Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Table Graphic Jump Location|Download (.pdf)|PrintPathophysiologyType 1Type 2GestationalIncidence0.4% of population in 20057% of population in 20054% of pregnant womenOnsetTypically before age 30Increases with increasing ageRisk factorsGenetics, environmentalObesity, geneticsObesityPathophysiologyAutoimmune destruction of beta cells, resulting in insulin deficiencyInsulin resistance, increased glucose productionSomatomammotropin causes insulin resistanceComplicationDiabetic ketoacidosis (DKA)Hyperglycemic–hyperosmolar nonketotic comaCongenital abnormalities, stillbirthOutcomeOcular: cataracts, retinopathy, blindnessVascular: coronary artery disease, peripheral vascular diseaseRenal: leading cause of renal failure in the United StatesNeurologic: peripheral neuropathy, autonomic neuropathyGI: delayed gastric emptyingNB: HTN accelerates microangiopathy and macroangiopathyMost resolve postpartum30–60% chance of developing diabetes postpregnancy later in life ++ See following table. ++Table Graphic Jump Location|Download (.pdf)|PrintTreatmentInsulinSulfonylureaMetformin (a biguanide)Acarbose (an intestinal alpha-glucosidase inhibitor)Thiazolidinediones (troglitazone, rosiglitazone, and pioglitazone)Meglitinides (repaglinide and nateglinide)Mechanism of actionAnabolic hormoneStimulates endogenous insulin secretionInhibits gluconeogenesisIncreases glucose uptake in skeletal muscleDecreases carbohydrate absorptionActivate peroxisome proliferator–activated receptorsIncrease secretion of insulinHypoglycemiaYesRareNoNoNoYesComplicationsHypoglycemia, high dose may be atherogenicHypoglycemiaRisk of perioperative lactic acidosis; renal clearanceGI upsetFluid retentionWeight gainWhat to do preoperatively?Administer half the dose of long-acting insulin; monitor blood glucose perioperatively; IV insulin has more reliable absorption than subcutHold while NPO to avoid hypoglycemiaHold 1–2 days preoperatively to avoid lactic acidosisHold while NPO; no benefit while NPOConsider holding 2 days preoperatively to avoid fluid retention++Table Graphic Jump Location|Download (.pdf)|PrintComplicationsDiabetic ketoacidosis (DKA) (see chapter 210 for more details)Nonketotic hyperosmolar coma (NKHC) (see chapter 211 for more details)HypoglycemiaPrecipitated byPoor patient compliance with insulinStress state, such as sepsis or myocardial infarctionStress leads to an increase in counterregulatory hormones, which cause insulin resistancePatients with NIDDM do not suffer from DKA because circulating insulin levels are sufficient to prevent ketogenesis, but instead are at risk for NKHCPrecipitated by stress or drugs, including corticosteroidsInsulin and/or oral medications in the absence of glucose intakeCounterregulatory hormones secreted in response to hypoglycemia include epinephrine, glucagon, growth hormone, and cortisolDiagnosisMetabolic acidosis and hyperglycemia present in a patient with IDDMConfirmation by urinalysis for ketonesExtreme hyperglycemia (>1,000 mg/dL) is sufficient for diagnosisSerum osmolality >320 mOsm/kgUrine ketones absentSigns and symptomsNausea, vomiting, abdominal painTachycardia and hypotension caused by dehydrationSomnolenceElderly individual with type 2 DMNausea/vomitingMuscle weakness and crampsPolyuria, and then oliguriaSlight hyperthermiaConfusion, lethargy, seizures, hemiparesis, and comaOften occurs when blood glucose falls below 30–50 mg/dLDiaphoresis, tachycardia, altered mental status, seizuresTreatmentSee chapter 210See chapter 211Oral 15 g carbohydrates (180 mL orange juice)Fluid resuscitation (1–2 L of NS over 1–2 h)25 mL 50% glucose (each milliliter of ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.