Abstract
The goal in type 1 diabetes (T1D) therapy is to maintain optimal glycemic control under any circumstance. Diabetes technology is in continuous development to achieve this goal. The most advanced Food and Drug Administration- and European Medicines Agency-approved devices are hybrid closed-loop (HCL) systems, which deliver insulin subcutaneously in response to glucose levels according to an automated algorithm. T1D is frequently encountered in the perioperative period. The latest international guidelines for the management of children with diabetes undergoing surgery include specific adjustments to the patient's insulin therapy, hourly blood glucose monitoring, and intravenous (IV) insulin infusion. However, these guidelines were published while the HCL systems were still marginal. We present a case of a 9-year-old boy with long-standing T1D, under HCL system therapy for the last 9 months, and needing surgery for an appendectomy. We agreed with the family, the surgical team, and the anesthesiologists to continue HCL insulin infusion, without further adjustments, hourly blood glucose checks or IV insulin, while monitoring closely. The HCL system was able to keep glycemia within range for the total duration of the overnight fast, the surgery, and the initial recovery, without any external intervention or correction bolus. This is, to the best of our knowledge, the first reported pediatric case to undergo major surgery using a HCL system, and the results were absolutely satisfactory for the patient, his family, and the medical team. We believe that technology is ripe enough to advocate for a “take your pump to surgery” message, minimizing the impact and our interventions. The medical team may discuss this possibility with the family and patients.
Highlights
As diabetes technologies evolve toward the artificial pancreas pursuing to achieve the maintenance of the patient’s glycemia within normal range, the number of children with type 1 diabetes (T1D) using these technologies is increasing
We present a case of a boy with long-standing T1D, using hybrid closedloop (HCL) system therapy for months with good results, who needed surgery for an appendectomy
To the best of our knowledge, we present the first pediatric case of a patient with T1D undergoing a major surgery with uninterrupted use of an HCL system running in automode
Summary
As diabetes technologies evolve toward the artificial pancreas pursuing to achieve the maintenance of the patient’s glycemia within normal range, the number of children with type 1 diabetes (T1D) using these technologies is increasing. The patient had used a HCL system (Medtronic 670G R in auto-mode) for 9 months, had improved metabolic control since its use (estimated HbA1c 7.3% and average blood glucose 162 ± 68 mg/dl; Figure 1), felt very comfortable with the device, and both the patient and the parents were reluctant to interrupt it (the system’s program details are shown in Supplementary Table 1) His ratios and sensitivities had been programmed in his last visit according to the patient’s glycemic response to prandial insulin, but this does not affect basal insulin administration since the basal rates are not altered by this program when the system runs in auto-mode. The basal insulin infusion at 48 h after surgery dropped down to 19.0 and 15.5 IU/day
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