Pediatric Diabetes. ISPAD Clinical Practice Consensus Guidelines 20062007 Diabetes in Children and Adolescents (5), and the Canadian Diabetes Association: …
Pediatric Diabetes 2007: 8: 242247 All rights reserved
2007 The Authors Journal compilation 2007 Blackwell Munksgaard
Pediatric Diabetes
ISPAD Clinical Practice Consensus Guidelines 20062007
Management of children with diabetes requiring surgery
Betts P, Brink SJ, Swift PGF, Silink M, Wolfsdorf J, Hanas R Management of children with diabetes requiring surgery Pediatric Diabetes 2007: 8: 242247
Royal Infirmary, Leicester LE1 5WW, UK; dInstitute of Endocrinology, The Childrens Hospital at Westmead, Sydney, Australia; eDivision of Endocrinology, Childrens Hospital, Boston, MA, USA; fDepartment of Pediatrics, Uddevalla Hospital, Uddevalla, Sweden Corresponding author: Ragnar Hanas, MD, PhD Department of Pediatrics Uddevalla Hospital S-451 80 Uddevalla Sweden e-mail: ragnarhanas@vgregionse Editors of the ISPAD Clinical Practice Consensus Guidelines 20062007; Ragnar Hanas, Kim Donaghue, Georgeanna Klingensmith, and Peter GF Swift
Peter Bettsa, Stuart J Brinkb, Peter GF Swiftc, Martin Silinkd, Joseph Wolfsdorfe, Ragnar Hanasf
a
Southampton University Hospitals Trust, Southampton, UK; b Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA; cChildrens
Hospital, Leicester
When children with diabetes require surgery or other procedures requiring sedation or anesthesia, optimal management should maintain adequate hydration and near to normal glycemia, while minimizing the risk of hypoglycemia The stress of surgery may cause acute hyperglycemia, which increases the risk of postoperative infection 1, 2 B Evidence-based controlled studies of perioperative care in children have not been conducted, but a review of management has recently been published in the anesthesiology literature 3; our current guidelines are consistent with the recommendations in that reference Perioperative management of type 1 diabetes in adults is reviewed in a separate reference 4 The current revised guidelines are based on those of the ISPAD Consensus Guidelines 2000 with additions and amendments from the Australian Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents 5, and the Canadian Diabetes Association: Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada 6 As there are few relevant scientific papers on management during surgery, the recommendations are mostly based on expert consensus
Glycemic
targets for surgery
In the past, adults with diabetes have had an increased risk of postoperative wound infections
approximately 10-fold in a study of 23 000 patients in 1973 7 C However, when blood glucose BG is maintained between 68 and 93 mmol/L 122 168 mg/dL, there is no difference in the risk of postoperative wound infections after major vascular surgery 8 B Maintaining BG levels below 11 mmol/L 200 mg/dL for the first two postoperative days decreased the risk of sternal wound infections after heart surgery from 24 to 15 9 C Improved postoperative glycemic control [plasma glucose levels of 4560 mmol/L 80110 mg/dL] using continuous intravenous IV insulin infusion significantly decreased mortality and morbidity in patients who required postoperative intensive care and mechanical ventilation after major surgery 10 A With this degree of tight glycemic control, 52 of subjects experienced hypoglycemic episodes compared with 08 in the control group; however, none of the episodes was severe 11 A The safe implementation of such intensive glycemic control with a continuous IV insulin infusion requires a written protocol and staff training to ensure effectiveness and to minimize the
risk of hypoglycemia To achieve optimal glycemic control, insulin dosage may need to be increased on the day of major surgery and for approximately 2 d after surgery This is best achieved by continuous IV insulin infusion even after the resumption of oral feeding 12 C
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Surgery in children with diabetes Appropriate perioperative glycemic targets for brief and minor surgical procedures are less clear To date, no intervention studies have assessed the impact of different BG levels on morbidity or mortality in these circumstances However, a few studies in adults that compared different methods of achieving glycemic control during minor and moderate surgery did not show any adverse effects of maintaining perioperative glycemic levels between 5 and 11 mmol/L 90 200 mg/dL 13, 14 A 15 B Because the data in adults show adverse effects of hyperglycemia, and support tight perioperative control of glucose in patients undergoing major surgery, it seems reasonable to aim for BG levels between 5 and 10 mmol/L 90180 mg/dL during surgical procedures in children E The benefits of tight glycemic control must be weighed against the risk of perioperative hypoglycemia, which may not be recognized
during anesthesia; however, this risk can be mitigated by frequent capillary BG monitoring iii The elective surgery should be scheduled as the first case on a surgical list, preferably in the morning E iv Centers performing surgical procedures on children with diabetes should have available written protocols for postoperative management of diabetes on the wards where children are admitted E v IV access, infusion of glucose, and frequent BG monitoring is essential in all situations when general anesthesia is given Glucose 5 is usually sufficient; glucose 10 may be necessary when there is a risk of hypoglycemia E vi Elevated blood ketone beta-hydroxybutyrate, BOHB and BG concentrations require extra insulin and possibly IV fluids for correction Such correction also requires the consideration of delay and rescheduling of an elective surgical procedure A bedside meter for BOHB levels works well in a hospital setting and may suffice for monitoring 16 B, E
Children with type 1 diabetes or type 2 treated with insulin requiring a major surgical procedure
d
It is helpful in the management of children with diabetes undergoing surgery to divide procedures into two categories: i Minor
surgery or procedures that require a brief GA or heavy sedation, usually of less than 1-h duration, and that should not have a major impact on glycemic control Examples include endoscopies, jejunal biopsy, adenotonsillectomy, grommet insertion, or repeated short procedures such as in oncology or burns wards The child will usually be discharged from hospital on the day of procedure ii Major surgery that requires more prolonged general GA is associated with greater risks of metabolic decompensation, and the child is unlikely to be discharged from hospital on the day of procedure Although the majority of surgical procedures are elective, both types of procedure may occur as emergencies
d d
d
Must be admitted to hospital for general anesthesia GA Need insulin, even if fasting, to avoid ketoacidosis Should receive a glucose infusion when fasting for more than 2 h before an anesthetic to prevent hypoglycemia Should be carefully monitored via capillary BG measurement for hyperglycemia as stress caused by surgery may cause hyperglycemia and increased insulin requirements Anesthesia may cause vasodilatation and drop the blood pressure BP If there is an unexpected acute event bleeding,
drop in BP, normal saline 09 NS or Ringers lactate must be infused rapidly In this case, potassium-containing fluids must not be infused rapidly
Recommendations
i Whenever possible, surgery on children and adolescents with diabetes should be performed in centers with appropriate personnel and facilities to care for children with diabetes E ii To ensure the highest levels of safety, careful liaison is required between surgical, anesthetic, and childrens diabetes care teams before admission to hospital for elective surgery and as soon as possible after admission for emergency surgery E
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Elective surgery
This should be performed when the diabetes is under the best possible control If glycemic control is uncertain or poor;
d
Consider admission to hospital prior to surgery for assessment and stabilization of glycemic control If control remains problematic;
d
Surgery should be cancelled and rescheduled
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Betts et al
Scheduling of surgery
d
d
d
Procedures are preferably scheduled first on surgical lists, ideally in the morning Admit to hospital in the afternoon prior to surgery for major operations, but in appropriate circumstances, it is
possible to admit early on the day of surgery for both minor and major operations E
When oral intake is not possible, the IV infusion should continue for as long as necessary
Minor surgery where discharge home usually occurs later in the day of surgery
d
d
Procedures preferably should be first on a surgical list, ideally in the morning Aim for BG 510 mmol/L 90180 mg/dL during and after surgery E
Evening prior to surgery
d
d
d
Frequent BG monitoring is important especially before meals and snacks and at bedtime measure blood ß-hydroxybutyrate and/or urinary ketone concentration if BG is 1520 mmol/L E Give the usual evening or bedtime insulins and bedtime snack Ketosis or severe hyperglycemia will necessitate correction, preferably by overnight IV insulin infusion, and might delay surgery
Algorithms for different types of insulin regimens are suggested below For more detail, see Rhodes et al 3
d d
No solid food for at least 6 h prior to GA Clear fluids including breast milk are allowed up to 4 h before anesthesia check with anesthetist
Patients treated with twice daily insulin regimens
Morning operations scheduled 0800 h to 0900 h d At 0700 h, give 50 of the usual morning
dose of intermediate-acting insulin NPH, lente Omit the short- or rapid-acting insulin unless needed to correct hyperglycemia Commence IV fluids use glucose 510, as necessary, to prevent hypoglycemia d After surgery, start oral intake or continue IV glucose depending on the childs condition Give small doses of short- or rapid-acting insulin based on the childs usual correction factor, if needed, to reduce hyperglycemia or to balance food intake The dinner or evening dose of insulin is given as usual d Alternatively, IV insulin infusion may be started at 0700 h see below d If IV insulin has been used, continue the insulin infusion until lunch and then given a small dose of short- or rapid-acting insulin to last until the dinner or evening insulin dose d If the child is fully recovered, it may be possible to discharge the child from hospital later in the day Afternoon operations scheduled for 1300 h to 1400 h At 0700 h, give 50 of the usual dose of intermediate-acting insulin NPH, lente and the usual dose of short- or rapid-acting insulin d Alternatively, give 3040 of the usual morning insulin dose of short- or rapid-acting insulin but no intermediate- or long-acting insulin and use
an IV insulin infusion beginning at least 2 hours before surgery Table 1 d Allow the child to eat a light breakfast Clear fluids may be allowed up to 4 hours before anesthesia Start IV fluids and IV insulin infusion, if applicable 2 hours before surgery or no later than midday Table 1 d Thereafter, proceed as for morning operations above
d
Major elective surgery that requires, at a minimum, overnight hospital stay postoperatively
d
d d
d d
d
d
d
d
Procedures preferably should be first on the list, ideally, in the morning No solid food for at least 6 h prior to surgery Clear fluids including breast milk may be allowed up to 4 h before surgery check with anesthetist Omit the usual morning insulin dose At least 2 h before surgery start, an IV insulin infusion with glucose 5 10 if there is concern about hypoglycemia see Table 1 4 E If BG is high 14 mmol/L, 250 mg/dL, use 05 NS or NS without glucose and increase insulin supply, but add 5 dextrose when BG falls below 14 mmol/L 250 mg/dL Monitor BG hourly before surgery and every 30 60 min during the operation and until the child awakens from anesthesia E Monitor BG hourly for 4 h after surgery or for as long as the patient is
receiving IV insulin Aim to maintain BG between 5 and 10 mmol/L 90180 mg/dL and use correction rates of IV insulin during surgery E With IV insulin, a suitable ratio of insulin to glucose for prepubertal children is typically 1 unit per 5 g of IV glucose and for adolescents 1 unit per 3 g of IV glucose 3 E The dose is adjusted based on BG response Once the patient is awake, it should be possible to adjust the IV insulin to maintain BG in the ideal range, 458 mmol/L 80160 mg/dL, without excessive risk of hypoglycemia Table 1 E
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Table 1 Infusion guide for surgical procedures Maintenance fluid guide Glucose 5 glucose; 10 if there is concern about hypoglycemia If BG is high 14 mmol/L, 250 mg/dL, use 05 normal saline or normal saline without glucose and increase insulin supply but add 5 dextrose when BG falls below 14 mmol/L 250 mg/dL Sodium Saline 018025 2040 mmol Na/L with glucose is widely used There is evidence that the risk of acute hyponatremia may be increased when using hypotonic maintenance solutions ie, ,09 NaCl in hospitalized children 18 C Many centers, therefore, use saline 04509 77154 mmol Na/L A
compromise would be to give 045 saline with 5 glucose, carefully monitor electrolytes, and change to 09 saline if plasma-Na is falling Potassium Monitor electrolytes After surgery, add potassium chloride 20 mmol to each liter of intravenous fluid Some centers add potassium routinely only if infusion is required for more than 12 h Example of calculation of maintenance requirements 19 C, E, tables for this vary between centers, use one that is locally agreed and established For each kg between For each kg between For each kg over Max 2000 mL female, 2500 mL male Body weight 39 kg 1020 kg 20 kg Fluid requirement/24 h 100 mL/kg Add an additional 50 mL/kg Add an additional 20 mL/kg
Insulin infusion Add soluble insulin 50 units to 50 mL normal saline 09, making a solution of 1 unit insulin/mL; attach to syringe pump and label clearly Start infusion at 0025 mL/kg/h ie, 0025 U/kg/h if blood glucose is ,67 mmol/L, 005 mL/kg/h if 812 mmol/L, 0075 mL/kg/h between 12 and 15 mmol/L and 01 U/kg/h if 15 mmol/L Aim to maintain BG between 5 and 10 mmol/L, depending of the type of surgery, by adjusting insulin infusion hourly BG must be measured at least hourly when the patient is on IV insulin Do
not stop the insulin infusion if BG , 56 mmol/L 90 mg/dL as this will cause rebound hyperglycemia Reduce the rate of infusion The insulin infusion may be stopped temporarily if BG ,4 mmol/L 55 mg/dL but only for 1015 min BG, blood glucose
Patients on basal-bolus insulin regimens 17
Morning operations scheduled for 0800 h to 0900 h d Children on basalbolus regimens benefit from not discontinuing their basal insulin before minor surgical procedures as IV insulin will disrupt their usual basal insulin supply when restarting subcutaneous SC insulin injections This is particularly relevant for children requiring repeated procedures d Consider the need for reduction by 2030 of the preceding evening long-acting insulin if there is a pattern of low BG values in the morning d If the general anesthesia is short ,1 h, give 50 of the usual morning dose of intermediate-acting insulin dose NPH, lente or 75100 of the dose if the patient takes long-acting insulin glargine, detemir, ultratard at 0700 h and commence IV fluids containing glucose 5 10 if risk of hypoglycemia Do not give short- or rapid-acting insulin in the morning unless necessary to correct hyperglycemia d Alternatively, IV regular
insulin infusion may be started at breakfast time omitting all types of morning SC insulin
Pediatric Diabetes 2007: 8: 242247
d
d
d
Perform BG measurements before, during, and immediately after GA at least hourly and, if necessary, increase glucose concentration of IV fluids to 10 to prevent hypoglycemia Adjust glucose infusion and insulin by SC injection of rapid-acting insulin or IV infusion to maintain perioperative BG in the range 510 mmol/L E In the postoperative period, supplemental midmorning short-/rapid-acting insulin may be given if required 1025 of total daily dose and, when tolerated, a light meal Later in the day, the aim is to resume normal meals and premeal insulin doses as soon as the child is able to tolerate oral feeds
Afternoon operations scheduled for 1300 h to 1400 h The patient is usually allowed to eat breakfast and drink clear fluids until 4 h preoperatively d At breakfast, give the usual dose of rapid-acting or 5060 of the usual short-acting insulin and usual dose of basal intermediate- or long-acting insulin if usually given at this time d Commence IV fluids containing glucose 5 10 if risk of hypoglycemia at a maintenance rate approximately 2 h after
breakfast
d
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Betts et al
d
d
d
Measure capillary BG hourly and, if necessary, adjust the glucose concentration of IV fluids to prevent hypoglycemia Give supplemental IV insulin, if needed, to keep perioperative BG concentrations in the target range After surgery, IV insulin or additional short-/rapidacting insulin may be required until normal eating is resumed Later, if tolerated, resume meals and the childs usual insulin at the appropriate times
add small doses of rapid-acting insulin Give bolus dose and food when the child can eat again
Emergency surgery
Diabetic ketoacidosis may present as an Ôacute abdomen Acute illness may precipitate diabetic ketoacidosis with severe abdominal pain
Patients on insulin pumps
d
The diabetes team should determine the approach depending on the individual patient and procedure
d d
d
d
d d
When a child on continuous subcutaneous insulin infusion CSII goes to the operating theatre, it is important to secure the SC infusion site to prevent dislodgement and interruption of insulin supply during the procedure If the general anesthesia is short approximately ,1 h, the pump can be continued at the basal rate, keeping IV glucose 5 infusion
at the maintenance rate see below Do not give a morning/meal bolus dose unless necessary to correct hyperglycemia Monitor BG levels hourly preoperatively and at least half hourly during GA When necessary, correction doses can be given with the pump preoperatively and postoperatively Alternatively, give extra IV insulin to keep perioperative BG within target A meal bolus is given when the patient is ready to eat Alternatively, CSII can be discontinued and a continuous IV insulin and glucose infusion commenced, as described above, until feeding has been satisfactorily established
d
d
d
No fluid food or medication by mouth; in some emergency situations the stomach must be emptied by a nasogastric tube Secure IV access Check weight, measure serum electrolytes, BG, blood gases, and blood ß-hydroxybutyrate or urinary ketones before anesthesia If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery until circulating volume and electrolyte deficits are corrected If there is no ketoacidosis, start IV fluids and insulin infusions as for elective surgery
Type 2 diabetes
For those individuals who have type 2 diabetes and are treated with insulin, follow the
insulin guidelines as for elective surgery, depending on type of insulin regimen
Patients on oral treatment
Metformin: discontinue 24 h before the procedure for elective surgery, if ,24 h since the last dose for emergent surgery, it is essential to maintain hydration with IV fluids before, during, and after surgery Sulfonylureas or thiazolidinediones: stop for the day of surgery Monitor BG hourly and if greater than 10 mmol/L 180 mg/dL treat with IV insulin, as for elective surgery, to normalize levels, or SC insulin if it is a minor procedure
Minor procedures requiring fasting simplified procedure
For short procedures with or without sedation or anesthesia and when rapid recovery is anticipated, a simplified protocol may be formulated by personnel experienced in the anesthesia for children with diabetes and may include the following alternatives:
d
References
1 GOLDEN SH, PEART-VIGILANCE C, KAO WH, BRANCATI FL Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes Diabetes Care 1999: 22: 14081414 2 POMPOSELLI JJ, BAXTER JK 3rd, BABINEAU TJ et al Early postoperative glucose control predicts nosocomial infection rate in
diabetic patients JPEN J Parenter Enteral Nutr 1998: 22: 7781 3 RHODES ET, FERRARI LR, WOLFSDORF JI Perioperative management of pediatric surgical patients with diabetes mellitus Anesth Analg 2005: 101: 986999 4 GLISTER BC, VIGERSKY RA Perioperative management of type 1 diabetes mellitus Endocrinol Metab Clin North Am 2003: 32: 411436
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Early morning procedure eg, 0800 h to 0900 h: delay insulin and food until immediately after completion of the procedure
Twice daily insulin: give 50 of usual insulin dose NPH/lente and short-/rapid-acting or give repeated small doses of short-/rapid-acting insulin 2050 of morning short-/rapid-acting dose
d
Basal/bolus or CSII: give usual basal insulin/ continue basal rate in the morning and, if needed,
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5 APEG AUSTRALASIAN PAEDIATRIC ENDOCRINE GROUP Australian Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents, Australian Government: National Health and Medical Research Council, 2005 http://wwwchweduau/prof/services/endocrinology/apeg 6 CANADIAN DIABETES ASSOCIATION Clinical Practice Guidelines for the prevention and management of diabetes in Canada
Can J Diab 2003: 27Suppl 2: S84S93 7 CRUSE PJ, FOORD R A five-year prospective study of 23,649 surgical wounds Arch Surg 1973: 107: 206210 8 HJORTRUP A, RASMUSSEN BF, KEHLET H Morbidity in diabetic and non-diabetic patients after major vascular surgery Br Med J Clin Res Ed 1983: 287: 11071108 9 ZERR KJ, FURNARY AP, GRUNKEMEIER GL, BOOKIN S, KANHERE V, STARR A Glucose control lowers the risk of wound infection in diabetics after open heart operations Ann Thorac Surg 1997: 63: 356361 10 VAN DEN BERGHE G, WOUTERS P, WEEKERS F et al Intensive insulin therapy in the critically ill patients N Engl J Med 2001: 345: 13591367 11 VAN DEN BERGHE G, WOUTERS PJ, BOUILLON R et al Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control Crit Care Med 2003: 31: 359366 12 KAUFMAN FR, DEVGAN S, ROE TF, COSTIN G Perioperative management with prolonged intravenous insulin infusion versus subcutaneous insulin in children with type I diabetes mellitus J Diabetes Complications 1996: 10: 611 13 HEMMERLING TM, SCHMID MC, SCHMIDT J, KERN S, JACOBI KE Comparison of a continuous glucoseinsulin-potassium infusion versus intermittent bolus application of insulin
on perioperative glucose control and hormone status in insulin-treated type 2 diabetics J Clin Anesth 2001: 13: 293300 14 CHRISTIANSEN CL, SCHURIZEK BA, MALLING B, KNUDSEN L, ALBERTI KG, HERMANSEN K Insulin treatment of the insulin-dependent diabetic patient undergoing minor surgery Continuous intravenous infusion compared with subcutaneous administration Anaesthesia 1988: 43: 533537 15 RAUCOULES-AIME M, LUGRIN D, BOUSSOFARA M, GASTAUD P, DOLISI C, GRIMAUD D Intraoperative glycaemic control in non-insulin-dependent and insulin-dependent diabetes Br J Anaesth 1994: 73: 443449 16 REWERS A, MCFANN K, CHASE HP Bedside monitoring of blood beta-hydroxybutyrate levels in the management of diabetic ketoacidosis in children Diabetes Technol Ther 2006: 8: 671676 17 KILHAM H, ISAACS D eds Endocrinology and diabetes In: The Childrens Hospital at Westmead Handbook: Clinical Practice Guidelines in Paediatrics, 4th edn Australia: McGraw-Hill Australia Pty Ltd, 2004: 186216 18 CHOONG K, KHO ME, MENON K, BOHN D Hypotonic versus isotonic saline in hospitalised children: a systematic review Arch Dis Child 2006: 91: 828835
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