September 3, 2003
Question from Clementon, New Jersey, USA:
My 12 year old son, who has had type 1 diabetes for five months, just changed to Lantus with Humalog bolus injections for meals last week, and we have not yet regulated his blood sugar levels, but I am working closely with a diabetes educator to try to straighten this out. His orthodontist wants him to have his wisdom teeth removed soon because he feels they are becoming impacted, and I would like to have this done by an oral surgeon. What type of precautions do I have to take regarding anesthesia? What can I expect with after care if he is unable to eat or drink? Should I wait until he has better control of his blood sugar levels? Will the doctor monitor his blood sugar during the procedure?
I think the basal/bolus insulin regimen is ideal when needing to make adjustments for injuries, illnesses, and operations, etc. So I would maintain the Lantus (preferably at bedtime for a procedure the next morning) and simply hold the Humalog. Then when your son is able to take in calories, he can dose his Humalog based on his carb intake, which is what I presume he is doing now. His activity may be a little less during the subsequent days while recovering from the oral surgery.
I’d ask for a time slot such that your son will be the surgeon’s planned first case of the day. Please discuss options with your son’s own diabetes team.
Additional comments from Dr. Andrea Scaramuzza:
You have many questions on the table. First of all, the glycemic control. You don’t say whether your son takes Lantus at dinner or breakfast, and if blood sugar levels are high after every meal or one in particular. In my experience, it could be useful to switch the Lantus from dinner time to breakfast time on some occasions or divide the total amount into two doses (one at breakfast and the other at dinner) so you can have a better control. Otherwise, could be taken into account the possibility to change Regular insulin from analog.
Second, undergoing a surgery could be disturbing for metabolic control, so if you can wait until the control is better, this could be beneficial for your son. I don’t think that your child need any precautions regarding anesthesia (the same as other patients). If after intervention he can’t eat or drink, it might be useful to stay in hospital for a glucose/saline plus insulin infusion to keep blood glucose level under control. Last, if the doctor monitor blood glucose levels during the procedure that would surely be a good thing.
Additional comments from Dr. Philip Ledereich:
I have a few of suggestions:
If your son tends to be in the 200s mg/dl [11.1 mmol/L] two hours after a meal, but then comes down to a normal range four to five hours after a meal, you might consider trying NovoLog instead of Humalog since some people respond to differently even though they both are supposed to be rapid acting insulins.
The nice thing about Lantus, is that you do not haveHAVE to eat at a certain time each day, and it is a bit easier to be NPO [medical jargon for “nothing allowed by mouth”]. If he is under anesthesia, then they would put in an IV and can give him IV glucose if needed.
It probably would be better to wait until you have better control of his blood sugar levels in order to help avoid an infection of the spaces in the mouth.
The doctor probably will not monitor since most are not savvy with diabetes care. You should probably do it yourself. I have heard stories of physicians giving insulin to children who were NPO because their glucose were high just before general anesthesia, but on the blood test done the day before the surgery the patient was actually low and giving him insulin followed by general anesthesia (not being able to monitor his behavior), may have killed him. Luckily for the patient the patient’s mom was on top of the situation, and asked the doctor why was he getting the insulin, then stopped and educated the physician (and saved her own child’s life).
Additional comments from Dr. Donough O’Brien:
I talked briefly to our dental department about your son and got the impression that the oral surgeon would consider the removal of all four wisdom teeth as a minor outpatient procedure that would take place under light intravenous anaesthesia. If such is the case, your son would be able to drink right after the operation. It was also clear that if he was in reasonable control they would not consider it necessary to monitor blood glucose and indeed did not have the equipment to do so. I think that you should discuss these issues with whoever is going to do the extractions in your area.
[Editor’s comment: Also see Surgery Pre-Op Advice at the Diabetes Monitor.