Management of Perioperative Blood Glucose in Children

Educational Objectives

The goal of this program is to improve the management of hypoglycemia and hyperglycemia in pediatric patients during the perioperative period. After hearing and assimilating this program, the clinician will be better able to:

1. Compare requirements for dextrose during the perioperative period in patients on subcutaneous vs intravenous insulin.
2. List diagnostic procedures in which automated insulin delivery systems are contraindicated.

Summary

Prevalence of glucose-related disorders in pediatric patients: Vanderhoek et al (2023) reported dysglycemia in ≈27% of pediatric patients; patients with higher American Society of Anesthesiologists (ASA) status, infants, premature babies, and patients with nutritional support are more likely to have dysglycemia in the perioperative period; the study also reported dysglycemia to be related to specific outcomes; dysglycemia can be a marker of perioperative stressors; Hirshberg et al (2008) evaluated dysglycemia in the pediatric intensive care unit (PICU); the study reported a higher rate of hypoglycemia, hyperglycemia, or mixed dysglycemia, especially in patients undergoing cardiac surgery; ≈20% of the patients had glucose levels of >300 mg/dL, but none were treated with insulin; 10% of patients had hypoglycemia in the absence of any insulin treatment; in pediatric patients, clinicians witness a higher rate of hypoglycemia compared with hyperglycemia

Management considerations: the threshold for euglycemia changes rapidly in pediatric patients; normal glucose levels in neonates in the initial few days are 40 to 50 mg/dL; in general, patients with or at risk for hypoglycemia should receive some glucose; some patients require insulin, usually those with type 1 diabetes mellitus (DM); adults suffer from stress hyperglycemia, but in pediatrics, clinicians aim high and try to avoid hypoglycemia, so treatment of stress hyperglycemia with insulin is rare in children

Metabolic pathways: when glucose is low, the body relies on fats and proteins for energy; it is the balance of insulin and glucagon and stress hormones that regulates the use of glucose; during physiologic stress, there is more emphasis on glucagon and the stress hormones, which prevent the influx of sugar into the cells, leading to serum hyperglycemia; use of fats and proteins in such conditions may result in ketonemia; the literature suggests that most healthy children tolerate fasting; although children maintain normal blood sugars, they may have ketonemia, indicating the use of fats and proteins as an alternative energy source; blood glucose generally rises intraoperatively because physiologic stress stimulates the release of catecholamines and cortisol; however, children on nutritional support or with higher glycogen reserve may not have an increase in blood glucose levels; normal blood glucose does not necessarily indicate adequate energy as the child may be relying on fats and proteins to maintain glucose levels; this could be detrimental in a specific patient population; studies report no correlation of blood glucose with age and size of patients, type of anesthesia, type of surgery, or duration of fasting

Intraoperative glucose requirements: despite best practices, it is difficult to frequently check glucose levels in small children; most children without prolonged fasting time do not require dextrose; patients should have adequate intravenous (IV) fluid replacement to maintain normal volume status and avoid acidosis; however, certain patients may need dextrose, including patients with prolonged surgery (>3 hr), low body weight, undergoing regional anesthesia, low metabolic stores, metabolic disorders, or high catabolic states; the recommendation is to administer lower concentration dextrose (D1%-2.5%) and higher concentration (5%-10%) in specific patient populations; neonates require D10% at half to total maintenance rates to meet glucose requirements; infants and children respond well to D5% at half maintenance

Neonates: during the first few days, the kidneys are not working effectively and are not concentrating urine well; glycogen stores are low; they require a constant supply of dextrose; neonatologists initiate with a low volume of dilute solution followed by an increased rate with the addition of solutes; these patients have limited reserves

Metabolic disorders: patients with carbohydrate metabolic disorders are unable to store glucose as glycogen and lack reserves; patients with fat or protein disorders can become clinically decompensated if they initiate the breakdown of fats and proteins and require a constant supply of higher concentration dextrose to avoid decompensation (D10% at 1-2 times maintenance rates)

Ketogenic diet: is commonly prescribed for patients with intractable seizures; the presence of ketones at certain levels may suppress seizures; such patients have very low carbohydrates in their diet, and most of their intake involves fats and proteins; if such patients are given dextrose, their ketosis can be altered, which may lead to seizure recurrence; avoid glucose administration in these patients; the average fasting glucose is 60 to 70 mg/dL; avoid accidentally giving sugar contained in medications

Hypoglycemia management: administer dextrose IV or orally in patients with hypoglycemia (<70 mg/dL) who are symptomatic; typically, glucose in gels and tablets is not considered a violation of fasting guidelines; hold insulin if the patient is on insulin, but avoid holding it for too long in patients with type 1 DM to prevent ketosis; check glucose at least every 15 min until it is normalized

Insulin requirements: pediatric patients with type 1 DM require insulin; insulin moves sugar into the cell; the absence of sufficient insulin results in hyperglycemia, leading to osmotic diuresis and electrolytic abnormalities; the lack of intercellular sugar leads to energy deficiency, and patients rely on fats and proteins, leading to ketosis; treating with insulin is a long-term medical management rather than intraoperative management; the aim is to mimic physiologic secretion; patients require basal and bolus secretion; this is typically achieved by a daily injection regimen of 1 to 2 injections of long-acting insulin plus multiple short-acting insulin injections to correct or prevent hyperglycemia; some patients are on insulin pump therapy or a continuous subcutaneous (SC) insulin infusion; a pump continuously administers insulin to provide basal and bolus insulin; these patients only have rapid-acting insulin, and no long-acting insulin is administered; if the pump is stopped, there is no basal insulin, and clinicians should know this during the perioperative period

Continuous glucose monitors (CGM; eg, Dexcom, Freestyle Libre, Medtronic): one brand (Freestyle Libre) uses a filament inserted subcutaneously that continuously detects glucose and sends that information every 1 to 5 min to a device; insulin pumps are available in 2 basic varieties, the traditional or tubed insulin systems (eg, iLet Bionic Pancreas, Medtronic MiniMed, Tandem t:slim) and the tubeless systems; traditional systems have a metal or plastic cannula inserted under the skin connected to a tube and a pump; the insertion site, but not the pump, is disposable; if the pump is discontinued for surgery, it should be disconnected and the insertion site left in place; if the insertion site is metal, it may need to be removed for electrocautery or magnetic resonance imaging; in the tubeless system, the pod itself contains the insulin reservoir; it communicates wirelessly with the device that controls the function of the pump; the device is not physically connected to the patient; it is important to take the controller of the pod from family members to manage insulin delivery during surgery

Automated insulin delivery systems: hybrid systems comprise a CGM and a pump; the software allows for their interaction; clinicians should specifically ask about the fixed or variable rate of insulin infusion from the pump

Perioperative use of DM technology: ensure that the device is located in a nondependent area based on planned patient positioning; it should have been replaced in the previous 3 days, be working properly, and have adequate insulin for the perioperative period; the anesthesiologist must be comfortable using that device; CGMs are not validated for treatment decisions perioperatively; they can be used to follow trends, but readings should be confirmed with point-of-care tests before altering the rates of dextrose or insulin infusion; CGMs become inaccurate when glucose levels are changing rapidly, if the patient is hypothermic, hypovolemic, or acidotic, or if there is pressure on the sensor; if the patient is using automated insulin delivery, change the pump to a fixed delivery rate because automated delivery follows the CGM parameters; contraindications vary by device; these are absolutely contraindicated in MRI and relatively contraindicated with other radiation sources (eg, computed tomography, fluoroscopy, catheterization laboratory); exercise caution with electrocautery and x-ray

Perioperative guidelines: Martin et al (2020) and University of North Carolina at Chapel Hill School of Medicine Kapellen et al (2022) published recommendations; preoperative communication is important; in nonemergency surgeries, ensure discussion with endocrinologists about baseline insulin management, frequency of fasting hypoglycemia, frequency of diabetic ketoacidosis, and requirement for insulin adjustments; plan for frequency of sugar evaluation and insulin management; check sugar at least hourly; increase frequency if there are treatment changes; patients maintained on SC insulin or not having fasting hypoglycemia generally do not require dextrose; dextrose is needed with IV insulin

Route of insulin administration: can be SC or IV depending on the patient, surgery, and stability; patients with minor procedures (<2 hr and rapid return to oral intake), who are metabolically stable, may be kept on SC insulin throughout the perioperative period; short-acting insulin boluses are needed only in case of hyperglycemia with blood glucose levels >250 mg/dL; in patients with major procedures (>2 hr and delayed return to oral intake), who are metabolically unstable, or whose insulin pump cannot be used during surgery, switch to IV insulin; tables in the published guidelines are based on patients with diabetic ketoacidosis and may overestimate the amount of insulin required; insulin pumps are based on weight (units/hr); IV insulin is units/kg per hr; consider appropriate corrections while switching from insulin pumps to IV insulin

Adjuvant medications: are generally used for patients with type 2 DM or who are overweight; some data suggest benefits for type 1 DM; metformin can cause lactic acidosis; sodium glucose transporter-2 (SGLT2) inhibitors may cause normoglycemic ketosis; hold both perioperatively; glucagon-like peptide 1 receptor agonists are associated with delayed gastric emptying, leading to aspiration

Hyperglycemia management: avoid treating with SC insulin unless blood glucose is >250 mg/dL to prevent unrecognized hypoglycemia; consider checking for diabetic ketoacidosis; correct with insulin; avoid repeating SC bolus more frequently than every 3 to 4 hr; assess volume status as significant hyperglycemia may lead to osmotic diuresis making the patient unstable

Readings

Dogra P, Anastasopoulou C, Jialal I. Diabetic perioperative management. StatPearls Publishing. 2024 Jan 25. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540965/; Foster NC, Beck RW, Miller KM, et al. State of type 1 diabetes management and Outcomes from the T1D Exchange in 2016-2018 [published correction appears in Diabetes Technol Ther. 2019;21(4):230. doi:10.1089/dia.2018.0384.correx]. Diabetes Technol Ther. 2019;21(2):66-72. doi:10.1089/dia.2018.0384; Hirshberg E, Larsen G, Van Duker H. Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity. Pediatr Crit Care Med. 2008;9(4):361-366. doi:10.1097/PCC.0b013e318172d401; Kapellen T, Agwu JC, Martin L, et al. ISPAD clinical practice consensus guidelines 2022: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes. 2022;23(8):1468-1477. doi:10.1111/pedi.13446; Martin LD, Hoagland MA, Rhodes ET, et al. Perioperative management of pediatric patients with type 1 diabetes mellitus, updated recommendations for anesthesiologists. Anesth Analg. 2020;130(4):821-827. doi:10.1213/ANE.0000000000004491; Niezgoda J, Morgan PG. Anesthetic considerations in patients with mitochondrial defects. Paediatr Anaesth. 2013;23(9):785-793. doi:10.1111/pan.12158; Reddy N, Verma N, Dungan K. Monitoring technologies-continuous glucose monitoring, mobile technology, biomarkers of glycemic control. [Updated 2023 Jul 8]. In: Feingold KR, Anawalt B, Blackman MR, et al, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279046/; Salik I, Doherty T, Kelley A, et al. Perioperative use of glucose containing solutions in infants less than 6 months of age: A clinical practice survey among US academic centers. Paediatr Anaesth. 2022;32(5):625-630. doi:10.1111/pan.14420; Sudhakaran S, Surani SR. Guidelines for perioperative management of the diabetic patient. Surg Res Pract. 2015;2015:284063. doi:10.1155/2015/284063; Vanderhoek SM, Prichett L, Hardeo H, et al. Association of dysglycemia with post-operative outcomes in pediatric surgery. J Pediatr Surg. 2023;58(3):365-372. doi:10.1016/j.jpedsurg.2022.09.019; Yen PM, Young AS. Review of modern insulin pumps and the perioperative management of the type 1 diabetic patient for ambulatory dental surgery. Anesth Prog. 2021;68(3):180-187. doi:10.2344/anpr-68-03-16.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Hoagland was recorded at the Carolina Refresher Course 2024: 35th Annual Update in Anesthesiology, Pain, and Critical Care Medicine, held June 19-22, 2024, in Kiawah Island, SC, and presented by the University of North Carolina at Chapel Hill School of Medicine. For information on future CME activities from this presenter, please visit https://www.med.unc.edu/cpd. Audio Digest thanks the speakers and the University of North Carolina at Chapel Hill School of Medicine for their cooperation in the production of this program.

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