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Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists

Martin, Lizabeth D. MD*; Hoagland, Monica A. MD; Rhodes, Erinn T. MD, MPH; Wolfsdorf, Joseph I. MB, BCh; Hamrick, Jennifer L. MD, ASMG§; Fehr, James MD; Kim, Ellen MD; Tommerdahl, Kalie MD; Gleich, Stephen J. MD; O’Reilly-Shah, Vikas MD, PhD; Tosone, Steve MD; Keech, Kathrine MD; D’Souza, Genevieve MD; Honkanen, Anita MD; on behalf of the Society for Pediatric Anesthesia Quality and Safety Committee Diabetes Workgroup Society for Pediatric Anesthesia Diabetes Workgroup members

Author Information
doi: 10.1213/ANE.0000000000004491

Abstract

An estimated 200,000 youth in the United States have type 1 diabetes mellitus (T1D),1 many of whom require anesthesia for surgery, diagnostic procedures, or imaging studies. Over the past 10 years, there have been remarkable advances in diabetes management including novel insulin formulations, continuous glucose monitoring (CGM) devices and continuous subcutaneous insulin infusion systems (CSII or insulin pumps), including hybrid closed-loop insulin delivery.2–4 Despite improved therapies, a majority of patients do not achieve optimal glycemic control,5 and health care advocacy groups, including the National Institutes of Health6 and American Diabetes Association,7–9 have highlighted the need for improved multidisciplinary guidance to manage patients with T1D.

As the perioperative care coordinators for surgical patients with medical diseases, anesthesiologists should recognize and plan for the specific challenges in patients with T1D. Multidisciplinary communication and planning, scheduling, and handoffs are complex. Fasting time, variability in surgical course and duration, differential response to surgical stress, and postoperative nausea and vomiting (PONV) must be considered.4,10,11 Attention to blood glucose (BG) monitoring and insulin therapy is required to maintain normoglycemia and avoid patient harm, which could result from persistent hypo- or hyperglycemia.10–13

The advances in diabetes management and technology, especially the use of insulin pumps and CGM systems,14 are highly relevant to the management of patients with T1D undergoing anesthesia. Given the limited available evidence to guide practice, the Society for Pediatric Anesthesia Quality and Safety Committee formed a multi-institutional working group to identify best practice recommendations and promote safe, quality perioperative care for this patient population.

METHODOLOGY

A multidisciplinary, multi-institutional approach was utilized to add rigor to these recommendations. Contributing authors were selected based on known expertise in pediatric anesthesiology and/or pediatric endocrinology with additional knowledge in local practices of perioperative diabetes mellitus management. Initially, content was derived based on literature review using PubMed (publication dates 1999–2019) and pre-existing guidelines at the authors’ institutions. These recommendations were developed through an iterative process with input from participants who represent 7 children’s hospitals through the Society for Pediatric Anesthesia Quality and Safety Committee. They were subsequently vetted with pediatric endocrinologists identified as local and/or international content experts.11,12 Three participating endocrinologists practice in centers that are different from the primary coauthors.

These recommendations do not encompass all clinical situations, are not intended to replace local institutional policies, and will require revision as clinical practice evolves. Deviation may be necessary, per the judgment of the anesthesiologist.

PREOPERATIVE MANAGEMENT

If available, preoperative consultation with the primary endocrinologist to coordinate a patient-specific perioperative plan is considered best practice.11,12 General recommendations, which may be useful in emergencies or practice settings where expert consultation is not available, are provided below.

Preoperative Planning

Preanesthesia evaluation, including assessment of glycemic control, serum electrolytes, and ketones (serum or urine), is recommended for all patients undergoing elective surgery.11,12 If glycemic control is suboptimal, it is ideal to delay elective surgery.11,12,15 There is no consensus in the pediatric literature regarding a glycated hemoglobin (HbA1c) cutoff to define adequate glycemic control with regard to perioperative risk.12 The adult literature has suggested that a HbA1c > 8% in adults with T1D warrants consideration of surgical delay.16 If surgery cannot be delayed, consider hospital admission to optimize glycemic control.11,12 Patients with T1D should be scheduled as first case of the day whenever possible11,12,15–17 to minimize fasting time and decrease the likelihood of delays.

Verify the patient’s usual insulin regimen, as well as dose and time of the last insulin administration. It is important to note the patient’s insulin-to-carbohydrate (I:C) ratio, correction factor (CF) or insulin sensitivity factor (ISF), and glucose targets preoperatively, because this patient-specific information is required to appropriately dose subcutaneous insulin. See Supplemental Digital Content, Appendix 1, http://links.lww.com/AA/C950, for guidance in calculating an appropriate subcutaneous insulin dose. Common insulin types used in pediatric patients are summarized in Table 1.

Table 1. - Common Types of Subcutaneous Insulin Used in Children
Generic Name Brand Name Time to Onset (h) Time to Peak (h) Duration (h)
Rapid-acting insulin
 Lispro (U-100) Humalog Admelog Within 0.25 0.5–1.5 4–6
 Aspart Novolog
Fiasp
Within 0.25 0.5–1.5 4–6
 Glulisine Apidra Within 0.25 0.5–1.5 4–6
Short-acting insulin
 Regular Human Insulin (U-100) Humulin R
Novolin R
0.5 1.5–2.5 8
Intermediate- and long-acting insulin
 NPH Insulin Humulin N
Novolin N
2–4 4–10 12–18
 Detemir Levemir 2–4 Flat 14–24
 Glargine (U-100) Lantus
Basaglar
2–4 Flat 20–24
 Degludec (U-100) Tresiba 1 Flat >42
Reprinted with permission from The American Diabetes Association. Copyright 2019 by the American Diabetes Association.
Refers to subcutaneous dosing. Onset, peak, and duration of action may vary by individual. Duration is dose dependent (larger doses result in longer duration).
N
PH insulin 4–10 h peak may predispose fasting patients to hypoglycemia.
A
bbreviation: NPH, neutral protamine Hagedorn.

The perioperative plan for insulin management depends, in part, on the type and duration of procedure being performed. In this discussion, procedures will be classified as follows:12

  • Minor procedures: Procedures lasting ≤2 hours where rapid recovery and a return to normal oral intake is expected.
  • Major procedures: Procedures lasting >2 hours or any procedure with a high likelihood of delayed return to normal oral intake due to PONV, prolonged bowel rest, or other medical concerns.

Preoperative communication with the patient and family is essential to confirm preoperative insulin and fasting instructions.

  • For all nonemergent procedures, patients should follow typical fasting instructions. Until 2 hours before the procedure, non–glucose-containing clear liquids may be encouraged to minimize hypovolemia and sugar-containing clear liquids may be considered to treat hypoglycemia. Anticipatory guidance for hypoglycemia should be provided to the patient and family during the fasting period, particularly those who have recently experienced hypoglycemia or are using a regimen that includes neutral protamine Hagedorn (NPH) insulin.
  • For minor procedures, reasonable preoperative insulin instructions include:
    • Basal-bolus regimen: Administer the patient’s usual dose of long-acting insulin, such as glargine (Lantus/Basaglar), detemir (Levemir), or degludec (Tresiba) the night before and/or morning of surgery per the patient’s usual regimen.11,12,15,18 Some endocrinologists may reduce this dose by 20%–30% if a pattern of low BG levels has been observed. Hold rapid-acting insulin on the day of surgery unless the patient has hyperglycemia that requires correction.11,12
    • Insulin pump: Continue the patient’s basal regimen preoperatively. Hold rapid-acting insulin boluses on the day of surgery unless the patient has hyperglycemia.12,17–19 Document the last pump site change and discuss the site plan for surgery. In anticipation for surgery, the insulin pump insertion site should be placed in a nondependent location away from the surgical field.17 Verify appropriate pump function and location before the procedure. See Methods of Insulin Administration (below) and Supplemental Digital Content, Appendix 2, http://links.lww.com/AA/C950, for detailed insulin pump recommendations.
  • For major procedures or for patients receiving NPH insulin, additional consultation with endocrinology and coordination with the surgical team is recommended for perioperative planning. Expert consultation is preferred for regimens that include NPH insulin because it has a peak effect at 4–10 hours, unlike other long-acting insulins, which may predispose fasting patients to hypoglycemia if the dose is not correctly adjusted in the perioperative period. Patients having major procedures will require an insulin infusion as outlined below.
Figure.
Figure.:
Emergency surgery algorithm for children with type 1 diabetes mellitus. Flow chart shape interpretation: Diamonds are decision points, used to ask a question. Rectangles are action steps. *Major procedures: last >2 h or any procedure with a high likelihood of delayed return to normal oral intake due to PONV, prolonged bowel rest, or other medical concerns. ^Minor procedures: last ≤2 h and rapid recovery with a return to normal oral intake is expected. BOHB indicates β-hydroxybutyrate; DKA, diabetic ketoacidosis; IV, intravenous; PONV, postoperative nausea and vomiting.

Emergency procedures warrant further discussion (Figure). If the emergent procedure is minor and the child is metabolically stable without evidence of diabetic ketoacidosis (DKA), subcutaneous insulin therapy may be continued for the procedure. However, if the procedure is major, the child is metabolically unstable, the anesthesiologist is uncomfortable evaluating and managing an insulin pump in an emergent situation, and/or the patient’s insulin status cannot be confirmed, then intravenous insulin therapy should be administered.12

Day of Surgery

Check BG before administering anesthesia and hourly if delays occur. The recommended perioperative BG target is 90–180 mg/dL (5–10 mmol/L).12

  • If the BG is >250 mg/dL, check for ketones (urine or serum) to exclude ketosis or DKA.12 Positive urine ketones (greater than or equal to small urine ketones) should be confirmed with a blood sample for β-hydroxybutyrate (BOHB).
    • If BOHB is ≥0.6 mmol/L,20 consult endocrinology to evaluate further for DKA and, if appropriate, follow DKA treatment protocols.21 Nonemergent procedures should be delayed until volume status and electrolytes normalize.
    • If BOHB is <0.6 mmol/L, treat hyperglycemia with rapid-acting insulin (see Methods of Insulin Administration) and consider fluid resuscitation with 0.9% normal saline as required.12
  • If the BG is <70 mg/dL, begin treatment for hypoglycemia (Supplemental Digital Content, Appendix 3, http://links.lww.com/AA/C950).10

INTRAOPERATIVE MANAGEMENT

Glucose Monitoring

Frequent BG monitoring is essential. Check BG at least hou-rly.4,11,12,15,18,22 Increase the frequency of BG monitoring to every 30 minutes if there is a change in therapy or to every 15 minutes if BG is <80 mg/dL.

The use of CGM systems has increased considerably in the pediatric diabetes mellitus population over the past decade. CGM devices measure the glucose concentration in the subcutaneous interstitial fluid and report values every 5 minutes.14 The reliability of CGM in the perioperative setting is uncertain. Measurements may not be accurate in the setting of profound hypoperfusion or hypothermia (<36°C),23 and certain medications may interfere with the accuracy of the sensor. For example, acetaminophen can cause a false elevation of glucose values for up to 8 hours after a dose with some sensor types.24 Further investigation suggests that other medications may impact CGM readings,25 and anesthetic medications have not been rigorously evaluated. Another important consideration is “compression artifact,” which refers to falsely low glucose readings when the sensor is located on a compressed body surface area.26,27 For these reasons, CGM can be used to follow trends,12,28 but it is recommended that perioperative CGM readings be verified with BG measurements before making treatment decisions.12 See Supplemental Digital Content, Appendix 2, http://links.lww.com/AA/C950, for more CGM considerations.

Methods of Insulin Administration

Table 2. - Intravenous Insulin Infusion Starting Rates and Titration12
Starting Blood Glucose (mg/dL) Insulin Infusion (Units/kg/h)
110–140 0.025
140–220 0.05
220–270 0.075
>270 0.1
C
heck BG at least hourly. Increase to every 30 min after a change in therapy or to every 15 min for blood glucose <80 mg/dL.
T
itrate infusion by 0.01–0.03 units/kg/h to achieve blood glucose target range of 90–180 mg/dL.

  • I. Subcutaneous Insulin
    • Subcutaneous basal-bolus insulin may be continued for minor procedures according to the patient’s usual regimen.
    • Rapid-acting insulin boluses (eg, insulin aspart, lispro, or glulisine) are used perioperatively to treat BG >250 mg/dL.
    • Subcutaneous insulin boluses for treatment of hyperglycemia should not be given more often than every 3 hours. Frequent dosing may result in insulin accumulation (“stacking”) and lead to subsequent hypoglycemia.
    • Use the patient-specific CF or ISF and a target BG of 150 mg/dL to determine the appropriate dose11 (Supplemental Digital Content, Appendix 1, http://links.lww.com/AA/C950).
  • II. CSII (insulin pump therapy):
    • Insulin pump therapy can be continued perioperatively for minor procedures if a competent caregiver or trained diabetes provider is available to review pump functions with the anesthesia team.11,12,17,18,22,29 If the patient is undergoing a major procedure, is metabolically unstable, a competent caregiver or trained provider is not available, or the pump is not in an accessible location due to draping and positioning, then insulin pump therapy should be discontinued and intravenous insulin administered.12,17,30 Insulin pumps may also be contraindicated in some procedures involving radiology and electrocautery (Supplemental Digital Content, Appendix 2, http://links.lww.com/AA/C950).
    • If insulin is delivered via a pump perioperatively, the patient’s basal rate should be continued. Hyperglycemia (BG >250 mg/dL) should be treated with subcutaneous rapid-acting insulin boluses as previously noted.
    • Any unexplained hyper- or hypoglycemia or metabolic derangement in the immediate perioperative period warrants discontinuation of the insulin pump and management with an intravenous insulin infusion.17
    • When a subcutaneous insulin pump is discontinued in well-controlled patients with near-normal glucose levels, plasma insulin levels begin to decline, and plasma glucose and plasma ketone levels rise within 60 minutes.31 It is recommended that an intravenous insulin infusion be started within 30 minutes12,17 and no more than 60 minutes after discontinuation,31 because even brief discontinuation can result in persistent hyperglycemia.32 If BG is elevated when the subcutaneous insulin pump is removed, an intravenous insulin infusion should be started immediately.
  • III. Intravenous Insulin Infusion:
    • Only regular insulin is used for intravenous infusions.
    • Intravenous insulin should not be administered as a bolus.
    • Recommended starting rates for insulin infusions in the operating room are shown in Table 2.12 After starting the insulin infusion according to Table 2, titrate dosing by 0.01–0.03 units/kg/h to keep BG within the target range of 90–180 mg/dL (5–10 mmol/L).
    • Intravenous insulin infusions require concurrent administration of dextrose-containing maintenance fluids.12 It is optimal to administer dextrose and insulin via a dedicated intravenous line, independently titrated and physically separate from bolus fluids.
    • The half-life of intravenous regular insulin is approximately 5 minutes. Therefore, administration of a dose of subcutaneous insulin by injection or resumption of insulin pump therapy should be started at least 15 minutes before discontinuation of an intravenous insulin infusion.

Dextrose-Containing Intravenous Fluids

For minor procedures, patients with a normal preoperative BG level may not require dextrose-containing fluids.12 Patients undergoing major procedures, those receiving a home insulin regimen that includes NPH (which may predispose the patient to hypoglycemia, noted above), or those on intravenous insulin infusions require administration of dextrose-containing intravenous fluids. Fluids containing 5% dextrose at the patient’s maintenance rate are generally sufficient, but fluids containing 10% dextrose may be required if the patient is at high risk for hypoglycemia or if initial BG is <100 mg/dL.10,12 The use of dextrose-containing fluids does not alter the basic principle that isotonic solutions are generally preferred in the perioperative period.33,34 Normal saline may be preferred in patients with metabolic derangements or hemodynamic instability; avoiding potassium-containing fluids is advised.12

PONV Prophylaxis

PONV prevention is particularly important in patients with T1D because refractory PONV can delay a return to normal oral intake and usual home insulin management. Consider 2 or more PONV prophylaxis interventions.4,15 Dexamethasone can cause undesirable perioperative hyperglycemia in patients with diabetes mellitus,35 and is not an ideal choice for routine prophylaxis in patients with T1D. In cases where dexamethasone may be needed (eg, airway surgery) and the benefits are considered to outweigh the risks, it may be used and close perioperative BG monitoring is recommended. Consider ketosis or DKA as possible etiologies of refractory PONV.

POSTOPERATIVE MANAGEMENT

Check BG on arrival to the postanesthesia care unit (PACU) and at least hourly until PACU discharge. For day surgery patients, resume home insulin regimen once oral nutrition is tolerated.11,12,19 If the patient is using an insulin pump, verify with patient and family that the pump is functioning properly with preoperative settings.

Consider admission and endocrinology consultation if the patient is not tolerating oral intake, has persistent PONV, BG values are persistently >250 mg/dL, or if BOHB is ≥0.6 mmol/L. For patients admitted to the hospital, provide direct, timely handoff to the service responsible for diabetes management.

CONTRIBUTORS

Society for Pediatric Anesthesia Diabetes Workgroup members: James Fehr, MD (Professor of Anesthesiology and Pediatrics, Washington University, St Louis, MO. Contribution: Project proposal and facilitation. Content review and revision of the manuscript), Ellen Kim, MD (Associate Professor of Pediatrics, Division of Pediatric Endocrinology, St Louis Children’s Hospital, Washington University, St Louis, MO. Contribution: Content review and revision of the manuscript), Kalie Tommerdahl, MD (Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO. Contribution: Content review and revision of the manuscript), Stephen J. Gleich, MD (Assistant Professor of Anesthesiology and Pediatrics, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN. Contribution: Content review and revision of the manuscript), Vikas O’Reilly-Shah, MD, PhD (Children’s Health care of Atlanta Division of Pediatric Anesthesiology & Emory University School of Medicine, Department of Anesthesiology, Atlanta, GA. Contribution: Content review and revision of the manuscript), Steve Tosone, MD (Associate Professor of Anesthesiology and Pediatrics, Children’s Health care of Atlanta, Emory University School of Medicine, Atlanta, GA. Contribution: Content review and revision of the manuscript), Kathrine Keech, MD (Assistant Professor of Anesthesiology, University of Iowa Department of Anesthesiology, Iowa City, IA. Contribution: Content review and revision of the manuscript), Genevieve D’Souza, MD (Clinical Assistant Professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA. Contribution: Content review and revision of the manuscript), Anita Honkanen, MD (Professor of Anesthesiology, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA. Contribution: Content review and revision of the manuscript).

DISCLOSURES

Name: Lizabeth D. Martin, MD.

Contribution: This author helped with literature review, coordination and vetting of content, and manuscript preparation.

Conflicts of Interest: None.

Name: Monica A. Hoagland, MD.

Contribution: This author helped with literature review, reviewed content, and helped with manuscript preparation.

Conflicts of Interest: None.

Name: Erinn T. Rhodes, MD, MPH.

Contribution: This author helped review the content and prepare the manuscript.

Conflicts of Interest: E. T. Rhodes is the Site Principal investigator for a clinical trial sponsored by Astra Zeneca and was formerly Site Principal Investigator for a clinical trial sponsored by Merck.

Name: Joseph I. Wolfsdorf, MB, BCh.

Contribution: This author helped review the content and prepare the manuscript.

Conflicts of Interest: None.

Name: Jennifer L. Hamrick, MD, ASMG.

Contribution: This author helped with literature review, reviewed content, and helped with manuscript preparation.

Conflicts of Interest: None.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

FOOTNOTES

GLOSSARY

BG = = blood glucose

BOHB = = β-hydroxybutyrate

CF = = correction factor

CGM = = continuous glucose monitoring

CSII = = continuous subcutaneous insulin infusion (insulin pump therapy)

DKA = = diabetic ketoacidosis

HbA1c = = glycated hemoglobin or hemoglobin A1c

I:C ratio = = insulin-to-carbohydrate ratio

ISF = = insulin sensitivity factor

IV = = intravenous

NPH = = neutral protamine Hagedorn

PACU = = postanesthesia care unit

PONV = = postoperative nausea and vomiting

T1D = = type 1 diabetes mellitus

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