Diabetes - Child on emergency surgery list

Appropriate bloods as necessary

Normal Insulin Regimen:

Pre-breakfast, Pre-Lunch, Pre-Tea, Pre-Bed

• Confirm dose and time of last insulin injection
• Confirm intake of food since last injection

(Children with diabetes need regular dietary intake – no longer than 2½ hours during day without carbohydrate)

Check blood glucose immediately 

• Check blood ketones
• If ketotic – check venous blood gas

Is the child decompensated?

• Urinary ketones plus
• Blood gas pH <7.3 and/or
• Standard bicarbonate <15mmol/l

YES, decompensated

Follow Protocol for Management of DKA and liaise with Surgical Team regarding timing of operation

NO, not decompensated

Liaise with Surgical Team regarding length of the operation >30min or <30min?

Short Procedure <30 minutes

Nil by mouth

IV 5% Dextrose + 0.45% Saline at maintenance values

Check blood glucose every 30 minutes in Theatre + in Recovery

If Blood glucose <4.5mmol/l, give IV 10% Dextrose until blood glucose >11mmol/l for 1 hour, then decrease to 5% Dextrose + 0.45% Saline

Long Procedure >30 minutes

IV insulin infusion + IV 5% Dextrose + 0.45% Saline at maintenance + KCL to maintain plasma potassium 4-5mmol/l

Commence insulin infusion 0.03 units/kg/hour – (note time of last injection)

Aim to maintain blood glucose 7-13mmol/l

• Monitor blood glucose hourly (½ hourly in Theatre) using Blood Glucose Meter whilst insulin infusion running.
• Alter rate of insulin infusion in alloquots of 0.1ml/hour
  (insulin infusion: 50 units Novorapid or Humalog in 50ml Normal Saline - therefore 0.1ml = 0.1 unit).

AIM TO MAINTAIN TARGET BLOOD GLUCOSE VALUES OF 7-13MMOL/L

• Expect steady state to be reached but small alterations may be required.
• If blood glucose rises by >3mmol/l/hour - INCREASE insulin rate by 0.1ml/hour.
• If blood glucose rises to >13mmol/l/hour INCREASE insulin infusion rate by 0.1ml/hour and continue to do so HOURLY until target range (7-13mmol/l) is again reached.
• If blood glucose <7.0mmol/l change immediately to 10% dextrose & 0.45% saline WITHOUT decreasing rate of insulin infusion.
• Minimum insulin infusion rate is expected to be 0.03u/kg/hour. Therefore, if blood glucose readings
  falling towards 7.0mmol/l, change to 10% dextrose & 0.45% saline instead of decreasing rate of insulin infusion.
• Continue IV insulin infusion until 30 minutes after subcutaneous insulin administered pre-meal.
• Discontinue IV fluids as the child is eating the meal.
• Ensure appropriate meal with carbohydrate content given.

BLOOD GLUCOSE MONITORING SHOULD TAKE PLACE IN THEATRE AND IN RECOVERY AREA HALF HOURLY – USE RECORD SHEET PROVIDED

• Check blood glucose level
• Contact Paediatric clinical team on call regarding insulin prescription doses (May require increased dose Novorapid and decreased dose Lantus or Levemir)
• Administer insulin as prescribed
• Allow patient to eat and drink as tolerated, ensuring that the patient receives IV fluids (Dextrose/Saline) if unable to manage oral intake
• Appropriate care related to surgery
• If child requires wound checks, Surgical Team on discharge please fill in referral form for community nurses

Blood glucose recording chart PDF

HYPOGLYCAEMIA IS BLOOD GLUCOSE LESS THAN 4MMOL/L
Treating a mild to moderate “hypo”
(Patient conscious and able to swallow)

NOTE:

1. Children who are using an insulin pump DON’T require a snack once blood sugar >4mmol/l.
2. If you have treated for hypoglycaemia x3 continuously and blood glucose remains below 4mmol/l child will need IV dextrose bolus/ IV fluids.
3. Do not give a correction at next meal if this will be less than 2 hours since hypo. Recheck blood glucose in an hour.
4. If patient has their own specific management plan for treating a hypo or uses Glucotabs® or anything other than above please record below for nursing staff to follow in ward.
5. If not tolerating oral fluids, give IV 10% Glucose 2mls /kg bolus.