Child/Adolescent Health

A surgery management protocol helps children with diabetes prepare for surgery

Surgery causes a complex neuroendocrine stress response that can lead to hyperglycemia (excessively high blood-sugar levels) and diabetic ketoacidosis (a life-threatening condition in which the pH of the blood decreases) in children with diabetes. These metabolic effects may be compounded by the requirement of "nothing by mouth" prior to surgery. The resulting hyperglycemia can impair wound healing and the body's infection-fighting ability, needed to recover from surgery. Thus, children with diabetes, who either have no insulin (type 1 diabetes) or not enough insulin (type 2 diabetes) to metabolize sugar, must be carefully managed prior to surgery. A surgery management protocol for children with diabetes was recently developed at Children's Hospital Boston, supported in part by the Agency for Healthcare Research and Quality (HS00063).

According to the protocol, the anesthesiologist should schedule a preoperative consultation to assess the child's metabolic control with the Pre-Op Clinic and Endocrine Service at least 10 days before surgery. When feasible, elective surgery for children with diabetes should be delayed until metabolic control is acceptable: no ketonuria, normal serum electrolytes, and HbA1c (blood-sugar) values close to the ideal range for the child's age. Also, these surgeries should be scheduled, whenever possible, as the first case in the morning to avoid prolonged fasting and so that diabetes treatment regimens can be most easily adjusted.

The preoperative management plan should be based on the child's typical treatment regimen. The regimen for managing diabetes before, during, and after surgery should aim to maintain near-normal blood glucose levels of about 100-200 mg/dL. A child with diabetes should never undergo anesthesia without a blood glucose determination before the anesthetic is started. The insulin and fluid regimen during and after surgery depends on the duration of the procedure, as outlined in the protocol. Also, frequent post-surgical blood glucose monitoring and monitoring of blood or urine ketones is essential.

More details are in "Perioperative management of pediatric surgical patients with diabetes mellitus," by Erin T. Rhodes, M.D., M.P.H., Lynne R. Ferrari, M.D., and Joseph I. Wolfsdorf, M.B., B.Ch., in the October 2005 Anesthesia Analog 101, pp. 986-999, 2005.

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