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

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.

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.

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.

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).  

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.

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

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.

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.

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

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%.

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

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

14 Questions Take questions

novo nordisk changing diabetes - Outro Changing Diabetes® and the Apis bull logo are registered trademarks of Novo Nordisk A/S 15 15 novo nordisk changing diabetes - Outro