The mini-dose recommended for age is administered using a conventional insulin syringe after reconstituting the glucagon (Fig. 1). It can be repeated after 30−60 min.

This treatment can only be effective if the patient has eaten beforehand or if there is an excess of insulin. It will not effective in the case of fasting or persistent vomiting.

Frequent monitoring of blood glucose and ketone levels is essential. Treatment involves rehydration with dextrose/sugar-containing fluids and adjusting insulin doses based on dietary intake.

• -

  No ketosis (< 0.6 mmol/L):

  • ◦

    Blood glucose < 90 mg/dL → Reduce insulin doses based on carbohydrate intake (reduce long-acting insulin by 20% and rapid-acting insulin by 50%). Consider an antiemetic and postprandial insulin if the patient experiences vomiting without ketosis.

  • ◦

    Blood glucose 90−180 mg/dL → Usual insulin dose.

• -

  Mild-moderate ketosis (0.6−3 mmol/L):

  • ◦

    Blood glucose < 90 mg/dL → Assess for ketosis due to lack of dietary intake. Administer fast-acting carbohydrates and the usual dose of rapid-acting insulin after verifying intake and if blood glucose is above 90 mg/dL. Usual long-acting insulin dose.

  • ◦

    Blood glucose 90−180 mg/dL → Usual rapid-acting insulin if carbohydrates are consumed. Usual long-acting insulin dose.

• -

  Severe ketosis/risk of DKA (>3 mmol/L):

  • ◦

    Blood glucose < 90 mg/dL → Management according to the previous section (mild ketosis, blood glucose < 90 mg/dL).

  • ◦

    Blood glucose 90−180 mg/dL → If CHs are consumed, usual dose of rapid-acting insulin plus an additional 0.05 IU/kg.

Figure 2.

Risk of hypoglycemia in patients managed with MDI.

Usual long-acting insulin. If there is oral intolerance, evaluate blood gas levels and administer intravenous fluid therapy.

Persistent hyperglycemia increases the risk of ketosis. Frequent monitoring of blood glucose and ketone levels is essential.

Figure 3.

Risk of ketosis in patients managed with MDI.

The insulin dose to correct hyperglycemia can be calculated based on weight and/or the insulin sensitivity factor (ISF) as follows: current blood glucose − target blood glucose / ISF; ISF = 1800 / TDD (total daily dose: rapid-acting + long-acting).

• -

  Hyperglycemia without ketosis (< 0.6 mmol/L): correction bolus of rapid-acting subcutaneous insulin every 2–4 h (dose: based on ISF + 10%, or 0.1 IU/kg).

• -

  Hyperglycemia with moderate ketosis (0.6−3 mmol/L): administer a correction insulin dose every 1–2 h (dose: ISF + 20%, or 0.15 IU/kg).

• -

  Hyperglycemia with severe ketosis (>3 mmol/L): perform blood gas analysis and implement DKA protocol.

Oral or intravenous hydration with dextrose-containing fluids should be administered if the blood glucose is below 250 mg/dL, and with fluids without dextrose if it is above 250 mg/dL.

If the intercurrent illness is expected to last more than 2 or 3 days, increasing the usual dose of long-acting insulin by 20%–30% should be considered.

Insulin pump (MiniMed™ 780G) paired with a continuous glucose monitor (CGM) (Guardian™ 4 or Simplera Sync™); the algorithm is embedded in the pump.

The target can be adjusted (100, 110, or 120 mg/dL), and basal insulin is delivered automatically, in addition to correction microboluses.

It has a “temp target” feature to set a temporary target that may be useful when there is a risk of hypoglycemia (the target increases to 150 mg/dL and autocorrections are turned off).

Meal boluses cannot be modified.

Infusion pump (Tandem t:slim X2™) and sensor (Dexcom G6™/G7™). The algorithm is embedded in the pump, which can be controlled either from the pump itself or from a mobile app.

Insulin delivery is guided by an adjustable ISF to maintain blood glucose between 112.5 and 160 mg/dL. Basal insulin is adjusted automatically, and the system delivers autocorrection boluses.

It has specific functions for “exercise activity” (target: 140−160 mg/dL) and “sleep activity” (target: 112.5−120 mg/dL).

Meal/correction boluses can be adjusted.

Infusion pump (mylife YpsoPump) and sensor (Dexcom G6™ or FreeStyleLibre3™). The algorithm is in a mobile app with remote control.

It allows blood glucose target adjustment (80−198 mg/dL). The basal rate is automated, and corrections are delivered as extended boluses.

It has an Ease-Off mode (prevention of hypoglycemia) and a Boost mode (treatment of hyperglycemia) that can be programmed or activated in the moment.

Meal/correction boluses can be adjusted.

The special modes available on each device can be used in the management of the patient. Hydration with sugar-containing fluids.

• -

  Absence of ketosis (< 0.6 mmol/L):

  • ◦

    Blood glucose < 90 mg/dL → Reduce insulin dose according to carbohydrate intake:

    • MiniMed™ 780G system:

      • •

        Maintain “SmartGuard” automated insulin delivery and change settings: increase blood glucose target and/or increase active insulin time (AIT).

      • •

        Set Temp Target.

      • •

        Switch to Manual mode and set temporary basal rate between 0%–100%.

    • Tandem Control-IQ™ system:

      • •

        Increase ISF.

      • •

        Enable Exercise Activity mode.

    • CamAPS™ FX system

      • •

        Increase blood glucose target.

      • •

        Activate Ease-off mode.

  • ◦

    Blood glucose 90−180 mg/dL → maintain usual mode/settings.

• -

  Mild-to-moderate ketosis (0.6−3 mmol/L): maintain usual mode/settings.

  • ◦

    Blood glucose < 90 mg/dL → consider ketosis due to fasting.

    If blood glucose > 90 mg/dL, offer rapid-acting carbohydrates and deliver insulin bolus at usual doses after verifying intake.

  • ◦

    Blood glucose 90−180 mg/dL → if the patient receives carbohydrates, the usual insulin boluses will be delivered.

• -

  Severe ketosis/risk of DKA (> 3 mmol/L): maintain usual mode/settings.

  • ◦

    Blood glucose < 90 mg/dL and blood glucose 90−180 mg/dL: see previous section.

    If the patient develops vomiting or oral intolerance, evaluate blood gas levels and start intravenous fluids.

Figure 5.

Decreased insulin requirements in patients managed with CSII.

The first step is to immediately replace the infusion set and cannula.

• -

  Hyperglycemia without ketosis (< 0.6 mmol/L): after replacing infusion set/cannula, administer correction bolus via the new set:

  • ◦

    MiniMed™ 780G: switch to Manual mode and enter blood glucose value to deliver correction bolus.

  • ◦

    Tandem Control-IQ™: automatic correction boluses.

  • ◦

    CamAPS (YpsoPump): enter blood glucose level to administer correction bolus.

  • Maintain systems in automated mode and check blood glucose at 2 h: if it has decreased and/or is below 250 mg/dL, resume usual therapy. If blood glucose is not decreasing, repeat the process and consider measurement of blood ketone levels.

• -

  Hyperglycemia with moderate ketosis (0.6−3 mmol/L): replace infusion set/cannula and deliver correction bolus with insulin pen. Correction dose: 0.1−0.15 IU/kg and/or using the ISF. The bolus calculator of the pump can be used to calculate the dose to deliver with the pen.

  Check blood glucose/ketone levels again at 2 h:

• ◦

  Decrease in ketone levels (<0.6 mmol/L): maintain automated mode and reevaluate in 2 h. In absence of ketosis, ensure the infusion set is replaced and verify that the replacement is functioning properly.

  If ketones remain elevated: administer 20 g of carbohydrates via subcutaneous injection. Once ketosis resolves, check that the replacement cannula is functioning properly.

• ◦

  Increase in ketone levels (>0.6 mmol/L): transition to basal-bolus insulin therapy (MDI) with carbohydrate intake.

  Oral hydration with sugar-free fluids if blood glucose >250 mg/dL and sugar-containing fluids if < 250 mg/dL.

• -

  Hyperglycemia with severe ketosis (>3 mmol/L): Suspend insulin delivery and/or remove the cannula; consider blood gas analysis and DKA protocol. Once ketosis has resolved, replace the infusion set/cannula and check that it is functioning properly.

  If the condition causing hyperglycemia persists for 2–3 days, consider making adjustments to the devices to facilitate management:

• -

  MiniMed™ 780G: optimize settings (AIT 2 h and/or blood glucose target 100 mg/dL) or switch to Manual mode and set temporary basal rate between 100%–200%.

• -

  Tandem Control-IQ™: reduce ISF and/or enable sick day profile (if it has been configured).

• -

  CamAPS YpsoPump: reduce target in Auto mode and/or activate Boost mode.

Figure 6.

Increased insulin requirements in patients managed with CSII.

• -

  Minor surgery or procedures lasting less than 2 h, skipping one meal

  • 1

    Nil per os (NPO), fluid therapy with 5% dextrose/0.9% sodium chloride solution at baseline maintenance dose (Holliday: first 10 kg, 100 mL × kg; next 10 kg, 50 mL × kg; >20 kg, 20 mL × kg).

  • 2

    Measure capillary blood glucose hourly or use sensor glucose readings as a guide (if levels remain between 90−180 mg/dL). Keep the sensor in place before, during, and after surgery.

  • 3

    Usual subcutaneous basal insulin dose (consider reducing the dose by 20%–30% if values tend toward hypoglycemia).

• -

  Major surgery or procedures expected to last more than 2 h with prolonged fasting. In addition to diet, fluid therapy, and use of CGM, insulin will be administered as intravenous (IV) insulin therapy: dilute 50 IU of rapid-acting or regular insulin in 50 mL of normal saline (1 IU/mL) and adjust the rate based on blood glucose readings:

  • • •

      <70 mg/dL: suspend insulin for 15 min, correct the hypoglycemia, and resume the IV infusion when blood glucose is >70 mg/dL

    • •

      70−140 mg/dL: 0.025 U/kg/h

    • •

      140−200 mg/dL: 0.05  U/kg/h

    • •

      >200 mg/dL: 0.1 U/kg/h

Consider continuing the subcutaneous regimen or switching to intravenous insulin therapy based on the general condition of the patient and the type and duration of the surgery.

• -

  Contact the pediatric care and/or pediatric diabetes team in advance.

• -

  Use of CGM:

  • ◦

    Check that the CGM has 72 h of battery left and is functioning properly.

  • ◦

    Ensure that the placement of the sensor does not interfere with the operative field or the electrosurgical unit (CGM devices are compatible with both unipolar and bipolar electrosurgical units; the sensor may remain in place as long as it is not in the operative field or the diathermy plane).

• -

  Maintain blood glucose between 90−180 mg/dL.

  • ◦

    In the case of sustained blood glucose values >200 mg/dL, check blood ketones.

    • •

      If patient is receiving intravenous insulin, adjust the infusion rate; otherwise, administer a subcutaneous bolus using a rapid-acting insulin pen based on the ISF, provided that no dose has been administered in the last 3 h.

  • ◦

    If blood glucose is < 70 mg/dL, administer a bolus of 10% dextrose solution (2 mL/kg) and measure blood glucose again in 15 min. Consider switching fluid therapy to 10% dextrose. If the patient is receiving intravenous insulin and develops hypoglycemia, suspend the infusion for 15 min until blood glucose increases.

• -

  Continue intravenous fluid therapy until the patient tolerates oral nutrition.

• -

  Maintain blood glucose levels between 90 and 180 mg/dL. If the patient requires admission to the pediatric intensive care unit (PICU), increase the blood glucose target to 140−180 mg/dL.

• -

  Resume subcutaneous insulin therapy at the usual dosage once oral tolerance has been restored to maintain blood glucose within the target range and prevent ketosis.

• -

  Use the insulin-to-carbohydrate ratio and the ISF to adjust the insulin dose.

• -

  Postoperative insulin requirements vary depending on weight, gastrointestinal symptoms, the severity of pain, and any concomitant medication.

• -

  Minor surgery or procedures lasting less than 2 h, skipping one meal

  • 1

    Manage diet, fluid therapy, and monitoring as described in the previous section (minor surgery in patients treated with MDI regimen).

  • 2

    Maintain usual CSII or consider temporary basal rate reduction 4–6 h before the procedure:

    • •

      MiniMed™ 780G: increase blood glucose target or set Temp Target.

    • •

      Tandem Control-IQ™: enable Exercise Activity.

    • •

      CamAPS YpsoPump: increase blood glucose target and/or activate Ease-off mode.

• -

  Major surgery or procedure expected to last more than 2 h with prolonged fasting

  • 1

    In addition to dietary management, fluid therapy, and sensor,

  • 2

    Turn off subcutaneous infusion pump (remove pump).

  • 3

    Intravenous insulin therapy, as described in the previous section.

Consider maintaining CSII based on the general condition of the patient and the type and duration of surgery.

• -

  Use CGM (as described in previous section).

• -

  Use of insulin pump:

  • ◦

    Battery is fully charged or sufficient battery left.

  • ◦

    Cartridge has enough insulin left (at least 36 h).

  • ◦

    Transmitter is connected to the pump.

  • ◦

    Alarms and audio activated.

  • ◦

    Airplane mode off.

  • ◦

    Verify that an insulin bolus is not being delivered before surgery.

  • ◦

    Check that predictive low glucose/threshold suspend is activated (devices in manual mode).

• -

  Maintain CGM. Insulin can be delivered through the patient’s infusion set with the usual settings or via intravenous infusion.

• -

  Maintain blood glucose levels between 90 and 180 mg/dL

  • ◦

    Sustained levels >200 mg/dL, check ketones:

    • •

      If intravenous insulin is used, proceed as described above.

    • •

      If CSII is maintained, resume usual basal rate (if it had been reduced) or administer a subcutaneous correction bolus using a rapid-acting insulin pen, or consider switching to intravenous insulin therapy.

  • ◦

    < 70 mg/dL: correct blood glucose and consider suspending insulin infusion (intravenous or subcutaneous) for 15 min until the condition resolves.

• -

  Management of fluid therapy and monitoring as described in the previous section.

• -

  If the pump was removed prior to or during surgery, resume normal pump operation once oral tolerance is achieved, blood glucose is within target range in absence of ketonemia.