BNF for Children (BNFC) 2018-2019

.Once blood glucose falls to 14 mmol/litre,glucose

intravenous infusion 5 %or 10 %should be added to the

fluids.

.The insulin infusion rate can be reduced to no less than

0. 05 units/kg/hour when blood-glucose concentration has

fallen to 14 mmol/litreandblood pH is greater than 7. 3 and

a glucose infusion has been started; it is continued until

the child is ready to take food by mouth. Subcutaneous

insulin can then be started.

.The insulin infusion should not be stopped until 1 hour

after starting subcutaneous soluble or long acting insulin,

or 10 minutes after starting subcutaneous insulin aspart

p. 455 , or insulin glulisine p. 456 , or insulin lispro p. 456.

Hyperosmolar hyperglycaemic state or hyperosmolar

hyperglycaemic nonketotic coma occurs rarely in children.

Treatment is similar to that of diabetic ketoacidosis,

although lower rates of insulin infusion and slower

rehydration may be required.

Diabetes, surgery and medical

illness 05-Jun-2017

Management of diabetes during surgery

gChildren with diabetes should undergo surgery in

centres with facilities and expertise for the care of children

with diabetes. Detailed local protocols should be available to

all healthcare professionals involved in the treatment of

these children. All surgery requiring general anaesthesia in

children with type 1 and type 2 diabetes requires hospital

admission.h

Note:The following recommendations provide general

guidance for the management of diabetes during surgery.

Local protocols and guidelines should be referred to

where they exist.

Use of insulin during surgery

Elective surgery—minor procedures

gMinor procedures(procedures of less than 2 hours

requiring either general anaesthesia or heavy sedation) in

children who have type 1 or type 2 diabetes should not have

a major impact on glycaemic control, and a slight

modification of the usual regimen may be all that is

necessary—adjustments should be made following local

protocol; taking into consideration the type of insulin or

antidiabetic drugs the child usually takes, whether fasting is

required, the time of day of the operation, and requirement

for intravenousfluids and glucose. All children who are

usually prescribed insulin require intravenous insulin during

surgery, to avoid ketoacidosis.h

Elective surgery—major procedures

gMajor procedures(procedures requiring general

anaesthesia for more than 2 hours) in children who have type

1 or type 2 diabetes, should ideally be performed when

diabetes is under optimal control. If glycaemic control is

poor, the procedure should be delayed if possible; otherwise

it is advisable to admit the child well in advance of surgery

for stabilisation of glycaemic control.

Blood-glucose concentration should be maintained within

the usual target range of 5 – 10 mmol/litre throughout the

peri-operative period for all surgical procedures.

Children usually prescribed insulin for type 1 or type 2

diabetes require an intravenous insulin infusion p. 454

during surgery (even if fasting) to avoid ketoacidosis.

Detailed local protocols should be consulted. In general, the

following steps should be followed:

.on theevening before surgery, the usual insulin regimen

should be given as normal; the usual bedtime snack should

be given and hourly capillary blood-glucose monitoring

should be initiated to detect hypoglycaemia or

hyperglycaemia before the procedure. Ketones should also

be checked if blood-glucose is above 14 mmol/litre, and an

appropriate dose of short-acting insulin should be

administered to restore blood-glucose to the target range;

.on themorning of surgerytheusualinsulin dose should be

omitted;

.at least 2 hours before the procedure, a maintenancefluid

infusion of sodium chloride 0. 45 % and glucose 5 %

(sodium chloride with glucose) intravenous infusion

should be started. A switch to sodium chloride 0. 9 %

infusion may be required if sodium concentration falls and

there is risk of hyponatraemia. After surgery, potassium

chloride p. 601 should be added to the intravenousfluid,

according to the child’s body weight andfluid

requirements. Electrolytes must be measured frequently

throughout, and adjustments to the infusion made as

necessary;

.soluble human insulin 1 unit/mL in sodium chloride 0. 9 %

intravenous infusion should be started with the

maintenancefluids at an infusion rate appropriate to the

blood-glucose concentration, to maintain a concentration

between 5 and 10 mmol/litre, adjusted according to hourly

blood-glucose monitoring;

.if the blood-glucose concentration falls below

6 mmol/litre the insulin infusion shouldnotbe stopped as

this will cause rebound hyperglycaemia; instead the rate

should be reduced; however, if blood-glucose

concentration drops below 4 mmol/litre the insulin

infusion can be stopped temporarily for 10 – 15 minutes.h

gAfter surgery, continue the glucose infusion, and the

intravenous insulin infusion or additional short-acting

insulin as necessary, until the child can eat and drink

normally and their usual treatment regimen can resume. A

short-acting insulin can also be given if required to reduce

hyperglycaemia.h

Emergency surgery

gChildren with diabetes (type 1 and 2 ) requiring

emergency surgery, should always have their blood-glucose,

blood or urinary ketone concentration, and serum

electrolytes checked before surgery. If ketones are high,

blood gases should also be checked. If ketoacidosis is

present, recommendations for Diabetic ketoacidosis p. 449

should be followed immediately, and surgery delayed if

possible. If there is no acidosis, intravenousfluids and an

insulin infusion should be started and managed as formajor

elective surgery(above).h

Use of antidiabetic drugs during surgery

gIf electiveminor surgical proceduresonly require a

short-fasting period (just one missed meal), it may be

possible to adjust antidiabetic drugs to avoid a switch to a

variable rate intravenous insulin infusion; normal drug

treatment can continue.

Children who usually takesulfonylureasshould have

their medication stopped on the day of surgery.h

gSulfonylureasare associated with hypoglycaemia in

the fasted state and therefore should not be recommenced

until the child is eating and drinking normally.l

gChildren undergoingminor proceduresrequire hourly

blood-glucose monitoring and, if blood-glucose

concentration rises above 10 mmol/litre, should be treated

with subcutaneous rapid-acting insulin no more frequently

than every 3 hours.

Children undergoing amajor surgicalprocedure expected

to last at least 2 hours should be managed on an intravenous

insulin infusion following the recommendations forElective

surgery(above).h

gInsulin is almost always required in medical and

surgical emergencies.l

gMetformin hydrochloride p. 452 is renally

excreted; renal impairment may lead to accumulation and

lactic acidosis during surgery. In children undergoingmajor

surgerylasting more than 2 hours, metformin hydrochloride

450 Diabetes mellitus and hypoglycaemia BNFC 2018 – 2019

Endocrine system

6