Diabetes surgical (Paediatric Guidelines)

Guidelines for management of minor and majory surgery in children with different types of insulin regimens, including injections, insulin pump therapy and those wearing continuous glucose monitoring devices.

Minor Surgical Procedures and Dental Work

Children and young people who take insulin injections

1. The child should be placed first or second on the morning operating list.
2. Please get in touch with the Paediatric Diabetes Specialist Nurses (Bleep 2052) who will liaise with the anaesthetist.
3. The child or young person should take food and insulin as normal on the day before the operation, and be fasted from 6 hours prior to operation. Clear fluids (water, apple juice, squash) can be taken up to one hour before elective general surgery, at a maximum volume of 3mls/kg.  If blood glucose is <5 mmol one hour before, give apple juice.  If blood glucose is >5 mmol give water or sugar free squash.
4. If the child is on basal bolus therapy, they should have their normal basal insulin, which may be Lantus or Degludec (Tresiba) the evening before or Levemir in the morning of surgery.
5. The anaesthetist will site a cannula immediately after the induction of anaesthesia, and a reagent strip blood sugar test will be checked. Intravenous fluids will not normally be required.
6. The blood glucose will be monitored on return from theatre.
7. When the child is ready to eat, give insulin at the same time (if you are not sure if the food will stay down, you can give the insulin after the child has eaten). Make the following dose adjustments:

Pre-mixed insulin (eg Humulin M3/NovoMix 30) in the morning:

• If the food taken is the morning snack, give ¾ of the usual morning dose.
• If the first food taken is at lunchtime, give ½ of the usual morning dose.

Basal Bolus insulin:

• Take the usual rapid acting insulin dose with or after first food.

8. After lunch has been eaten the child may be discharged. Eat and take insulin normally for the rest of the day.
9. Children unable to eat lunch are liable to become ketotic, and will likely need intravenous fluids (dextrose/saline) and insulin infusion. Use prescription chart on page 4.

Minor Surgical Procedures and Dental Work

Children and young people on insulin pumps

1. The child should be placed first or second on the morning operating list.
2. Please get in touch with the Paediatric Diabetes Specialist Nurses (Bleep 2052) who will liaise with the anaesthetist. For minor operations the insulin pump could be continued if the anaesthetist is in agreement.
3. The child or young person should take food and insulin as normal on the day before the operation, and be fasted from 6 hours prior to operation. Clear fluids (water, apple juice, squash) can be taken up to one hour before elective general surgery, at a maximum volume of 3mls/kg.  If blood glucose is <5 mmol one hour before, give apple juice.  If blood glucose is >5 mmol give water or sugar free squash.
4. Continuous glucose monitors should be removed pre-surgery, so the pump will default into manual mode.
5. The anaesthetist will site a cannula immediately after the induction of anaesthesia, and a reagent strip blood sugar test will be checked. Intravenous fluids will not normally be required.
6. The blood glucose will be monitored on return from theatre. A new Continuous Glucose Monitor could be placed by the parent/carer so the pump can revert to its hybrid closed loop functionality.

When the child is ready to eat, give a bolus of insulin through the pump (if you are not sure if the food will stay down, you can give the insulin after the child has eaten).

Please inform Dr Franklin or Dr Ferguson if any child with diabetes is admitted and requiring emergency surgery, even if out of hours.  Remember DKA can mimic an acute abdomen.  Ensure blood glucose and ketones are checked in patients who present with abdominal pain.  If glucose or ketones are elevated, check a blood gas.

Children who need major surgery and are not expected to eat or drink in the immediate post-operative period should be commenced on IV fluids and insulin.  0.9% NaCl, 5% Dextrose with 10mmol/mol KCl would be an appropriate starting fluid.  Changes may be required to Dextrose percentage and KCl depending on blood glucose levels and electrolytes.  If a prolonged period of post-operative fasting is expected, TPN may be appropriate.

Insulin Regimen:

• Long acting basal insulins Lantus/Glargine or Tresiba/Degludec should be prescribed and given.
• Shorter acting basal insulin such as Levemir should be discontinued.
• Insulin Pump: IV insulin should be started without delay and then the insulin pump should be stopped and removed. This is important as a patient on a pump has no long acting insulin, so blood glucose levels will quickly rise.

Insulin should be prescribed on 'Medication Prescription Chart' - please tick that there are additional prescribing sheets in use (Insulin) and prescribe under 'Regular Therapy' Actrapid iv according to sliding scale. As this is an infusion, this should also be prescribed in the fluids section of the 'Medication Prescription Chart'. Please prescribed Actrapid iv, add 50 units of soluble insulin (Actrapid) to 49.5ml 0.9% NaCl. Rate is according to sliding scale. Print the last page of this document to form the prescription, complete and then file in the patient's nursing folder.

Insulin should be prescribed on the prescription chart below.  Write Actrapid  iv, according to sliding scale).  Add 50 units of soluble insulin (Actrapid) to 49.5ml 0.9% NaCl.. Print the last page of this document to form the prescription, complete and then file in the patients nursing folder.

Check Blood Glucose levels hourly whilst on the sliding scale and check electrolytes every 12 hours whilst on IV fluids.  When ready to eat and drink, please prescribe their usual subcutaneous insulin on the paediatric prescription chart for subcutaneous insulin.  It is often appropriate to give the first post-operative dose of rapid acting insulin after the initial oral intake to ensure that the food is tolerated.

N.B. Sliding scale may need re-prescription in light of clinical response (e.g., if persistent low or high Blood Glucose levels) or if on TPN where the concentration of dextrose will be higher than 5%.  Please contact Dr Ferguson or Dr Franklin for advice.

Paediatric diabetes surgery monitoring chart click here

Paediatric diabetes surgery sliding scale prescription chart, click here

• If patient develops DKA
• If blood sugars are not stable on the intravenous insulin infusion