“Type 1 diabetes and general anethesia”
My 15 year old son had had type 1 diabetes for 4 years. He has frequent episodes of both hyperglycemia and hypoglycemia. He is scheduled to have his deviated septum fixed and I want to know if he faces any additional risks because of his type 1 diabetes and if he should be doing anything differently with his insulin intake prior to surgery.
12 Answers
You should ask your son's diabetes health care team to look at your son's history (past diabetes control and most recent blood sugars) and help you to decide what to do with your son's insulin prior to surgery. Make sure that the doctors doing the surgery and anesthesia know your son has diabetes when the schedule the procedure.
Deviated nasal septum is a fairly safe and quick procedure depending on the complexity of the deviation and any associated problems with it. Most of the times, if it is straightforward, we are looking at up to 1 hour surgical time.
Generally speaking, if the procedure is long, we put the patients on what we call a sliding scale however in this circumstance, each doctor has their own idea about insulin. Some like to avoid the morning dose before surgery, then check blood sugars on admission for procedure, others will allow the patient to carry on as normal with their dosing (provided it is adjusted according to blood sugar levels given, there will be a period of fasting), then assess glucose levels on admission. Either way, some of us believe patients with type 1 insulin know their body better than the doctor when it comes to how their body responds to insulin at different times.
Generally speaking, if the procedure is long, we put the patients on what we call a sliding scale however in this circumstance, each doctor has their own idea about insulin. Some like to avoid the morning dose before surgery, then check blood sugars on admission for procedure, others will allow the patient to carry on as normal with their dosing (provided it is adjusted according to blood sugar levels given, there will be a period of fasting), then assess glucose levels on admission. Either way, some of us believe patients with type 1 insulin know their body better than the doctor when it comes to how their body responds to insulin at different times.
You should review his diabetes needs directly with his diabetes team,
either doctor or nurse. There are extra risks when those with type 1
diabetes require general anesthesia and a lot depends on his overall
diabetes care, A1c results as to whether these are high or low risks. More
frequent glucose monitoring, ketone testing all will help since the
surgical risks themselves as well as the anesthesia risks re all able to be
minimized by increased monitoring - much as would be expected during a sick
day. Often there is need for more insulin based on his usual treatment
regimen. Important to know that you can always call your diabetes team for
specific advice depending on such increased monitoring since they will have
the expertise to assist with changing insulin needs according to results
too. If the surgical and anesthesia people involved have questions, they
too can directly contact your diabetologists as well and should be
encouraged to do so if needed.
either doctor or nurse. There are extra risks when those with type 1
diabetes require general anesthesia and a lot depends on his overall
diabetes care, A1c results as to whether these are high or low risks. More
frequent glucose monitoring, ketone testing all will help since the
surgical risks themselves as well as the anesthesia risks re all able to be
minimized by increased monitoring - much as would be expected during a sick
day. Often there is need for more insulin based on his usual treatment
regimen. Important to know that you can always call your diabetes team for
specific advice depending on such increased monitoring since they will have
the expertise to assist with changing insulin needs according to results
too. If the surgical and anesthesia people involved have questions, they
too can directly contact your diabetologists as well and should be
encouraged to do so if needed.
This is a complex question that needs much more information than can be evaluated here. You need to have your pediatrician and your surgeon and your anesthesiologist all on the same page and realize that surgery is the greatest stressor to the patient, and that stress will change the way the insulin is handled for the individual patient. Extra care and planning are always good when evaluating and treating juvenile diabetics.
The biggest issue is the swings in his glucose levels which shows his diabetes is not very well controlled. A night before surgery he will not be able to eat or drink so his glucose levels need to be monitored. By itself his diabetes doesn't place him for particularly increased risk per se, but the fact that sugar levels are not well controlled makes the job more difficult. Alert your anesthesiologist on the day of surgery about diabetes do he can do appropriate physical exam and interview and decide if his glucose levels need to be adjusted immediately before the surgery. He will need close monitoring after surgery for an hour or two. Overall, I would expect him to be just fine, it's not a complex surgery and anesthesia is fairly straightforward for someone his age.
The risk associated is minimal. I suggest to contact the anesthesiologist who will be taking care of your son the day before surgery and ask him/her what you need to do with the insulin intake for the morning of surgery. There are different ways of handling this situation and the anesthesiologist in charge with the care of your son needs to feel comfortable with the management.
Yes, you definitely will need to coordinate with you pre-op nurse / surgeon's office for specifics. Each patient and their pre-op plans needs to be customized.
Not knowing what his insulin regimen is, I find this Question hard to answer. He should be receiving a basal insulin at night and this dose should be given as previous. Then since he is NPO the day of the surgery give no insulin in AM as his basal from the night before is working. When he gets to the surgical center the Dr. will take it from there. After surgery gauge insulin by his ability to eat. Consult your endo who cares for him to help. This surgery is with little risk & modifications is his insulin regimen should be minimal.
For patients with type 1 diabetes mellitus, it is best to be well controlled under the close guidance of an endocrinologist well before any elective surgery. In general, diabetic patients should not take any regular insulin on the morning of surgery when they are fasting. Continue to monitor his blood glucose and report those data to your anesthesiologist. Also discuss what symptoms your son has when his glucose is too low. Your anesthesiologist should be able to monitor your son's glucose during surgery (although deviated septum repair is a relatively short surgery) and nurses in the recovery room can check his blood glucose as well. Insulin is always available to treat significant hyperglycemia, and you can begin to restart his normal insulin regimen when he resumes a normal dietary intake.
Definitely make sure all involved know his diabetes history for the last few weeks
Type 1 diabetes and general anethesia
My 15-year old son had had type 1 diabetes for 4 years. He has frequent episodes of both hyperglycemia and hypoglycemia. He is scheduled to have his deviated septum fixed and I want to know if he faces any additional risks because of his type 1 diabetes and if he should be doing anything differently with his insulin intake prior to surgery.
Answer:
Surgery and diabetes can be tricky. If you have a pediatric diabetes team, I would suggest asking for specific information related to your son.
General answers:
Surgery in people with diabetes should be conducted first thing in the morning.
- would suggest blood sugar be on the higher side prior to surgery: 150-200 mg/dl
- would suggest checking blood sugars before, during and after surgery with the availability of IV dextrose, if needed.
Anesthesia should be asking the questions below
Questions:
- What kind of insulin regimen is he on?
If pump: basal rate should be continued, but if surgery first thing in the am- he will not need to bolus unless he is very high as he won't be eating. If on multiple daily doses of long acting insulin such as glargine, detemir, degludec etc. and rapid acting insulin such as Humalog, novolog, apidra, would suggest giving long acting insulin as usual (night for example) and if his fasting blood sugars have been at target range or lower, would lower long acting insulin dose by 2-3 units. If he is or has been high in the am, would suggest giving 1/2 correction to avoid lows.
Once again, you should consult your diabetes team as they know your child best and may provide more specific information in relationship to your son.
Good luck,
Fran R. Cogen, MD, CDE
My 15-year old son had had type 1 diabetes for 4 years. He has frequent episodes of both hyperglycemia and hypoglycemia. He is scheduled to have his deviated septum fixed and I want to know if he faces any additional risks because of his type 1 diabetes and if he should be doing anything differently with his insulin intake prior to surgery.
Answer:
Surgery and diabetes can be tricky. If you have a pediatric diabetes team, I would suggest asking for specific information related to your son.
General answers:
Surgery in people with diabetes should be conducted first thing in the morning.
- would suggest blood sugar be on the higher side prior to surgery: 150-200 mg/dl
- would suggest checking blood sugars before, during and after surgery with the availability of IV dextrose, if needed.
Anesthesia should be asking the questions below
Questions:
- What kind of insulin regimen is he on?
If pump: basal rate should be continued, but if surgery first thing in the am- he will not need to bolus unless he is very high as he won't be eating. If on multiple daily doses of long acting insulin such as glargine, detemir, degludec etc. and rapid acting insulin such as Humalog, novolog, apidra, would suggest giving long acting insulin as usual (night for example) and if his fasting blood sugars have been at target range or lower, would lower long acting insulin dose by 2-3 units. If he is or has been high in the am, would suggest giving 1/2 correction to avoid lows.
Once again, you should consult your diabetes team as they know your child best and may provide more specific information in relationship to your son.
Good luck,
Fran R. Cogen, MD, CDE
That's a complicated question.
First, being a diabetic predisposes him to infection as by definition, diabetics are considered immunocompromised. However, many diabetic patients undergo surgery with no complications.
The complicated part is regarding what to do with his insulin regimen. This depends on what type of insulin he takes, short or rapid-acting, intermediate or long acting. Also when is his surgery scheduled, first case of the morning, mid day, or the end of the day. The facility &/or anesthesiologist should be contacted if they haven't given you clear preoperative instructions.
Robert Pousman, DO
First, being a diabetic predisposes him to infection as by definition, diabetics are considered immunocompromised. However, many diabetic patients undergo surgery with no complications.
The complicated part is regarding what to do with his insulin regimen. This depends on what type of insulin he takes, short or rapid-acting, intermediate or long acting. Also when is his surgery scheduled, first case of the morning, mid day, or the end of the day. The facility &/or anesthesiologist should be contacted if they haven't given you clear preoperative instructions.
Robert Pousman, DO
