Hybrid Closed-Loop System Achieves Optimal Perioperative Glycemia in a Boy With Type 1 Diabetes: A Case Report

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.

Insulin pump therapy and glucose control during Ramadan fasting in an adolescent with type 1 diabetes: from an open-loop sensor-augmented pump therapy with predictive low-glucose management to an advanced hybrid closed-loop system

“…The first-generation hybrid closed-loop (MINIMED Medtronic 670G) system without an autocorrecting algorithm was reported in a unique experience during RF, and no changes in TIR were reported [ 3 ]. The same device has been successfully used in different challenging experiments and led to optimal perioperative glycaemia in a 9-year-old child with T1D [ 4 ]. We present the case of a T1D patient in whom glucose control was managed using the AHCL system during 1 month of continuous diurnal fasting.…”

Insulin Pumps and Hybrid Close Loop Systems Within Hospital: A Scoping Review and Practical Guidance From the Joint British Diabetes Societies for Inpatient Care

“…There are few case reports of using hybrid closed-loop systems in surgery, 21,22,26 but overall data on the safety or maximum safe duration of hybrid closed-loop control during anesthesia are limited. 13 Elective surgeries provide the opportunity for preadmission preparation, and these systems should only be used with the anesthetist working in close collaboration with the diabetes inpatient teams, with close monitoring and a clear plan and knowledge of using these systems.…”

Perioperative maintenance of hybrid closed loop insulin pump systems in youth with type 1 diabetes mellitus: A case series

“…CGMs and insulin pumps are now being integrated into hybrid closed loop systems to automatically adjust rates of insulin delivery in response to real‐time changes in BG 9 . These systems, such as Omnipod 5, Tandem t:slim with Control‐IQ, and Medtronic 670G, have demonstrated improved glycemic control with more time spent in target range and less hypoglycemia for both adults and children 10–15 . With increasing use of these advanced diabetes technologies among individuals with diabetes, it is inevitable that providers will encounter hybrid closed loop systems in all settings, including the perioperative space.…”

“…However, there is limited data regarding the use of hybrid closed loop systems in pediatric patients undergoing anesthesia and surgery. 10,16 The ISPAD recommendations acknowledge there is no evidence regarding the perioperative use of automated insulin delivery systems. 8 We therefore describe our experiences with the perioperative use of hybrid closed loop systems in the pediatric population and present a case series of seven pediatric patients with type 1 diabetes who underwent anesthesia for procedures and minor surgery and were successfully managed with this technology.…”

“…9 These systems, such as Omnipod 5, Tandem t:slim with Control-IQ, and Medtronic 670G, have demonstrated improved glycemic control with more time spent in target range and less hypoglycemia for both adults and children. [10][11][12][13][14][15] With increasing use of these advanced diabetes technologies among individuals with diabetes, it is inevitable that providers will encounter hybrid closed loop systems in all settings, including the perioperative space. However, there is limited data regarding the use of hybrid closed loop systems in pediatric patients undergoing anesthesia and surgery.…”