Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
Short Title:
Diabetes – Surgery and Diabetes Mellitus
Full Title:
Date of production/Last revision:
Guideline for the management of diabetes mellitus in children and young
people undergoing surgery
January 2006
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Tabitha Randell, Consultant Paediatrician
Ext: 63328
January 2009
Revision Date
This guideline has been registered with the Trust. 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.
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.
2.
3.
Please select morning (preferably first on the list) theatre session.
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)
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)
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
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.
2.
3.
4.
The usual regimen will be continued up to bedtime of the evening before surgery.
Capillary blood sugar measurements need to be performed before meals and at
bedtime.
Check admission urine for ketones.
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)
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
at breakfast as well) and omit lunchtime dose of Novorapid.
3)
4)
5)
6)
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.
Fluids: 5% Dextrose & 0.45% NaCl plus potassium, 10mmol per 500 ml (see Table
1)
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)
Start 2 hourly blood glucose monitoring
*Humulin S may be used as an alternative to Actrapid
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
Table 1.
Fluid infusion rate guide
Body weight
(kg)
5% Dextrose + 0.45%NaCl +
10 mmol KCl /500ml
rate ml/hr
40
60
70
80
90
100
10
20
30
40
50
60 and above
Table 2. Insulin infusion rate guided by serial blood glucose measurement
Standard insulin infusion rate
0.025units/kg/hr
(Initial infusion rate in unwell child
0.05units/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.
Blood glucose above 14 mmol / l
Increase insulin infusion to 0.05units / kg / hr or
by 50% if already at this rate
Decrease from 0.025 to 0.015 units / kg / hr
Do not stop insulin infusion, continue dextrose
infusion and add additional dextrose as
needed. Inform diabetes team.
Blood glucose Below 7 mmol / l
Blood glucose < 4 mmol/l
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.
2.
3.
4.
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.
Prolonged dependence on intravenous infusion such as after GIT surgery will require
adjustments to the fluid replacement.
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.
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.
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
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.
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
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
4.
Discuss intravenous strategy with Surgeons, Anaesthetists and Diabetes Team.
Consider priorities:
 Correction of circulating volume
 Correction of electrolyte deficit
 Correction of ketoacidosis
5.
6.
Diabetic ketoacidosis: plan to correct before surgery if possible. See protocol
DIABETIC KETOACIDOSIS
Diabetes without ketoacidosis: plan to use 5% dextrose/0.45% saline and insulin
infusion as detailed under routine surgery.
PAEDIATRIC CLINICAL GUIDELINES
ISSUE:
Title:
VERSION: FINAL
Surgery & Diabetes
Author: Dr Tabitha Randell
Job Title:
Consultant in Paediatric Endocrinology and Diabetes
First Issued:
Aug 2004
Date Revised: Jan 2006
Review Date: Jan 2006
Document Derivation:
Consultation Process:
References:
Medicines for Children
Dr Josie Drew, Associate Specialist
ISPAD Consensus Guidelines 2000
Dr 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
Tabitha Randell
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January 2006
Paediatric Clinical Guideline
Endocrine
9.2 Diabetes - Surgery
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)
Date
Author Description
Tabitha Randell
Page 7 of 7
January 2006