Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus

Updated Recommendations for Anesthesiologists

Lizabeth D. Martin, MD; Monica A. Hoagland, MD; Erinn T. Rhodes, MD, MPH; Joseph I. Wolfsdorf, MB, BCh; Jennifer L. Hamrick, MD, ASMG


Anesth Analg. 2020;130(4):821-827. 

In This Article

Abstract and Introduction


Approximately 1 of every 300 children in the United States has type 1 diabetes mellitus (T1D), and these patients may require anesthetics for a variety of procedures. Perioperative coordination is complex, and attention to perioperative fasting, appropriate insulin administration, and management of hypo- and hyperglycemia, as well as other metabolic abnormalities, is required. Management decisions may be impacted by the patient's baseline glycemic control and home insulin regimen, the type of procedure being performed, and expected postoperative recovery. If possible, preoperative planning with input from the patient's endocrinologist is considered best practice. A multi-institutional working group was formed by the Society for Pediatric Anesthesia Quality and Safety Committee to review current guidelines in the endocrinology and anesthesia literature and provide recommendations to anesthesiologists caring for pediatric patients with T1D in the perioperative setting. Recommendations for preoperative evaluation, glucose monitoring, insulin administration, fluid management, and postoperative management are discussed, with particular attention to increasingly prevalent insulin pumps and continuous glucose monitoring (CGM).


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 Health[6] 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.