Children with diabetes who need surgery.

A surgical operation needing a general anaesthetic carries a greater risk to the child with diabetes than to the child without diabetes. I do not think it necessary nowadays to try and avoid general anaesthesia in the child with diabetes, but I do think that every such surgical procedure and anaesthetic should be taken seriously and a meticulous team approach adopted if peroperative hypoglycaemia, hyperglycaemia, or electrolyte disturbance are to be prevented. This means that every anaesthetic, however short, in a child with diabetes should be given in hospital, using an insulin infusion regime such as that to be described. Diabetes is a practical subject and diabetologists tend to be possessive about their patients and their own regimens. There are different ways to the same end, and the important point in surgery and diabetes, as in diabetic ketoacidosis, is to have a simple, rational regimen and to stick to it. Again as in diabetic ketoacidosis the clearest writer has been Alberti,' who states that 'many different regimens have been proposed . . . for the treatment of diabetes during surgery of the diabetic patient, most of which are based on dogma and idiosyncrasy rather than logic and reason'.2 Our regimen is an adaptation of the Alberti method for children with diabetes. The Royal Aberdeen Children's Hospital diabetic clinic, covering a total population of 500 000 in the Grampian Region, Orkney, and Shetland, is attended by 130 children with diabetes under the age of 13 years, all maintained on twice daily rapid acting and isophane insulin (either highly purified pork or human). In the past six years an average of seven of our children with diabetes have required elective surgery each year, perhaps regrettably about half of these for dental procedures and the rest mostly for ear, nose, and throat operations. There has been an average of one emergency operation a year over the same period, all for appendicectomy or trauma.