Brit. J. Anaesth. (1972), 44, 712

BLOOD GLUCOSE LEVELS IN CHILDREN DURING SURGERY

B. G. WATSON

SUMMARY

Changes in blood glucose levels in children during surgery have been found not tofollow the pattern reported in adults, no relationship being found between the "stress-fulness" of the operation and the rate of rise of blood glucose concentration. In 10per cent of the children studied the blood glucose level immediately after inductionwas within the hypoglycaemic range.

There has been no report of the changes whichoccur in the blood sugar in children in response todifferent types of surgery. A recent report by Clarke(1970), showed that in adults a progressive rise inblood sugar occurred during surgery, which wasmore marked during abdominal than duringbody surface surgery, and was linear with time.

METHOD

Eighty patients aged between 22 months and 15years were studied. They were premedicated withoral trimeprazine (Vallergan Forte), 1.7 mg/kg to amaximum of 30 mg, 3 hours preoperatively, andintramuscular morphine 0.25 mg/kg with atropine0.02 mg/kg 1 hour preoperatively. Anaesthesia wasinduced with thiopentone 4 mg/kg followed bytubocurarine 0.8 mg/kg or pancuronium 0.13mg/kg and, following intubation, pulmonary venti-lation was controlled with nitrous oxide and oxygen.Patients having major procedures were givenintravenous infusions of Hartmann's solution5 ml/kg/hr during surgery. No patient was knownto suffer from any metabolic disease.

The operations performed were: 1 hiatus herniarepair; 23 laparotomies; 1 thoracotomy; 25 minorplastic procedures; 2 cleft lip and palate repairs; 2revisions of Spitz-Holter valve catheters; an eleva-tion of a depressed fracture of the skull; 18 squintand ptosis corrections; 2 inguinal hernia repairs; 4orchiopexies; and a biopsy of an osteochondromaof the femur. Local infiltrations of adrenaline wereused in three plastic cases.

Two ml samples of venous blood were taken fromeach patient into fluoride bottles, one after inductionof anaesthesia but before surgery had begun, andone at a variable time later. Samples were takenfrom the arm without an intravenous infusion.Glucose concentrations were measured by the tech-nique of Morley, Dawson and Marks (1968). This is

a glucose oxidase method with an accuracy of +5%.The normal fasting range is between 40 and 100mg/100 ml. In infants over 6 months a level of40 mg/100 ml or below is regarded as hypogly-caemic.

RESULTS

The age distribution of the patients is shown infigure 1.

20 -

c

COQ .

•s 10 -

eZ

FIG.

-2 -4 -G -S -1G-12-1A--.GAge (in years)

1. Age distribution of patients.

The mean of all the preoperative blood glucoselevels was 60 mg/100 ml. The mean of the secondsamples taken between 20 and 110 min later was68 mg/100 ml, a highly significant difference(P<0.001; table I). In none of the patients givenadrenaline to aid surgery did a rise in blood glucoseoccur.

B. G. WATSON, M.B., B.S., F.F.A.R.C.S., Department ofAnaesthesia, Alder Hey Children's Hospital, Liverpool.

Present address: Department of Anaesthesia, RoyalVictoria Infirmary, Newcastle upon Tyne, NE1 4LP.

BLOOD GLUCOSE LEVELS IN CHILDREN DURING SURGERY 713

The 80 cases were subdivided into a group of25 having major operations (laparotomy, thoraco-tomy), and 55 having lesser procedures. The groupswere not identical as regards either age or the dura-tion of preoperative starvation (tables II and III),though neither of these factors significantly affectedthe rate of rise of blood glucose which occurred.This rate was not significantly different in the twogroups (table IV).

TABLE I. Mean values of first and second samples(.glucose mg/100ml blood + 1 SD)

Mean of first samples 60.3+ 21Mean of second samples 68.5+ 46Significance P<0.001

TABLE II. Mean ages of patients (years).

Patients having major operationsPatients having minor operations

10.8 (range 3-16)7.7 (range 2-14)

TABLE III. Duration of pre-operative starvation (hours).

Patients having major operationsPatients having minor operations

12.5 (range 7-18)9.5 (range 3-17)

TABLE IV. Rate of rise of blood glucose (mg/min+ 1 SD).

No. ofcases

Rate ofrise Significance

Major operationsMinor operations

2555

0.53 ±0.470.59 + 0.76

The distribution of the initial blood glucose levelsis shown in figure 2. Eight cases were within thehypoglycaemic range. They were younger (mean

0<31 31- 41- 51- 61- 71- 81- 91- >100

40 50 60 70 80 90 100

Blood glucose levels (mg/100ml)

FIG. 2. Distribution of initial blood glucose levels.

age 4.25 + 3.3 yr) than the others (mean age6.45 ± 3.7 yr) but the difference was not significant(P>0.1). There was no association between theoccurrence of hypoglycaemia and the duration ofpreoperative fasting: the mean duration of fastingin the hypoglycaemic and non-hypoglycaemic groupwas identical at 10J hours, though older childrentended to have been starved longer. Nor was thereany difference between these two groups as regardstheir rate of rise of blood glucose during surgery(table V). No patient gave any reason for believingthat he was hypoglycaemic at the time of induction.Details of the hypoglycaemic patients are given intable VI.

The choice of relaxant did not effect the rate ofrise of blood glucose (table VII).

TABLE V. Rate of rise of blood glucose in patientsinitially hypoglycaemic, and in those not hypoglycaemic

(mg/min + 1 SD)

Initially hypoglycaemicNot hypoglycaemic

TABLE VII. Influenceglucose

PancuroniumTubocurarine

No. ofcases

872

Mean rateof rise

0.64 + 0.70.56 + 1.04

of relaxant on rate of(mg/min +1 SD).

No. ofcases

2553

Mean rateof rise

0.49 + 1.90.63 ±0.45

Significance

n.s.

rise of blood

Significance

n.s.

DISCUSSION

In adults the hyperglycaemic response to surgeryis related to the duration and stressfulness of theoperation. Clarke (1970) measuring total reducingsubstances rather than glucose found a highly signi-ficant difference between body surface and intra-abdominal surgery, using groups of 20 and 30patients respectively. The intra-abdominal groupshowed a highly significant increase over thebody surface group at 30, 45 and 60 minafter the initial sample, though not at 15 min(P<0.001 in each case). The mean rises were of10 mg/100 ml at 60 min in the body surface groupand 38 mg/100 ml in the intra-abdominal group.Anaesthesia consisted of thiopentone, tubocurarine,and nitrous oxide. When propanidid was used therises were higher, and thoracic surgery was foundto have an intermediate effect, suggesting that the

714 BRITISH JOURNAL OF ANAESTHESIA

TABLE VI. Details of children who were hypoglycaemic before surgery.

No.

12

34

567

8

Operation

SquintExcisionnaevusPyeloplastyElevation offractured skullThoracotomyCleft palateExcision ofbald patch ofscalpUretericimplantationinto colon

Age(yr)

12

43

532 5/12

3

15

Blood glucose(mg/100 ml)

Initial

28

4038

303040

30

25

Final

90

4058

304555

30

30

Timestarved

(hr)

8

914

1386

8

18

Intervalsamples

1A A * • « T A A r\

oetween(min)

20

2480

303030

20

29

Relaxant

Pancuronium

33

33

Tubocurarine) 3

33

33

33

Case No. 2 had a local infiltration of 2 ml lignocaine 0.5% with 1:80,000 adrenalineCase No. 8 was said to have a poor appetite.

greater "stressfulness" of abdominal surgery may bedue to traction on the peritoneum and mesentery.

It is unlikely that this difference was related to arise in reducing substances other than glucose.

In the present study, there was a wide scatter inthe results, but no difference was seen between themajor and minor procedures. Premedication andanaesthesia were light. This would have tended toexaggerate any difference which exists, if this is dueto an increased sensory input, as the response hasbeen shown to be smaller with deep anaesthesia(Clarke, 1970).

Attention was drawn initially to the problem ofhypoglycaemia by a child who was sweating andcomplaining of headache before induction, and wasfound to be hypoglycaemic. None of the 80 childrensubsequently studied showed any signs of hypogly-caemia, though this is unlikely under 5 years ofage. An incidence of 10% of hypoglycaemia inchildren about to undergo surgery is unacceptablyhigh, even though none showed a further fall duringoperation. Shortening of the period of preoperativestarvation would be expected to reduce the incidencedespite the absence of statistical evidence of an asso-ciation. The danger of regurgitation of gastric con-trie content at induction outweighs the beneficialeffect of a high glucose content of the last preopera-tive feed. Vallergan Forte contains 65 g of sucroseper 100 ml, and is strongly hypertonic. The maxi-mum dose of this was limited to 5 ml.

Routine rapid estimation of blood glucose afterinduction by testing with Dextrostix (Ames) would

be of help, and urine testing for ketones before thepatient comes to theatre might detect those at risk.

There can be no doubt that intravenous infusionsduring paediatric surgery should contain glucose. Asuitable fluid is 5 % dextrose in half-strength Ringerlactate. Although there was no evidence that thehypoglycaemia was harmful in any of the childrenstudied, the results justify further study of themetabolic response of children to surgery.

ACKNOWLEDGEMENTS

I am very grateful to Mr J. Ireland and the staff of theBiochemistry Department of Alder Hey Children'sHospital, who performed the estimations, and to DrG. H. Bush for his h;lp and encouragement.

REFERENCES

Clarke, R. S. J. (1970). The hyperglycaemic response todifferent types of surgery and anaesthesia. Brit. J.Anaesth., 42, 45.

Morley, G., Dawson, A., and Marks, V. (1968). Manualand autoanalyser methods for measuring blood glucoseusing guanicum and glucose oxidase. Proc. Assn. Clin.Biochem., 5, 42.

TAUX DE LA GLYCEMIE CHEZ L'ENFANTDURANT LA CHIRURGIE

SOMMAIRE

On a observe que les modifications de la glycemie chezl'enfant durant la chirurgie ne sont pas similaires acelles observers chez l'adulte et on ne trouva aucunrapport avec le degrd de stress provoque par Pop^rationet le taux d'augmentation de la glycemie. La glycemie.augmenta chez dix pourcent des enfants etudies aussit6tque Pinduction atteignait le niveau hypoglycemique.

BLOOD GLUCOSE LEVELS IN CHILDREN DURING SURGERY 715

BLUTGLUCOSESPIEGEL BEI KINDERNWAHREND EINER OPERATION

ZUSAMMENFASSUNG

Es wurde beobachtet, dass sich die Veranderungen derBlutglucosewerte bei Kindern wahrend einer Operationanders verhalten, als es fiir Erwachsene beschriebenwurde; zwischen der "Schwere des Stress" einer Opera-tion und der Rate des Blutzuckeranstieges konnte keineBeziehung gefunden werden. Bei 10% der untersuchtenKinder bewegte sich der Blutzuckerspiegel unmittelbarnach der Einleitung der Narkose im hypoglykamischenBereich.

NIVELES DE LA GLUCOSA SANGUINEA ENNINOS DURANTE OPERACIONES QUIRURGICAS

RESUMEN

Ha sido observado que los cambios en los niveles de laglucosa sanguinea en ninos durante operacionesquinirgicas no siguen el patt6n comunicado para losadultos, no encontrandose ninguna relation entre el"stress" de la operaci6n y el aumento de la concentrationde glucosa en la sangre. En el 10 por ciento de los ninosestudiados el niyel de la glucosa sanguinea inmediatamentedespues de la induction estaba dentro de los limites dela hipoglicemia.

YORKSHIRE SOCIETY OF ANAESTHETISTS

Programme 1972-1973

October 11, 1972

November 8, 1972

December 13, 1972

January 10, 1973

February 14, 1973

Professor B. S. Simpson, Anaesthetic UnitLondon Hospitals"Halothane Hepatitis—Fact or Fallacy?"

Dr S. H. Taylor, Consultant CardiologistDr M. D. Hargreaves, Consultant AnaesthetistDr K. Exley, Consultant Neurophysiologist"Symposium on Cardiac Arrest".

Dr J. S. Inkster, Consultant AnaesthetistUnited Newcastle upon Tyne Hospitals"Current Practices and Techniques in Anaesthesiaand Intensive Care for Small Children".

Dr W. D. A. Smith, Department of AnaesthesiaUniversity of Leeds"Research related to the uptake of Nitrous

Oxide and the changes which occur infunctional residual capacity".

Wg Cmdr J. Ernsting, RAF Institute ofAviation Medicine"Hypoxia in Aviation".