give 20% of the usual morning insulin dose as soluble insulin e.g. Novorapid.  Do not give any long acting insulin, so no insulin mixture
  • Fast after breakfast and admit to Hospital
  • Clear fluids up to 2 hours pre-operatively
  • Start intravenous fluids and insulin by 11am at the latest 
  • Then follow 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.

 During surgery:

  • 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)
    • >12mmol/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% 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 4 as this will cause hyperglycaemia.  Reduce the rate of the insulin infusion further.  Continue with glucose infusion and increase the rate if required.
 

 After surgery:

  • Hourly capillary blood glucose measurements for 4 hours post-operatively.
  • 6 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 2 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 5% dextrose 0.45% 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 ultrashort-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 or 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.

 

Maintenance fluid guide

5% Dextrose and 0.45% saline with 10 mmol added potassium chloride per 500ml bag.

Body Weight (Kg)

Maintenance Fluid (ml/Kg/day)
For First 10kg body weight

 100

For each kg between 10 and 20 kg

 50

For each kg above 20 kg

 25

Insulin infusion regimen for patients with diabetes undergoing surgery

  1. Draw up 50 mls 0.9% Saline into 50 ml syringe.

  2. Draw up Soluble Insulin (Velosulin is best as it is stable for 24 hours) 50 units (0.5ml) into insulin syringe.

  3. Add 0.5ml Insulin to the 50 mls of saline in the syringe and attach to syringe pump (1 ml 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 (see Page 11) to maintain blood glucose between 5-11 mmol/L.

If blood glucose levels are not returned to target range after one adjustment of insulin infusion rate:

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

NOTE: insulin is like a controlled drug and the infusion system that is set up, the dosing schedule used and each change of infusion rate needs to be checked by 2 people.

References/Bibliography

Reference 1:
Edge JA, Swift PG, Anderson W, Turner B, Youth and Family Advisory Committee of Diabetes UK (2005) Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines?. Arch Dis Child 90 (10): 1005-9.

Document control information

Lead author(s)
Name Becky Thompson Position Clinical Nurse Specialist Dept/speciality Endocrinology
Document owner
Name Peter Hindmarsh Position Professor of Paediatric Endocrinology Dept/speciality Endocrinology
Approved by
Name Peter Hindmarsh Position Professor of Paediatric Endocrinology Dept/speciality Endocrinology

Literature review undertaken no
Audit/evaluation of current practice undertaken yes
All staff groups involved in the care of these patients have had input into the development/review yes

First introduced June 1 2005 Review schedule Two years
Date approved July 31, 2007 Next review July 31, 2009
Document version 1.1 Replaces version 1.0
These guidelines are intended to guide and facilitate the care of patients at Great Ormond Street Hospital for Children NHS Trust (GOSH). The guidance contained therein is not intended to replace individual assessment and personalised treatment of the patient. The authors attempt to base the guidance on best available evidence and ensure that content is up to date. The guidelines may not necessarily represent the views of all clinicians at GOSH. This information may be used for private education, research and institutional education but if used for any other purposes, consent must first be obtained from GOSH. Any person intending to use the guidelines should assess the suitability of use. GOSH will not accept any responsibility for use by external agencies or individuals. No part of this publication may be reproduced, stored in or introduced into a retrieval system or transmitted in any form without prior consent and acknowledgment of GOSH. GOSH retains copyright.

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This page was last reviewed on 22 October 08 12:33