Emergency Care Part 3: Surgery in Children with Diabetes

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Emergency CarePart 3 Surgery in Children with
Diabetes
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Emergency care
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Managing DKA
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Treating and preventing hypoglycaemia
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Surgery in children with diabetes
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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

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Surgery at Echelons 1-2

• Consider surgery at echelons 1-2 only if
• Minor surgery
• Emergency major surgery

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General Principles

• Correct DKA/ketosis before surgery
• First on a surgical list (ideally morning)
• Maintain blood glucose of 510 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

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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

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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 lt5 mmol/l, start IV dextrose (5 or
  10) infusion

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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

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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

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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

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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)

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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

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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 gt15 mmol/l

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Questions
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