Guidelines for the Management of Paediatric
Surgical Patients with Insulin Dependent Diabetes
Mellitus.


Liaise with the diabetes team
Liaise with the Anaesthetist
All Major Elective Surgery and Elective day-case surgery on
Morning List
Children who are first on the list, undergoing a quick day-case procedure, and
likely to be able to eat by lunchtime might require only a small reduction in the
morning insulin dose without any further fluid administration i.e the children
who have a short anaesthetic on Disney ward. Discuss with anaesthetist and
diabetes team.
Otherwise:

Day before
o normal insulin and diet
o admit the child on the afternoon/evening prior to surgery
o insert an IV cannula and take FBC, U&Es and do a capillary
blood glucose

Morning of operation
o the child should be first on the list
o omit usual morning insulin dose
o nothing to eat 6 hours before surgery
o can drink clear fluids until 2 hours before theatre
o start IV fluids and insulin at 06:00 on morning of operation (see
appendix). Perform a capillary blood glucose just before
commencing IV fluids
o capillary blood glucose hourly (including theatre) until the IV
infusion comes down, unless agreed with a paediatric diabetes
consultant
o adjust insulin to keep the blood glucose between 5 and 12
mmol/l
o IF the blood glucose is >15mmol/l at the time they are sent for
theatre, postpone or cancel the operation
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
After the operation
o if eating normally post-op refer to the appendix for restarting
insulin:
 stop IV infusion of insulin 60 minutes after
subcutaneous insulin started
 if not eating, or vomiting post-op continue IV fluids and IV
insulin infusion until ready to start s/c insulin
 leave IV cannula in until discharge
Day cases on Afternoon list:

Day before
o normal insulin and diet

Morning of the operation
o For patients on multiple dose injection regimen (ie
glargine at night, and novorapid with meals), give usual
novorapid bolus with breakfast
o For insulin pumps give normal bolus with breakfast and
normal basal rate until theatre
o For twice daily regimens, give 20% of the usual morning
insulin dose as soluble insulin eg Novorapid. Do not give
long acting insulin, so NO insulin mixture
o This will need to be conveyed to parents as this is likely
to happen at home.
o Fast after breakfast
o admit by 10:00 on the morning of admission
o on arriving, site cannula
o no insulin at lunchtime for those on multiple injection
regimen
o nothing to eat 6 hours before the operation
o can drink clear fluids up to 2 hours before the operation
o start IV fluids and insulin at 11:00 pm at the latest,
see appendix. Perform capillary blood glucose just
prior to commencing IV fluids
o capillary glucose hourly (including theatre) until the IV
infusion comes down, unless agreed with a paediatric
diabetes consultant
o adjust insulin to keep blood glucose between 5 and
12mmol/l
o if the capillary blood glucose is >15mmol at the time they
are sent for theatre, cancel/postpone the operation
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
After the operation
o
o if eating normally by tea-time give usual evening insulin for
every type of insulin regimen
o stop IV insulin 60 minutes after subcutaneous insulin
started
o if not eating or vomiting post-op continue IV fluids and IV insulin
until ready to start s/c insulin
o see appendix for changing back to s/c insulin
o leave IV cannula in until discharge
Emergency Surgery:



on arriving, measure blood glucose, venous blood gases, check urine
for ketones
if ketoacidotic, consult DKA guidelines and inform paediatric diabetes
team
if not ketoacidotic
o establish when likely to go to theatre, and when they will
become nil by mouth then
o start on maintenance fluids and insulin (0.05u/kg/hour)
o measure capillary blood glucose before starting IV fluids, and
then hourly and check urine for ketones at every sample
o adjust insulin to maintain blood glucose between 5 and12mmol/l
o continue IV fluids and insulin infusion until ready to eat
Appendix(diabetes and surgery)
NB These guidelines are NOT the same as DKA guidelines
USE PRE-PREPARED FLUID CHART.
1. Maintenance fluid guide:
 0.45%saline and 5% dextrose with 10mmol added potassium per
500ml bag

Body weight
Fluid requirement
1st 10kg
2nd 10kg
3rd 10kg
100mls/kg/day
50mls/kg
20mls/kg
eg for 32kg child
10 x 100 = 1000
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10 x 50 = 500
12 x 20 = 240
total = 1740mls for 24 hour period


Run fluids at 73 mls/hour
per-operative fluids will be determined by the anaesthetists
some post-operative patients may need less fluids, e.g post-op appendix,
and we should aim for 2/3rds maintenance and on-going losses, in which
case reduce maintenance fluids and add ongoing losses where
appropriate.
2. Insulin infusion
 Add 50units of actrapid to 50mls of 0.9% saline, making a solution of
1unit/ml
 Start infusion at 0.025u/kg/hour (i.e 0.025mls/kg/hour)
 Aim to maintain blood glucose levels between 5 and 12 mmol/l
o If blood glucose above 12mmol/l, increase infusion by 50%, i.e
0.025 to 0.05mls/kg/hour
o If blood glucose below 5 mmol/l, stop insulin and call a doctor,
although it is preferable to reduce the rate of the infusion rather
than to stop the insulin altogether as this will cause rebound
hyperglycaemia
3. Restarting insulin:
 If ready to eat breakfast:
o twice/three injection regimen – give usual insulin in the morning
o multiple injection regimen – give usual short acting insulin, plus half
of the usual evening dose of long-acting insulin before breakfast,
then usual short acting insulin doses before the other meals
o usual long acting dose that evening

If ready to eat lunch
o twice/three injection regimen – 1/3rd of usual morning insulin before
lunch, then normal insulin from then on
o multiple injection regimen – give usual short acting insulin before
lunch plus ¼ of the usual long acting insulin, usual insulin that
evening

If ready to eat evening meal
o usual insulin for all types of regimen
FOR ALL REGIMENS
Stop IV insulin 60 minutes after s/c insulin has started
FMA, ALS, Anaesthetists August 2004
Updated May 2008, review 2010
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