1. Emergency Care Part 3: Surgery in Children with Diabetes
Presentation title
Emergency Care Part 3: Surgery in Children with Diabetes
In this session we shall cover aspects if the emergency care of a child with diabetes

2. Emergency care 1 2 3 Managing DKA
Treating and preventing hypoglycaemia 3
Surgery in children with diabetes
This session shall cover 3 aspects namely the management of diabetic ketoacisosis, treating and preventing hypoglycaemia and managing the child who has to undergo surgery.

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
Surgery in children is a complicated process and is even more complicated with the child has diabetes. The child need continuous monitoring and has risks for developing hypoglycaemia, hyperglycaemia and ketones. Because food intake is restricted before surgery, insulin administered must also be reduced to maintain the balance. If insulin is reduced excessively, the child is at risk of ketoacidosis. The stress of surgery may cause high blood glucose and the appearance of ketones.
Elective surgery for a child with diabetes should not be carried out in a Level 1-2 facility, where the specialised knowledge is not likely to be sufficient. Whenever possible, a child with diabetes requiring surgery should be evacuated to a centre with expertise in treating children with diabetes.

4. Surgery at Echelons 1-2 Consider surgery at echelons 1-2 only if
Minor surgery
Emergency major surgery
Surgery should only be considered at echelon 1and 2if it is minor surgery or if it is major surgery only in a dire emergency.
If surgery is to be carried out in your centre, there are general principles that need to be followed.

5. 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
Children with type 1 diabetes should be first on a surgical list, ideally in the morning. Aim to maintain blood glucose of 5–10 mmol/l during and after surgery. Therefore the child needs frequent monitoring during this period. The child may need repeated doses of short-acting insulin and maintenance intravenous fluids.
No solid food should be given for at least 6 hours before a general anaesthetic
Clear fluids (including breast milk) are allowed up to 4 hours before anaesthesia (but check with the anaesthetist).

6. 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
The next few slides outline management of surgical conditions that have to be done at your centre.
For minor procedures where rapid recovery is anticipated eg grommets, endoscopy, I&D of superficial abscess:
Early morning procedure (eg 08.00–09.00): delay insulin and food until immediately after completion of the procedure
Check blood glucose 0-1 hour pre-operatively
After surgery, check glucose, give full dose of insulin and food to the child.

7. 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
For short procedures (with or without sedation or anaesthesia) that require fasting, and when rapid recovery and/or early feeding may not occur e.g. appendectomy, I&D of multiple or deep abscesses and short procedures that are done late in the day.
Give 50% of usual insulin dose (NPH insulin e.g. Monotard)
Monitor glucose 2 hours and 2 hourly pre-operatively
If glucose rises above 10 mmol/l, give dose of short-acting insulin (0.05u/kg) OR start insulin infusion at 0.05u/kg/hour
If glucose <5 mmol/l, start IV dextrose (5 or 10%) infusion to prevent hypoglycaemia

8. 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
Check blood glucose hourly during surgery and post-operatively
After surgery, start oral intake or continue IV glucose, depending on the child’s condition. Give small doses of short-acting insulin, if needed, to reduce hyperglycaemia or for food intake.
Give the dinnertime or evening dose of insulin as usual.
If home glucose monitoring is not available, admit the child overnight to monitor glucose values.

9. 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
Major surgery should be undertaken in healthcare facilities that have resources for optimal management of the child’s diabetes. These resources should include infusion controllers and close nursing supervision.
Consider major surgery at an echelon 1-2 centre only in dire emergency or if transfer to a echelon 3-4 centre is not possible.

10. 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
For emergency major surgery, the following protocol should be followed as closely as possible. Prepare for surgery.
Procedures should preferably be scheduled first on surgical lists, ideally in the morning
If glycaemic control is uncertain or poor, admit to hospital prior to surgery 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

11. 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%)
In the evening before surgery
Frequent blood glucose monitoring is important to ensure optimal control
Give the usual evening or bedtime insulin(s) and snack
Additional doses of short-acting insulin may be necessary to correct high blood glucose values
Keep nil by mouth from midnight
If the child develops hypoglycaemia, start an IV infusion of dextrose (5-10%.

12. 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
On the day of surgery
Omit the usual morning insulin dose
2 hours before surgery start an IV insulin infusion at 0.05 u/kg/hour and half-normal saline with 5% dextrose.
Monitor glucose 1-2 hourly before surgery. Aim to keep glucose between 5-10 mmol/l, by adjusting infusion rates

13. 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
Monitor glucose every 30 minutes during surgery, and hourly in the post-operative period
Aim for a glucose of 5-10 mmol/l. Adjust rate of insulin infusion and intravenous fluids to keep the glucose between 5and 10 mmol/l.
Once the patient is awake, start feeds and regular doses of insulin (see chapter 3.1 on DKA, for transition from IV insulin to subcutaneous insulin)
Remember to monitor ketones if glucose is above 15 mol/l

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