Presentation title

Emergency Care
Part 3: Surgery in Children
with Diabetes
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Emergency care

1 Managing DKA

2 Treating and preventing hypoglycaemia

3 Surgery in children with diabetes

 Slide no 3

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 <5 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 >15 mmol/l
Questions
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