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[IP] Surgery & Pumping (long)

Below is what I wrote to a mom on another list whose (non-pumping) daughter 
was facing a surgical procedure (outpatient, but with general anesthesia).  
I'd be interested in getting feedback on that from anyone who has anything to 
add or change.  Since my daughter is also looking at some pretty serious 
heart surgery in the near future, I would really like to hear from any of you 
pumpers who have had major surgery like this since you've been on the pump -- 
what were your exeriences as far as managing your diabetes during surgery and 
afterwards while you were still in the hospital ??? 
Lyndy  (Katie's PumpMama)
I wrote:
So far, since dx'd with diabetes my daughter has only had an outpatient 
procedure where she was sedated but not anesthetized.  However, she will be 
having heart surgery (2 valve replacements to correct a congenital defect) in 
the next 6-12 months, so I have been reading carefully all posts on the 
Insulin Pumpers lists about having surgery (since there are lots of adults on 
that list, there are a lot more with experience with dealing with surgeries). 
 Below is our experience with managing things for that out patient procedure, 
and what I've got planned for when she has her heart surgery:

For the outpatient procedure, when she was still on shots (2 a day, with NPH 
plus H), the night before she had her regular "cocktail" shot and 
meal+bedtime snack.  She was to have nothing but clear liquids after 
midnight, and nothing by mouth starting for 3 hours before the procedure was 
scheduled (our CDE told us to make sure that they scheduled her for 1st thing 
in the morning).  

I got up at 4am (right before the "nothing by mouth" cutoff point), checked 
her BG level (which was in the low 100s) and then hade her drink enough apple 
juice (a clear liquid with sugar in it) to raise her BG level to about 180 
(on our CDEs recommendation).  If she had been high at that point, I was 
supposed to give her a shot of H to bring her to 200.  At her regular 
injection time, the CDE had me give her a shot with HALF of her normal 
morning NPH dose (and NO humalog).  

This worked well for us, as her BGs stayed in the 120-150 range for the next 
five hours until she was hungry and able to eat again.  The first time she 
ate after sedation, the CDE recommended that we wait to give her the shot of 
H (to cover the carbs she ate) until about 30 minutes after she ate too make 
sure that she kept the food down (sedatives & anesthesia make some people 
pretty nauseous).  

I brought food with me to the hospital that day the she would likely want to 
eat, with the carb counts already done (so we didn't have to think about 
that), and also didn't have to wait to try and get food from the dietary 
services.  I brought chicken noodle soup (in a thermos), vanilla pudding, and 
jello (NOT the sugar free kind), plus some crackers and melba toast. You 
should check with your doc regarding any dietary restrictions that may apply 
(depending on the nature of the procedure being done).

One of the most useful things I'd been told by another parent prior to the 
procedure was to have Katie's kit (meter, strips, lancet in a small case) 
with her on the bed and teach the nurse (who was with her during the 
procedure) how to use it.  Otherwise, they'd have to draw blood and send it 
to the lab and wait to get results just for blood glucose levels (why they 
don't have meters like we use available is a mystery to me).  The nurse was 
very glad to have our handy little One Touch Ultra available to use, and she 
checked Katie's BG every half hour while she was sedated and hourly 

In the case of a procedure where there's an anesthesiologist involved, you 
(or preferably your endo, too) need to meet/talk with him/her before the 
procedure and go over it with them -- since they're the ones who are 
responsible for checking all the vital signs. (Some people have reported that 
this-- having your meter with you during the procedure --  wasn't necessary 
in their particular hospital -- so this is definitely something to check into 
in advance).  

Even if you don't need to have the meter there with your child during the 
procedure, I would definitely have with you at the hospital your usual 
diabetes care kit (katie calls it her "D-Pak") with everything you need for 
glucose testing, treating lows, checking for ketones, and even insulin & 
syringes, as getting ahold of these things in a timely manner (and making 
sure that they have what you normally use like H and not R, or an ultra fine 
short-needle syringe) is an iffy proposition at best.

My daughter is now on the pump, so when she has her surgery we will have our 
endo talk to the surgeon and anesthesiologist ahead of time to arrange for 
her to keep her pump on (probably at about 70-80% of her normal basal rate, 
I'd guess) during the procedure and in recovery (with a likely target range 
of 120-180 during that time).  

The endo will also request that they DON'T run glucose through her IV unless 
necessary to raise her BG level at some point.  Glucose in the IV fluid is 
standard procedure at SOME hospitals, but not all, and several people have 
mentioned waking up from a procedure feeling like crap, only to find that it 
wasn't the surgery but BGs in the 3 or 4 hundreds (because of the glucosein 
the IV) that was making them feel lousy . . . 

For non-pumpers, I imagine you'd do some kind of reduced dose of long acting 
insulin depending on the timing and length of the procedure, and then the 
anesthesiologist would run insulin and/or glucose through the IV as needed to 
maintain an acceptable BG level (probably in the 180-250 range, would be my 
guess).  Many folks have mentioned how important it is to stress the need for 
them to to frequent BG checks while the person is unconscious or groggy . . .

Since my daughter's surgery involves the chest cavity, we will probably move 
her infusion site to her thigh (after some pre-surgery tesing of this site 
area) and put her pump there with a "thigh thing" to hold it in place (so 
it's not just loose where the tubing could get tangled when then move her 
from bed to table, and back again).

Getting your endo to talk to the surgeon and anesthesiologist in advance 
about, wearing the pump (if she has one), frequent BG checks, target BG 
ranges during the procedure, and the appropriate (for her!) insulin and 
glucose dosages to manage those BG levels is VERY important as they're much 
more likely to listen to this coming from another doctor instead of someone 
who is "just" a parent. Having your endo also issue WRITTEN care orders can 
be helpful as well -- for dealing with both the docs and the nursing staff.

If you child will be in the hospital for longer than a day, you may want to 
make sure that your endo/surgeon issues specific orders that s/he NOT be 
given the "diabetic" diet (notoriously yucky!).  You can also try to get the 
dietary department to provide carb counts for every item in their 
meals/snacks (or meals/snacks that are a fixed carb amount, if that is what 
you normally do) -- but that may be more difficult.  I suspect that I will be 
bringing in at least some food for my daughter since she will be in the 
hospital for at least a week.  If she were still on shots, I would definitely 
be bringing in foods because I would not want to trust that the timing of 
delivering meals and snacks at the hospital would coincide with our normal 
strict schedule (and the peaks in the long-acting insulin) .

You can also have your doc issue orders (for post surgery) regarding insulin 
dosages based on whatever calculation method you use (sliding scale, carb 
ratios, etc.).  Personally, except for during the actual procedure (when they 
absolutely won't let us be there), my daughter will have a parent with her at 
all times (24/7) and we will manage her pump, insulin requirements, and carb 

Some of my best friends are nurses, but all hospitals are currently 
inadequately staffed (IMO) and I am unwilling to trust that the nursing staff 
will have the knowledge and attentiveness that we have when it comes to 
managing our child's diabetes . . .
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