Management of children with diabetes requiring surgery or fasting

Elective surgery

• Operations are best scheduled early on the list, preferably in the morning
• Admit to hospital the afternoon prior to surgery for morning and major operations, or early morning for minor operations later in the day
• Earlier admission is important if glycemic control is poor
• Admission should be to a pediatric diabetes or pediatric surgical ward

Evening prior to surgery

• Frequent BG monitoring is important especially before meals and snacks and before bedtime (and check urinary ketones)
• Usual evening or bedtime insulin(s) and bedtime snack should be given
• Ketosis or severe hyperglycemia will necessitate correction, preferably by overnight IV infusion, and might cause a delay in surgery

Morning operations

• No solid food from midnight
• Clear fluids may be allowed up to 4 h preoperatively (check with anesthetist)
• Omit usual morning insulin dose
• Start IV fluid and insulin infusion at 6.00–7.00 am (Table 9)
• Hourly BG monitoring preoperatively; half-hourly during operation and until woken from anesthetic
• Hourly BG monitoring for 4 h postoperatively
• Aim to maintain BG between 5 and 12 (Table 9)
• Continue IV infusions until the child tolerates oral fluids and snacks (this may not be until 24–48 h following a major operation)
• Change to usual SC insulin regimen or short/rapid-acting insulin before the first meal is taken
• Stop insulin infusion 60 min after the SC insulin is given
• For minor operations it may be possible to discharge from hospital after the evening meal if the child is fully recovered

Afternoon operations

• Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
• Allow a light breakfast; clear fluids may be allowed up to 4 h preoperatively
• Start IV fluids and insulin infusion at midday at the latest (Table 9)
• Then as for morning operations (above).
  [Alternatively IV insulin infusion may be started at breakfast time]