dm_paed_theatre

Mx of diabetes in children going to theatre for surgery

introduction

general principles for minor procedures in a well patient

  • normal diet and insulin Rx on day prior to theatre
  • finger-prick blood glucose levels every hour starting at 6am, aiming to maintain BGL between 5-10 mmol/L, and every 2 hours post-operatively for 12-24hrs post-surgery
  • fast prior to theatre as per anaesthetist instructions
    • minimise the time patients with diabetes are fasted before theatre
    • can usually give clear fluids including glucose orally for Rx of hypoglycaemia, up until 2 hours prior to theatre
      • if BGL < 5mmol/L and delay in iv access, give 5-10mL/kg (max 200mL) of lemonade or other clear sugar-containing, non-particulate fluid (10% sugar)
  • commence IV infusion of 5% glucose and 0.45% sodium chloride at usual fluid maintenance rates if either:
    • on continuous S/C insulin infusion pump and one hour before induction of anaesthesia, or,
    • pre-op and BGL < 6mmol/L,
    • < 2 hours post-op and BGL < 4mmol/L
    • NB. discontinue iv fluids once patient is eating and drinking normally
    • NB. if extended fasting post-op, use intravenous infusion 5% glucose, 0.45% sodium chloride and 20mmol/L potassium chloride at the required maintenance rate as long as required and give reduced doses of long acting and short acting insulins, or use an iv insulin infusion
  • for type 1 diabetics, a basal insulin dose must be maintained:
    • patients on bd mixed insulin Rx:
      • omit morning short acting insulin and give usual dose of long acting unless otherwise directed
      • post-op, consider giving a stat dose of short acting insulin (0.1-0.25 units/kg) if BGL > 15mmol/L before lunch, check for ketones!
    • patients on basal bolus insulin Rx:
      • give the usual long acting insulin and omit the morning short acting insulin
      • continue to omit the usual short acting doses until eating normally, or BGL > 10mmol/L
    • patients with continuous S/C insulin infusion pump:
      • pre-op:
        • keep the pump on usual basal rates, giving correctional boluses (using the insulin pump bolus advisor facility) as usual if required.
      • during procedure, consider either:
        • disconnecting insulin pump just prior to starting theatre, give pump to parant, and reconnect when patient is in recovery, preferably in presence of paraent or guardian, or,
        • setting it to a temporary 80% of basal dose rate during procedure

emergency or major surgery

systemically unwell patient (eg. acute surgical abdomen)

  • assess for ketoacidosis and dehydration
  • if not ketotic:
    • consider iv insulin infusion at 0.02-0.04 units/kg/kr and adjust as needed according to hourly BGL, ketones/acidosis
    • ensure intravenous infusion of 5% glucose, 0.45% sodium chloride with 20mmol/L potassium chloride at required maintenance rate (with or without an insulin infusion) is running before, during and after surgery.
  • if dehydrated or ketotic:

systemically well patient

  • maintenance intravenous fluids (5% glucose, 0.45% sodium chloride with 20mmol/L potassium chloride) at required rate, until diet is re-introduced
  • discuss insulin Rx with paediatric endocrinologist
    • consider, intravenous insulin infusion at 0.02-0.04 units/kg/hr (usual total daily insulin in systemically well children and teenagers is 0.5 – 1 units/kg/day), and adjust according to hourly blood glucose concentrations and the presence of acidosis/ketones.
dm_paed_theatre.txt · Last modified: 2014/04/17 05:50 by gary1