Presentation title
Emergency Care
Part 3: Surgery in Children with Diabetes
Emergency care
Slide no 2
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Managing DKA
Surgery in children with diabetes
Treating and preventing hypoglycaemia
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
Slide no 3
Surgery at Echelons 1-2
• Consider surgery at echelons 1-2 only if• Minor surgery
• Emergency major surgery
Slide no 4
General Principles
• Correct DKA/ketosis before surgery • First on a surgical list (ideally morning)• Maintain blood glucose of 5–10 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
Slide no 5
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
Slide no 6
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
Slide no 7
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
Slide no 8
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
Slide no 9
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
Slide no 10
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%)
Slide no 11
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
Slide no 12
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
Slide no 13
Questions
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