Presentation title Emergency Care Part 3: Surgery in Children with Diabetes Slide no 2 Emergency care 1 Managing DKA 2 Treating and preventing hypoglycaemia 3 Surgery in children with diabetes Slide no 3 Surgery • Surgery is more complicated when the patient has diabetes • Need to monitor continuously • Risks for: • Hypoglycaemia • Hyperglycaemia • Ketones • Elective surgery only at a centre with expertise in treating children with diabetes Slide no 4 Surgery at Echelons 1-2 • Consider surgery at echelons 1-2 only if • Minor surgery • Emergency major surgery Slide no 5 General Principles • Correct DKA/ketosis before surgery • First on a surgical list (ideally morning) • Maintain blood glucose of 5–10 mmol/l during and after surgery • Frequent monitoring • May need repeated doses of short-acting insulin and maintenance IV fluids • No solid food for 6 hours before general anaesthesia Slide no 6 Minor Procedures (1) Rapid recovery anticipated: • Early morning procedure • Delay insulin and food until completion of the procedure • Check blood glucose 0-1 hour pre-operatively • After surgery, check glucose, give full dose of insulin and food Slide no 7 Minor Procedures (2) Rapid recovery and/or early feeding may not occur: • Give 50% of usual insulin dose • Monitor glucose 2 hours pre-operatively • If glucose above 10 mmol/l: • Give dose of short-acting insulin (0.05 U/kg) OR • Start insulin infusion at 0.05 U/kg/hour • If glucose <5 mmol/l, start IV dextrose (5 or 10%) infusion Slide no 8 Post-operation • Check blood glucose hourly • Start oral intake or continue IV glucose • Give small doses of short-acting insulin for hyperglycaemia or for food intake • Give the dinner time or evening dose of insulin as usual • Because of post-op DKA possibility, more overnight blood glucose monitoring at home or admit to hospital Slide no 9 Major Surgery • For emergency major surgery • Correct DKA/ketosis before surgery • Consider transfer to a centre with expertise in treating children with diabetes • Consider major surgery at echelon 1-2 only if: • Dire emergency • Unable to transfer to a centre with appropriate expertise • Take to operating theatre and start DKA protocol simultaneously Slide no 10 For elective surgery • First on surgical list (ideally morning) • If control is uncertain or poor, admit for stabilisation of glycaemic control • If diabetes is well controlled, admit to hospital on the day before surgery • Only consider surgery once diabetes is stable Slide no 11 Pre-operative • In the evening before surgery • Frequent blood glucose monitoring • Usual evening insulin(s) and snack • Short-acting insulin to correct high blood glucose values every 3-4 hours • Keep nil by mouth from midnight • If the child develops hypoglycaemia, start an IV infusion of dextrose (5-10%) Slide no 12 Intra- and Post operation • On the day of surgery • Omit usual morning fast or rapid insulin • Consider decreasing or omiting intermediate or long acting morning insulin • Instead give insulin by • IV insulin infusion at 0.05 U/kg/hour OR • Repeated doses of short-acting insulin every 3-4 hours • Give IV fluids (half normal saline with 5% dextrose). • Check blood glucose and electrolytes regularly • DKA can occur during or after surgery Slide no 13 Intra- and Post operation • Monitor glucose • 1-2 hourly before surgery • Every 30 minutes during surgery • Hourly post-operatively • • • • Aim for 5-10 mmol/l Adjust rate of insulin and dextrose-saline Feed and start regular doses of insulin once awake Monitor ketones if glucose is >15 mmol/l Questions Changing Diabetes® and the Apis bull logo are registered trademarks of Novo Nordisk A/S