Diabetes Surgery and Diabetes Mellitus

Paediatric Clinical Guideline

Endocrine

9.2 Diabetes - Surgery

Diabetes – Surgery and Diabetes Mellitus

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 protocols.

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 4 -14 mmol/l
• Minimise duration of hospital stay, the majority of children are better controlled by their parents in their own homes.

Section A - PLANNED SURGERY

Pre-admission checklist

1. Please select morning (preferably first on the list) theatre session.
2. Inform UHN/CHN Children’s Diabetes Team of planned date for admission. For the majority of diabetic children it is appropriate to admit on the afternoon prior to routine surgery. Children having minor procedures 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

QMC:

• Dr Randell/Denvir’s Secretary ext 63328/63394
• Ward E37
• Dr Randell/Denvir’s registrar (bleep 841411)
• Diabetes Specialist Nurse (8.00am – 6.00pm, Mon-Fri. Page via switch. 24 hour answer phone available, tel 0115 924 9924 x 61731)

CHN:

• Dr Drew’s Secretary ext 59792
• Papplewick ward ext 56471/2
• Renal SpR or Papplewick SpR
• Diabetes Specialist Nurse (8.00am – 6.00pm, Mon-Fri. Page via switch. 24 hour answer phone available, tel 0115 934 6412)

• The admission will be placed in the team diary so that paediatric 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 dietician will be alerted.

Admission Checklist

• Alert Children’s Diabetes Team of child’s arrival (see above) or Paediatric Registrar on call if admitted at weekend
• Alert Anaesthetist
• Check that the child has her/his own diabetes kit eg Insulin injection pen, capillary blood sampler and glucose monitor
• Check child’s current insulin regimen from family held record
• Check availability of IV infusion equipment and syringe infusor (see below)

Insulin Regimen on Day before Surgery

1. The usual regimen will be continued up to bedtime of the evening before surgery.
2. Capillary blood sugar measurements need to be performed before meals and at bedtime.
3. Check admission urine for ketones.
4. Contact the Diabetes team if blood sugars are elevated (above 15mmol/l) or more than slight ketonuria is present.

Insulin Regimen on Day of Surgery for procedures expected to take >1 hour

1)Guidance from anaesthetist regarding oral intake. See Protocol: Pre-operative fasting in children.

MORNING LIST:

No milk or food after midnight, unrestricted clear fluids until 2h before listed.

Omit morning insulin and set up infusion pump see 3).

AFTERNOON LIST:

Normal breakfast before 08.00, unrestricted clear fluids until 2hr before listed.

2)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 Human Mixtard 30 dose, 10 units

Therefore usual short-acting component is 3/10 x 10 = 3 units

The short acting insulin is given as Novorapid via pen device

If on a basal bolus regimen: give normal doses of breakfast insulin (usually just Novorapid although some small children will have their Glargine (long-acting insulin) at breakfast as well) and omit lunchtime dose of Novorapid.

3)Commence intravenous infusion pre-operatively, by 08.00 for morning list (consider option of inserting IV cannula on the previous evening) and by 1200hr for afternoon list.

4)Fluids: 5% Dextrose & 0.45% NaCl plus potassium, 10mmol per 500 ml (see Table 1)

5)Insulin: Human Actrapid* via syringe infusion pump connected to infusion line. Mix 50 units (0.5ml) of Actrapid with 49.5 ml 0.9% saline to give 1 unit/ml solution. Flush tubing with solution and commence Actrapid infusion (Table 2)

6)Start 2 hourly blood glucose monitoring

*Humulin S may be used as an alternative to Actrapid

Table 1.Fluid infusion rate guide

Table 2. Insulin infusion rate guided by serial blood glucose measurement

Standard insulin infusion rate0.025units/kg/hr

(Initial infusion rate in unwell child0.05units/kg/hr)

Monitor blood glucose at 2 hourly intervals if glucose levels in range 4-14 mmol/l

Monitor blood glucose at 1 hourly intervals if glucose levels outside this range or recent alteration to Dextrose or insulin infusion rate.

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

Insulin Regimen after Surgery

1. Continue Dextrose and insulin infusion with 2 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. The aim should be to recommence normal evening meal and normal evening insulin dose. One hour after this dose the sliding scale insulin and IV infusion can be stopped.
2. Prolonged dependence on intravenous infusion such as after GIT surgery will require adjustments to the fluid replacement.
3. 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.
4. Major surgery or gradual return to full diet. Plan s/c NovoRapid insulin before meals according to sliding scale after discussion with the Diabetes Team. Omit medium duration insulin until nearly full diet.

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 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 immediately after completion of procedure.

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. The amount and type of insulin given will depend on the insulin regimen being used.

PLEASE LIAISE WITH THE DIABETES TEAM SEVERAL DAYS BEFOREHAND SO THE FAMILY CAN BE ADVISED ABOUT INSULIN ADJUSTMENT.

If a reduced dose of insulin has been given, further doses of short acting insulin (eg Novorapid) may be required later when the child has recovered from the anaesthetic.

Delayed reintroduction of oral intake may require intravenous fluids and insulin.

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 Diabetes Team
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

1. Discuss intravenous strategy with Surgeons, Anaesthetists and Diabetes Team.

Consider priorities:

• Correction of circulating volume
• Correction of electrolyte deficit
• Correction of ketoacidosis

1. Diabetic ketoacidosis: plan to correct before surgery if possible. See protocol DIABETIC KETOACIDOSIS
2. Diabetes without ketoacidosis: plan to use 5% dextrose/0.45% saline and insulin infusion as detailed under routine surgery.

PAEDIATRIC CLINICAL GUIDELINES

ISSUE:VERSION: FINAL

Title: Surgery & Diabetes

Author: Dr Tabitha Randell

Job Title:Consultant in Paediatric Endocrinology and Diabetes

First Issued: Aug 2004Date Revised:Jan 2006 Review Date: Jan 2006

Document Derivation:Consultation Process:

References:Medicines for ChildrenDr Josie Drew, Associate Specialist

ISPAD Consensus Guidelines 2000Dr Louise Denvir, Consultant Paediatrician

PDSNs Vreni Verhoven, Karen Cuttell, Glyn Feerick

Ratified By:Paediatric Clinical Guidelines Committee

Chaired By:Dr Stephanie Smith

Consultant with Responsibility: Dr Stephanie Smith

Distribution:All wards QMC and CHN

Training issues: Included in Induction Programme

Audit:

This guideline has been registered with Nottingham City Hospital NHS Trust and QMC Clinical Guidelines Committee. 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.

MANUAL AMENDMENTS RECORD

(Please complete when making any hand-written changes/ amendments to guideline and not processed through guideline committee)

DateAuthorDescription

Tabitha RandellPage 1 of 7January 2006