Management of a patient with diabetes who needs endoscopy

Elective admissions for endoscopy should be planned in advance in consultation with the diabetes and endocrinology team.   

Patients with diabetes who require OGD +/- small bowel biopsy

• may be admitted on the day of the procedure, as long as diabetes management prior to and after the procedure is planned in advance and parents undertake to follow the management plan outlined by the diabetes team.  If these conditions aren't met, patients will be admitted on the night prior to the procedure.

Patients with diabetes who require colonoscopy

• will be admitted on the day prior to the procedure for management of i.v fluids and insulin during bowel preparation and fasting

Issues to consider

1. Type of endoscopy (OGD +/- biopsy or colonoscopy)
2. Current insulin regimen
3. Time of the procedure

Management guidelines for:

A     Patients with diabetes who require OGD +/- small bowel biopsy

If the patient is suitable for a same day admission, the family will be given advance written advice about BGL checks and changes to diabetes management prior to the admission.  This advice will be based on the following guideline, which outlines management according to current insulin delivery regimen.

This section includes management guidelines for those on:

1. Multiple daily injections 
2. Insulin pump therapy
3. Twice daily insulin regimens 

(1) Patients on multiple daily injections (basal-bolus) regimens

On the day prior to the procedure:

• Pre-meal insulin: The young person can eat and drink normally with their usual pre-meal insulin doses on the day prior to the procedure.  Fasting for solids is usually from midnight.
• Patients who normally have their basal insulin in the evening / before bed should have this insulin at their usual time, but at a dose of ~80% of usual
• Check BGLs before all meals and before bed, with blood ketones test if any BGL is >15.0 mmol/L.  The family will be advised that in the unlikely event that ketones are >=1.0, they should call RCH for advice (see separate section - advice for treating ketones on the  night before procedure). 

On the day of the procedure

If procedure is scheduled on a morning list:

• Patients who normally have their basal insulin in the morning should take 80% of their usual dose at their usual time
• No short-acting insulin is given in the morning prior to the procedure as the patient is fasting for solids. 
• BGL must be checked at home at 06.00am (2.5 hours before the procedure)
  • If BGL at 06.00am is <6.0 mmol/L, the patient should drink 200 mL of lemonade
• The patient will arrive at day surgical unit at 07.00am; BGL should be checked on arrival and again immediately prior to transfer to and from endoscopy unit.
  •  If within 2 hours of the procedure any BGL is <4.0 mmol/L, an intravenous line should be sited and 2-5 mL/kg of 10% dextrose given as a bolus, followed by maintenance Plasma-Lyte 148 and 5% Glucose OR 0.9% sodium chloride (normal saline) and 5% Glucose.  Check BGL after 30 mins and hourly until the child is ready to eat afterwards; adjust rate of fluids if necessary to keep BGL 5-10mmol/l.
• Once the child is awake and ready to eat after the procedure, they can have their usual pre-meal insulin prior to breakfast consisting of their usual carbohydrate serves.
• The patient can have their usual insulin and meals thereafter.

If procedure is scheduled on an afternoon list:

• Patients who normally have their basal insulin in the morning should take 80% of their usual dose at their usual time.
• At 07.00am on the morning of the procedure, the young person should have 80% of their usual short-acting insulin before a breakfast of their usual number of carbohydrate serves.  They will be fasting for solids from 07.30am.
• BGL should be checked again at 11.00am (2.5 hours before the procedure)
  • If BGL at 11.00am is <6.0 mmol/L, the young person should drink 200 mL of lemonade
• BGL should be checked at 12.00 on arrival to the day surgical unit and again immediately prior to transfer to and from the endoscopy unit
  • If within 2 hours of the procedure any BGL is <4.0 mmol/L, an intravenous line should be sited and 2-5 mL/kg of 10% dextrose given as a bolus, followed by maintenance 5% dex and 0.45% NaCl.  Check BGL after 30 mins and hourly until the child is ready to eat afterwards; adjust rate of fluids if necessary to keep BGL 5-10 mmol/L.
• Once endoscopy is complete, the young person can have their usual pre-meal insulin prior to a late lunch consisting of their usual carbohydrate serves.
• The patient can have their usual insulin with their evening meal (at least 3 hours after their late lunch) and their usual basal insulin from the next dose.

(2) Patients on continuous subcutaneous insulin infusions (insulin pump therapy)

On the day prior to the procedure, the patient should change the subcutaneous infusion site.  This should be done in time to have at least 2 subsequent BGL checks on that day that indicate the line is working well. 

• Patient can eat and drink normally administering insulin according to their individual pump settings until midnight the night before.
• Continue insulin administration using the usual basal infusion rates overnight.
• Check BGL before all meals and before bed.  Check ketones if any BGL is >15.0 mmol/L.  If ketones >= 0.6 are present, the young person will need to assume the infusion catheter / line is blocked or kinked and ensure it is changed.  The family will be asked to call RCH for advice (see separate section below ).

On the day of the procedure

If procedure is scheduled on a morning list:

• BGL must be checked at home at 06.00am:
  • If BGL is <4 mmol/L, give 200 mL of lemonade and commence a temporary basal rate of 70% of usual for 4 hours.  Recheck BGL after 30 minutes to ensure it has increased to >4.0 mmol/L
  • If BGL is between 4.0 and 10.0 mmol/L, commence a temporary basal rate of 70% of usual for 4 hours. 
  • If BGL at 06.00am is >10.0mmol/l, program the BGL into the pump and give the recommended correction dose of insulin.  A temporary basal rate of 70% of usual for 4 hours should also be commenced.
• The patient will come to the Day surgical unit for 07.00am.
• BGLs should be monitored on arrival to DSU and immediately prior to transfer to and from endoscopy.
  • If any BGL after arrival is >10.0, the temporary reduction in basal rate can be discontinued (ie go back to usual setting) but a correction bolus should be deferred in the first instance until after the procedure .  If repeat BGL 1 hour later is still above 10 mmol/L, a correction bolus can be given at this stage.  Please discuss this with the endocrine registrar (p4032).
  •  If any BGL is >15.0, please check ketones and inform the endocrine registrar
• The subcutaneous infusion site should be secured tightly prior to going to theatre to prevent dislodgement and interruption to insulin delivery intra-operatively.
• Check BGL in recovery, prior to transfer back to DSU:
  • If >10.0 mmol/L, enter the BGL into the pump and administer the recommended correction dose of insulin (parents can help with this)
  • If between 4.0 and 10.0 mmol/L continue with programmed basal rates. 
  • If <4.0 mmol/L treat with 2-5 mL/kg 10% dextrose given as an i.v. bolus and commence dextrose containing i.v. maintenance fluids.
• Once the young person is able to eat or drink, the temporary basal rate can be discontinued and the patient should recommence pre-meal or pre-snack insulin administration using their usual pump settings.

If procedure is scheduled on an afternoon list:

• At 07.00am on the morning of the procedure, the young person can have a light breakfast.  A BGL should be entered into the pump and pre-meal insulin administered based on the pump's usual settings.
• BGL should be checked at home at 11.00am (2.5 hours prior to procedure):
  • If BGL is <4 mmol/L, give 200mL of lemonade and commence a temporary basal rate of 70% of usual for 4 hours.
  • If BGL is between 4.0 and 10.0 mmol/L commence a temporary basal rate of 70% of their usual rate for 4 hours and recheck BGL hourly. 
  • If BGL is >10.0 mmol/L, program the BGL into the pump and give the recommended correction dose of insulin A temporary basal rate of 70% of usual for 4 hours should also be commenced.
• BGLs should be checked on arrival to Day Surgical unit and prior to transfer to and from endoscopy.  Management procedure thereafter is as outlined above for procedures on a morning list.

(3) Patients on twice daily injections of insulin:

On the day prior to the procedure:

• The child can eat and drink normally before going to bed; however evening insulin dose should be adjusted as follows:
• Prior to their evening meal on the night before the procedure the child should receive:
  • Their full usual dose of short-acting insulin, along with 
  • ~75% of their usual long acting insulin dose (adjusted down to nearest whole unit)
  • For example if a child usually has 11 units of levemir and 4 units of novorapid in the evening, the dose to be given prior to the procedure would be 8 units of levemir and 4 units of novorapid
• Check BGLs before meals and at bedtime - if any BGL is >15 mmol/L, check ketones.  Parents will be advised to call the specialty registrar in the unlikely event that ketones are >=1.0 .

On the day of the procedure:

If the procedure is in the morning:

• Morning insulin and breakfast will be delayed until after the procedure. 
• The child should be first or at latest second (if another child with diabetes is first) on the endoscopy list
• Check BGL at 06.00am at home.  If BGL is <8.0 mmol/L, the child should have 200mL of lemonade to drink.
• The child should arrive at the Day surgical unit at 07.00am.  BGL should be checked on arrival and immediately prior to transfer to and from endoscopy
• After the procedure, the child should be given insulin (75-100% of usual morning dose) prior to their breakfast back on DSU.  Parents will be advised that meal times for that day may need to be ~1-2 hours later than usual.  The child can have their usual evening dose of insulin that night.

If the procedure is in the afternoon:

• The child can eat breakfast consisting of 3 carbohydrate serves at ~07.00am.
• The usual morning dose of insulin will be replaced by a dose of short-acting insulin that is 10% of the patient's usual total daily dose (adjust down to nearest whole unit).
  • For example, if the normal insulin is 24 units levemir and  5 units novorapid in the morning plus 12 units levemir and 4 units novorapid  in the evening:
  • Total daily dose is 45 units / day, then 4 units of novorapid is given.
• BGL should be rechecked at home at 11.00am.  If BGL is <10 mmol 8.0 mmol/L, the child should drink 5mL/kg (up to a max of 200 mL) of lemonade. 
• BGLs should be rechecked on arrival to Day Surgical unit and immediately prior to transfer to and from endoscopy unit. 
• A further dose of short-acting insulin (~5-10% of total daily dose) should be given at 12.00pm if BGL is >12 mmol/L.  This dose can be discussed with the endocrinology resident (p4032).
• After the procedure, the child should have a late lunch consisting of ~ 3 carbohydrate serves with pre-meal short acting insulin (eg novorapid) at a dose of ~10-20% of total daily dose.  Please call for a phone order from the endocrine resident on pager 4032.
  • Patients who had insulin at 12.00pm should have ~10% of TDD with lunch (this can be increased if BGL still high);
  • if no insulin was given at 12.00pm then give 20% of TDD with lunch. 
    " Patients can have their usual evening insulin with their evening meal that night.

Advice for  families whose child develops ketones at home on the night prior to the endoscopy procedure

(i) Patients on MDI regimen or bd regimens (link to diabetes phone call - hyperglycaemia chart)

• If ketones are <1.0, no additional insulin is necessary.  Parents should be advised to repeat a BGL and ketones test in 2 hours.
• If the patient has ketones ≥1.0 and is unwell or vomiting, they should be advised to come to ED for assessment
• If ketones are >=1.0 at bedtime and the patient is well (no vomiting / other symptoms), an additional injection of short acting insulin at 10% of the patient's usual total daily dose should be recommended. 
  • The family should repeat BGLs 2 hourly until ketones have cleared.   
  • If ketones do not clear to <1.0 after 2 hours, give further 10% of daily dose as short acting insulin and come to ED for assessment

(ii) Patients on insulin pump therapy

Note lower ketones threshold requiring action (>=0.6) because pump patients have no long acting insulin on board; therefore we need to assume failure of insulin delivery

• If ketones are >=0.6 and patient is unwell (vomiting / abdo pain / other) they will need to come to ED to be assessed. 
• If ketones are >=0.6 and the patient is well (no vomiting / abdo pain), he or she requires an injection of extra insulin to clear ketones and correct the high BGL.  The dose required is ~25% of the child's average total daily insulin dose (which is recorded in their pump), given as a subcutaneous injection of short -acting insulin (note this is not given through the pump). 
  • Once this has been given, the pump infusion catheter should be resited (within the hour) and basal insulin recommenced. 
  • BGLs should be checked 2 hourly overnight (initially to ensure ketones cleared and then ensure new line is working). 
  • If ketones are not <1.0 within two hours of the insulin injection, the family should inform the specialty team at RCH.  A further 20%-25% injection of short acting insulin should be recommended and the diabetes and gastroenterology teams notified at handover in the morning.

B  Patients with diabetes who require colonoscopy

Bowel preparation prior to colonoscopy necessitates fasting for everything other than clear fluids from 16.00h on the day prior to the procedure.  Patients with diabetes who require colonoscopy should therefore be admitted and commenced on intravenous maintenance fluids (Plasma-Lyte 148 and 5% Glucose and 20 mmol/L KCl OR 0.9% sodium chloride (normal saline) and 5% Glucose and 20 mmol/L KCl) on the day before the procedure.

All patients will require ongoing insulin therapy to prevent ketosis. 

For patients on multiple daily injections of insulin (MDI) or insulin pump therapy, it should be possible to maintain BGLs in the target range with use of the patient's usual basal insulin alone.  This dose will not usually need to be decreased as the patient will be receiving some dextrose containing fluids.

This section includes the following information

1. MDI regimens
2. Insulin pump therapy
3. Twice daily regimens 

(1) Patients on MDI regimens:

• Can eat and have their usual pre-meal insulin up until the nominated fasting time
• Once fasting for solids and bowel prep commences, intravenous fluids should be commenced (as above)
• Patients should have their usual dose of basal insulin (in most cases this will be lantus) at their usual time
• Patients can drink clear fluids until 2 hours prior to the procedure. As dextrose-containing i.v. fluids will also be running, oral fluids should be given as water, unless BGL drops to <4.0 mmol/L (see below)
• Aim to keep BGLs between 5.0 and 10.0 mmol/L
• Monitor BGLs 2-4 hourly initially; then hourly in the 2 hours prior to the procedure. BGL should also be checked immediately prior to transfer to and from endoscopy.
  • If BGL drops to <4.0 mmol/L and they are still allowed clear fluids, the patient can have up to 200 mL of sugar-containing fluids (eg lemonade); the dextrose concentration of intravenous fluids should be increased to 10%
  • If BGL is <4.0 mmol/L within 2 hours of the procedure, a bolus of 2-5 mL/kg of intravenous 10% dextrose should be given and BGLs closely monitored
  • If any BGL is >15.0 mmol/L monitor ketones with bedside Optium meter and discuss with endocrinology team if result is >=1.0
  • If BGL is >15.0 mmol/L and ketones are negative, the rate of dextrose-containing intravenous fluids should be decreased to 50-75% maintenance. If the patient's clinical status does not allow iv fluids to be reduced, discuss the need for additional insulin with the endocrinology team
• After the procedure, check BGL prior to transfer back to the ward and hourly until tolerating oral intake. It should be possible to recommence normal pre-meal and basal insulin once tolerating oral intake; i.v fluids can be discontinued at this stage.

(2) Patients on insulin pump therapy:

• Can eat and have usual pre-meal insulin prior to the time they are directed to fast
• Once fasting for solids and bowel prep commences, intravenous fluids should be commenced
• Continue insulin delivery using the patient's programmed basal rates
• Aim to keep BGLs between 5.0 and 10.0 mmol/L
• Check BGLs 2-4 hourly initially; hourly in the 2 hours prior to the procedure. BGL should also be checked immediately prior to transfer to and from endoscopy.
  • If any BGL is >15 mmol/L monitor ketones with bedside Optium meter and discuss with endocrinology if result is >=1.0
  • If BGL is >10.0 mmol, a correction bolus can be administered using the patient's programmed settings; recheck after 1-2 hours to ensure BGL is decreasing
  • If BGL drops to <4.0 mmol/L, and clear fluids are still allowed, the patient can have up to 200 mL of sugar-containing fluids (eg lemonade); the dextrose concentration of intravenous fluids should also be increased to 10%.  If clear fluids are no longer allowed, 2-5 mL/kg of 10% dextrose should be given as an i.v. bolus. and BGLs closely monitored
  • After the procedure, check BGL prior to transfer back to the ward and hourly until tolerating oral intake. It should be possible to recommence normal pre-meal and basal insulin once tolerating oral intake; i.v fluids can be discontinued at this stage.

(3) Patients on twice daily insulin regimes:

• Can be advised to have their usual morning insulin and eat normally until the fasting time (as advised by gastroenterology team) on the day prior to the procedure
• Once fasting for solids and bowel prep commences, intravenous fluids should be commenced (as above)
• Check BGLs 2-4 hourly initially; hourly in the 2 hours prior to the procedure. BGL should also be checked immediately prior to transfer to and from endoscopy.
• If any BGL is >15 mmol/L monitor ketones with bedside Optium meter and discuss with endocrinology if result is >=1.0
• Patients will require subcutaneous insulin on both the evening before and morning of the procedure; however, it is more difficult to give a standardised guideline for all patients on bd insulin, as insulin doses and proportions of each insulin dose (as % of total daily dose etc) vary greatly amongst patients. 
• Doses for individual patients should be discussed with the endocrinology team at the time of admission
  • Evening dose (~18.00) will usually be ~75% of usual intermediate acting insulin; short acting insulin (in a reduced dose) will only be given at that stage if BGL has been running high
  • If colonoscopy is on a morning list, the morning dose of insulin can be delayed until after the procedure, but must be given by 10.00am at the latest (when ~75-100% of usual doses will be given)
  • If colonoscopy is on the afternoon list, morning insulin dose will also be individually prescribed (usually ~2/3 of usual morning intermediate acting insulin +/- short-acting insulin if BGLs are high).
• After the procedure, check BGL prior to transfer back to the ward and hourly until tolerating oral intake.  Patients on a morning list will require their morning insulin before a late breakfast (as above).  Those on an afternoon list should have a light snack (without extra insulin).  All patients can be advised to return to their usual evening insulin dose that evening

Last updated May 2011