39yo male for formation L RCF next week
- Diabetic nephropathy exacerbated by an AKI
- Currently dialysed through permacath. Some blockages (resolved) but nil infections.
- Secondary anaemia – EPO, Hb 109
- Smoker 10/d and cannabis ++
- Malnourished, dry weight 54kg
- Difficult phone consultation
- Patient extremely difficult to engage in conversation, became agitated with attempts to clarify information.
- Unable to ascertain functional capacity
- Poor diabetes control
- Multiple admissions to ICU with DKA
- Fasting sugars 10-15. HbA1c unknown
- Ultra-long acting/mixed insulin at midday. How to manage this perioperatively?
- Potential for optimisation?
- Undifferentiated HFrEF
- Sestamibi as part of transplant workup showed EF 30%, asymptomatic (as far as could be ascertained). New development.
- Awaiting TTE (although pt unaware of this), no current booking, should we pursue this?
- In absence of F2F review, preop TTE may be helpful and is a necessary step for him, it is unlikely to change management.
- Point-of-care TTEs from ICU unable to be located
- Could this be uraemic cardiomyopathy?
- Classically that would present as diastolic dysfunction with hypertrophy and fibrosis, although chronic severe hypertrophy may lead to cardiomyocyte death and systolic failure.
- Fibrosis may lead to dysrhythmias and sudden cardiac death.
- Thought due to pressure and volume overload (HTN and anaemia), fibroblastic growth factors, chronic inflammation, systemic oxidant stress, RAA activation, insulin resistance, abnormal mineral metabolism and endogenous cardiotonic steroids.
- Response to traditional therapies is limited.
- Endocrinologist says they have worked extremely hard to achieve the once daily ultra-long-acting insulin and no further optimisation possible.
- Profoundly depressed or cognitively impaired?
- Services available within renal or transplant spheres?
- W/H ultralong acting insulin DOS and use insulin infusion while in hospital. Resume normal insulin with normal diet.
- Attempt to obtain TTE but don’t delay surgery if not possible preop.
- Line up a procedural anaesthetist who will confidently do the procedure under regional anaesthesia only.