Diabetes mellitus type 2 - NYSORA | NYSORA

Diabetes mellitus type 2

Learning objectives

  • Anesthetic management of a patient with diabetes mellitus type 2
  • Physiological changes due to diabetes mellitus 

Definition and mechanisms

  • Diabetes mellitus type 2 is a consequence of peripheral resistance to insulin action 
  • Is characterized by insulin resistance (hepatic, extrahepatic, or both) probably due to a decreased stimulation of glycogen synthesis in muscle by insulin, related to impaired glucose transport
  • Insulin secretion and/or insulin action are thought to be deficient with  excessive hepatic glucose production
  • It is frequently associated with dysfunction in pancreatic β-cells responsible for insulin secretion
  • The age of onset is variable, however, it is usually a disease of adults with slow onset
  • Ketoacidosis is uncommon

Physiological changes 

Musculoskeletal system Stiff joint syndrome (SJS)
Renal Diabetic nephropathy
Neurological systemIncreased risk of cerebrovascular accident (CVA)
Nerve fibers at risk for ischemic injury
Peripheral neuropathies
Autonomic neuropathy Diabetic autonomic neuropathy
Resting tachycardia
Orthostatic hypotension
Intestinal constipation
Bladder dysfunction
Impaired neurovascular function
Loss of autonomic response to Hypoglycemia
Cardiovascular system Hypertension
Coronary artery disease
Silent myocardial ischemia
Systolic and diastolic heart failure
Congestive heart failure
Peripheral vascular disease
Retinal Diabetic retinopathy

Management of diabetes mellitus type 2

  • Diet 
  • Exercise
  • Medications:
    • Sulphonylureas (e.g. gliclazide) 
    • Biguanides (e.g. metformin) 
    • Thiazolidinediones (e.g. pioglitazone, rosiglitazone)
    • Meglinitides (e.g. repaglinidine, nateglinide)
    • Alpha-glucosidase inhibitors (e.g. acarbose, miglitol)
    • Incretin mimetics:
      • GLP-1 agonists (e.g. exanatide, liraglutide)
      • DPP-4 inhibitors (e.g. sitagliptin and vildagliptin) 
    • SGLT2 inhibitors (e.g. canagliflozin, dapagliflozin, empagliflozin)

Anesthetic management

Preoperative assessment

Diabetes mellitus type 2; preoperative assessment

Perioperative management

Diabetes mellitus type 2, blood glucose, insulin, normoglycemia, regional anesthesia

Glucose, insulin, potassium, sliding scale regimen, obesity

Postoperative care

  • Check blood glucose levels hourly until a normal diet is established
  • Monitor plasma potassium 3-4 hourly, or more frequently if clinically indicated
  • Administer appropriate analgesia
  • Use NSAIDs with great caution as they may further impair renal function in patients with a nephropathy
  • Avoid dexamethasone as it exacerbates insulin resistance

Keep in mind 

HbA1c has a strong predictive value for complications of diabetes

Suggested reading 

  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
  • Pontes JPJ, Mendes FF, Vasconcelos MM, Batista NR. Avaliação e manejo perioperatório de pacientes com diabetes melito. Um desafio para o anestesiologista [Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist]. Braz J Anesthesiol. 2018;68(1):75-86.
  • Cornelius BW. Patients With Type 2 Diabetes: Anesthetic Management in the Ambulatory Setting: Part 2: Pharmacology and Guidelines for Perioperative Management. Anesth Prog. 2017;64(1):39-44.
  • Stubbs, D.J., Levy, N., Dhatariya, K., 2017. Diabetes medication pharmacology. BJA Education 17, 198–207.
  • Nicholson G, Hall GM. 2011. Diabetes and adult surgical inpatients. Continuing Education in Anaesthesia Critical CAre & Pain. 11;6:234-238.
  • Robertshaw HJ, Hall GM. Diabetes mellitus: anaesthetic management [published correction appears in Anaesthesia. 2007 Jan;62(1):100]. Anaesthesia. 2006;61(12):1187-1190.
  • McAnulty GR, Robertshaw HJ, Hall GM. Anaesthetic management of patients with diabetes mellitus. Br J Anaesth. 2000;85(1):80-90.

We would love to hear from you. If you should detect any errors, email us customerservice@nysora.com