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Sales Documents | Sales Document Header | Define Sales Document Types Quantity contracts have their own pricing procedures, texts, partners, and so on, like any other document type They also have their own item categories Don t forget to set up the copy control to other order document types you may be using as release orders

3 Late Hypoglycemia (Occult Diabetes)

This condition is characterized by a delay in early insulin release from pancreatic B cells, resulting in initial exaggeration of hyperglycemia during a glucose tolerance test In response to this hyperglycemia, an exaggerated insulin release produces a late hypoglycemia 4 5 hours after ingestion of glucose These patients are usually quite different from those with early hypoglycemia occurring 2 3 hours after glucose ingestion, often being obese and frequently having a family history of diabetes mellitus In obese patients, treatment is directed at weight reduction to achieve ideal weight Like all patients with postprandial hypoglycemia, regardless of cause, these patients often respond to reduced carbohydrate intake with multiple, spaced, small feedings They should be considered potential diabetics and advised to have periodic medical evaluations

Service GJ et al Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery N Engl J Med 2005 Jul 21;353(3):249 54 [PMID: 16034010]

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Any patient who is considered a candidate for noninvasive ischemia testing independent of the planned noncardiac surgery should generally have such testing prior to surgery if the test result may lead to coronary revascularization This is particularly true for patients found to be at high risk during clinical assessment Most other patients can be accurately risk-stratified by history, physical examination, electrocardiogram (ECG), and use of a multifactorial index Patients who have mild symptoms (CCS class I or II angina) and a low or intermediate multifactorial index score are at low risk for cardiac complications Noninvasive testing in these patients is generally not helpful Patients with CCS class III or IV angina or a high multifactorial index score are much more likely to suffer cardiac complications, especially when

The cardiac complications of noncardiac surgery are a major cause of perioperative morbidity and mortality The most important perioperative cardiac complications are myocardial infarction (MI) and cardiac death Other complications include congestive heart failure (CHF), arrhythmias, and unstable angina The principal patient-specific risk factor is the presence of end-organ cardiovascular disease This includes not only coronary artery disease and CHF, but also

Unprovoked bruising on the trunk of > 5 cm in diameter Frequent unprovoked epistaxis or gingival bleeding Menorrhagia with iron deficiency Hemarthrosis with mild trauma Prior excessive surgical blood loss or reoperation for bleeding Family history of abnormal bleeding Presence of severe kidney or liver disease

undergoing high-risk operations Stress testing in these patients may be able to identify a low-risk subgroup In the case of high-clinical-risk vascular surgery patients, the absence of ischemia on dipyridamole scintigraphy or dobutamine stress echocardiography predicts a low risk of perioperative cardiac death or MI Pharmacologic cardiac stress testing should also be considered when a patient s poor functional capacity limits the accuracy of clinical risk assessment Inability to exercise may mask severe coronary disease in such patients

4:

Patients with stable coronary artery disease have a 1 5% risk of MI and about a 1% mortality rate An approach to perioperative cardiac risk assessment and management in patients with known or suspected stable coronary artery disease is shown in Figure 3 1 Patients with acute coronary syndromes are at extremely high risk for complications and require immediate management of their cardiac disease prior to any preoperative evaluation (see 10)

Preoperative antianginal medications, including -blockers, calcium channel blockers, and nitrates, should be continued preoperatively and during the postoperative period There have been several clinical trials demonstrating a reduction in perioperative cardiac morbidity and mortality with prophylactic -blocking agents A randomized trial in vascular surgery patients with ischemia on

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