February 16, 2001
Surgery
Question from North Ridgeville, Ohio, USA:
My six and one-half year old year old daughter was diagnosed with type 1 diabetes about three years ago. Her blood sugar has been in good control with three daily shots consisting of NPH and Humalog at breakfast, Humalog at dinner and NPH at bedtime. She does more than blood sugar tests per day.
Just recently, she came down with a flu that triggered an appendicitis attack. It was found that her appendix had in fact ruptured. Our children’s hospital is taking a new approach with ruptured appendices called,”interval appendectomy.” They treat the patient with seven days of IV antibiotics and then a course of oral antibiotics at home. She responded remarkably well with the IV antibiotics, and they fortunately let my husband and I remain in control of her blood glucose tests and insulin injections, with assistance from our endocrinologist when needed (especially on the days that she was NPO). Four days following the start of her IV antibiotics, they did a second CT scan, during which they would typically aspirate an abscess or put in a drain to drain a larger abscess. However, they found no abscess (a rarity), and it was even mistaken for an unruptured appendix by the physician doing the scan.
I had asked one of the physicians attending to her if they have any information on the interval appendectomy being performed on a child with diabetes, and he told me that this was the first one he had seen. I was also told that this hospital was only one of six doing this procedure.
My questions:
Are you at all familiar with this procedure on people with diabetes?
How does a typical appendectomy affect a child with diabetes children?
Is there anything that I need to be concerned about with her being put under general anesthesia?
How vital is her blood sugar control in this or any surgical case?
I know that I am my child’s best advocate, and I was pretty good about standing up to her surgeon about keeping me properly informed so that I could manage her diabetes while she was in the hospital, although it was difficult to do with her on-again, off-again surgery and feeding. It did seem that he only had in mind his own surgical agenda and seemed unconcerned about the requirements to care for her diabetes and her blood glucose control.
Answer:
I would not guess that having diabetes would do anything dramatically different with regard to appendicitis protocols or surgery or perforations, with the exception that any infection or similar stress would have an impact on glucose control. Not being able to eat also, of course, affects glucose control. Blood glucose monitoring that is frequent through the day and the night is critical to allow appropriate adjustment of intravenous fluids and any insulin administration. The surgeons should be in close contact with the diabetes team (pre-, intra- and post-surgery periods) during any treatment.
As part of being an advocate for children, parents should insist that surgeons talk to and consult directly with people knowledgeable about diabetes care for children (the best would be the child’s own diabetes team; next best would be any diabetologist/endocrinologist who knows about such insulin treatment and monitoring). If a surgeon or anyone else refused to make such a call, then call the diabetes team members yourself and ask that they contact the surgeon on your daughter’s behalf, or get another surgeon.
SB
[Editor’s comment: Also see Surgery Pre-Op Advice for some additional thoughts.
WWQ]
