190 Hypoglycemia and

Hyperglycemia
Ari Y. Weintraub

Case Synopsis
An otherwise healthy 4-year-old boy is scheduled for inguinal hernia repair. He has dinner at 5 pm the
evening before surgery, as well as milk and cookies before going to bed at 9 pm. He is offered apple
juice at 5:30 am (2 hours before his scheduled surgery), which he refuses. Owing to a surgical emer-
gency, the boy’s surgery is delayed 4 hours. Before induction of anesthesia, his vital signs are stable,
but he is drowsy and somewhat fussy. His serum glucose concentration in the operating room after
induction of anesthesia is 64 mg/dL.

PROBLEM ANALYSIS induce. A blood glucose determination is necessary to confirm

Definition
Clinical hypoglycemia can be defined as a plasma glucose con-
centration that is low enough to manifest as signs or symptoms of
impaired brain function. Although hypoglycemia is often defined
as a blood glucose concentration less than 55 mg/dL (3 mmol/L) in
infants and older children and 35 mg/dL (2 mmol/L) in premature
and term neonates, these values have been derived statistically and
cannot necessarily be applied to individual patients without regard
to clinical findings. (Note: To convert mmol/L to mg/dL, simply
multiply by 18.)
Hyperglycemia is usually defined as a blood glucose concentration
greater than 200 mg/dL (11 mmol/L).  • Premature infants and small-for-gestational-age neonates
Recognition
Hypoglycemia
Most hypoglycemic children are asymptomatic; some are lethargic,
irritable, or jittery. In infants and older children, symptoms may occur
at a blood glucose concentration below 75 mg/dL, and unconscious-
ness at less than 35 mg/dL. In neonates, chronic low blood glucose
concentrations can be associated with adverse changes in somatosen-
sory evoked potentials and neurodevelopmental outcomes. Clinical
signs of hypoglycemia (tachycardia, hypertension) may be masked
by preoperative sedation or general anesthesia or attenuated by
β-blockers.  continued acutely
Hyperglycemia
The stress response to surgery, and perhaps to anesthesia, may
result in a temporary intraoperative increase in blood glucose con-
centration. Intraoperative narcotics and regional analgesia ame-
liorate the stress response to surgery by reducing catecholamine
release, which in turn attenuates the increase in blood glucose
concentration. Hyperglycemia is not recognized clinically dur-
ing anesthesia, except perhaps by the osmotic diuresis it may
any suspicion. 
Risk Assessment
The incidence of preoperative hypoglycemia in healthy infants and
children who have fasted between 4 and 19 hours is quite low. Also,
there appears to be no correlation between blood glucose concentra-
tion and the duration of fasting (hours) in this population. The risk
of hypoglycemia has been significantly reduced by allowing healthy
children to ingest glucose-containing clear liquids up until 2 hours
before the induction of anesthesia.
The following patients, however, are at risk for preoperative hypo-
glycemia when fasting:
• Newborns and infants born to diabetic mothers, and children with
diabetes or insulinomas
• Patients with reduced oral intake (e.g., feeding aversions, vomit-
ing) or excessive fluid losses (e.g., diarrhea, bowel preparation for
colonoscopy)
• Malnourished patients
• Patients with severe hepatic failure
• Patients with abnormalities of lipolysis or amino acid metabolism
• Patients with myopathies, mitochondrial diseases, or glycogen
storage diseases
• Those receiving certain drugs (e.g., propranolol, alcohol)
• Patients receiving hyperalimentation solutions or simple dextrose
infusions (10% or 12.5%), especially when these infusions are dis-
Factors resulting in intraoperative hyperglycemia include the
following:
• Exogenous glucose administration at high rates (e.g., ≥20 mL/kg
per hour) or massive transfusion
• Exogenous corticosteroid administration (either chronic or acute/
intraoperative)
• Alteration of hormone levels affecting glucose control (e.g., stress)
• Decreased peripheral glucose utilization
• Continuation of 10% or 12.5% dextrose solution at the preopera-
tive rate 

732
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Implications
Hypoglycemia
Unrecognized hypoglycemia can lead to neurologic injury. The absolute
value at which hypoglycemia impairs neurologic function is unknown
but is seemingly related to its duration measured in hours or days. Brain
glucose metabolism increases markedly during development. Unlike the
adult brain during ischemia, the neonatal brain is able to use alternative
substrates such as lactate and glycogen for energy.
Throughout the 1980s, routine intraoperative administration of
dextrose to infants and children was the recommended practice. How-
ever, mounting concerns about the risks of hyperglycemia have led to
most clinicians avoiding the routine use of solutions containing glu-
cose, except perhaps in neonates, infants who are small for gestational
age, and children with special problems. It is worthwhile to note that
due to the common administration of large doses of glucocorticoids,
exogenous catecholamines, and glucose-containing blood products
to infants and children undergoing open heart surgery, the elimina-
tion of dextrose from intravenous solutions for these patients does not
seem to be associated with hypoglycemia.  • Be aware of patients at increased risk for hypoglycemia or hyper-
Hyperglycemia
Hyperglycemia can induce diuresis, dehydration, and electrolyte dis-
turbances and may increase the incidence of cerebral hemorrhage
in very small newborns. In adults, hyperglycemia existing before
an ischemic or hypoxemic event may increase neurologic injury. It
is postulated that in the presence of either insult, oxidative metabo-
lism of glucose fails and glycolysis increases, producing excess lactate.
With sufficient intracellular lactate accumulation, intracellular pH
decreases, which may lead to compromised cellular function or cell
death.
In neonates, however, moderate to profound hyperglycemia seems
to protect the brain from ischemic damage through several mecha-
nisms, including increased glycogen stores and cerebral high-energy
reserves, slower accumulation of lactate due to slower glucose uptake
and metabolism compared with adults, and enhanced lactate clear-
ance. Thus during pediatric cardiac surgery, the role of hyperglycemia
(if any) in neurologic injury is unclear. In fact, in one study of neo-
nates undergoing arterial switch operations, no relationship between
poor long-term neurologic and developmental outcomes and hyper-
glycemia could be demonstrated.
Hyperglycemia is also associated with adverse outcomes in adults
with sepsis. Glucose control in septic infants is poorly defined. How-
ever, most clinicians reduce 10% or 12.5% dextrose infusion rates by
one-third or one-half during surgery on septic infants.  22:61–75, 1995.
MANAGEMENT
The goals of intraoperative fluid management are to provide an appro-
priate amount of parenteral fluids (water plus electrolytes) to maintain
adequate intravascular volume, cardiac output, and urine output and,
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Chapter 190  •  Hypoglycemia and Hyperglycemia  733
in some instances, to provide sufficient glucose to prevent hypogly-
cemia or minimize the risk of perioperative hyperglycemia. To avoid
both hypoglycemia and hyperglycemia during surgical procedures,
some have suggested administering 2.5% dextrose in lactated Ringer’s
(LR) solution at maintenance rates, along with a glucose-free fluid
(e.g., LR or normal saline) for replacement of blood and third-space
losses. Because 2.5% dextrose–LR solution is not commercially avail-
able, either the practitioner or a pharmacist must prepare it. Blood
obtained from central venous or arterial catheters or from finger or
heel sticks is used to monitor glucose concentrations. Glucose test-
ing is usually available at the point of care. If not, concentrations are
measured in the blood gas laboratory. Serial blood glucose determina-
tions can be made, with the amount of intravenous glucose adjusted
accordingly. 
PREVENTION
Prevention of hypoglycemia and hyperglycemia requires a case-specific
risk-benefit analysis. Some caveats deserve special mention:
glycemia.
• Be judicious when administering glucose-containing solutions to
patients at risk for hypoglycemia.
• Withhold glucose-containing solutions when appropriate.
• Frequently monitor blood glucose concentrations.
ACKNOWLEDGMENT
The author wishes to thank Dr. D. Ryan Cook for his contribution to
the previous edition of this chapter.
Further Reading
Aun CD, Panesar NS: Paediatric glucose homeostasis during anaesthesia, Br J
Anaesth 64:413–418, 1990.
Datta PK, Pawar DK, Baidya DK, et al.: Dextrose-containing intraoperative
fluid in neonates: a randomized controlled trial, Pediatr Anesth 26:599–
607, 2016.
Ferranti SD, Gaureau K, Hickey PR, et al.: Intraoperative hyperglycemia dur-
ing infant cardiac surgery is not associated with adverse neurodevelopmen-
tal outcomes at 1, 4, and 8 years, Anesthesiology 100:1345–1352, 2004.
Leelanukrom R, Cunliffe M: Intraoperative fluid and glucose management in
children, Paediatr Anaesth 10:353–359, 2000.
Loepke AW, Spaeth JP: Glucose and heart surgery: neonates are not just small
adults (editorial), Anesthesiology 100:1339–1340, 2004.
Pereira GR: Nutrition care of the extremely premature infant, Clin Perinatol
Steven J, Nicolson S: Perioperative management of blood glucose during open
heart surgery in infants and children, Pediatr Anesth 21:530–537, 2011.
Welborn LG, Hannallah RS, McGill WA, et  al.: Glucose concentration in
routine intravenous infusion in pediatric outpatient surgery, Anesthesiology
67:427–430, 1987.
Welborn LG, McGill WA, Hannallah RS, et al.: Perioperative blood glucose
concentrations in pediatric outpatients, Anesthesiology 65:545–547, 1986.