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Therapy Goals -Appropriate measures under stages A, B, and C -Decision regarding appropriate level of care Options -Compassionate end-of-life care/hospice -Extraordinary measures heart transplantation chronic inotropes permanent mechanical support experimental surgery or drugs

Figure 10 1 Stages in the evolution of heart failure and recommended therapy by stage ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers (Reproduced, with permission, from Hunt SA et al ACC/AHA 2005 Guidelines Update for the evaluation and management of chronic heart failure in the adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure] ACC/AHA 2005 Guidelines Update for the diagnosis and management of chronic heart failure in the adult 2005, American Heart, Inc)

B cell adenomas do not reduce secretion in the presence of hypoglycemia, and the critical diagnostic test is to demonstrate inappropriately elevated serum insulin levels at a time when hypoglycemia is present A reliable serum insulin level (radioimmunoassay) of 6 microunit/mL or more in the pres-

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major tool in confirming the diagnosis of diffuse islet hyperplasia in the recently described noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) (see below) Since diazoxide might interfere with this test, it should be discontinued for at least 48 72 hours before sampling An infusion of dextrose may be required, therefore, and patients should be closely monitored during the procedure to avoid hypoglycemia (as well as hyperglycemia, which could affect insulin gradients) These studies combined with careful intraoperative ultrasonography and palpation by a surgeon experienced in insulinoma surgery identifies up to 98% of tumors

(1) Obtain baseline serum glucose, insulin, proinsulin, and C-peptide measurements at onset of fast and place intravenous cannula (2) Permit only calorie-free and caffeine-free fluids and encourage supervised activity (such as walking) (3) Measure urine for ketones at the beginning and every 12 hours and at end of fast (4) Obtain capillary glucose measurements with a reflectance meter every 4 hours until values < 60 mg/dL are obtained Then increase the frequency of fingersticks to each hour, and when capillary glucose value is < 49 mg/dL send a venous blood sample to the laboratory for serum glucose, insulin, proinsulin, and C-peptide measurements Check frequently for manifestations of neuroglycopenia (5) If symptoms of hypoglycemia occur or if a laboratory value of serum glucose is < 45 mg/dL, or if 72 hours have elapsed then conclude the fast with a final blood sample for serum glucose, insulin, proinsulin, C-peptide, -hydroxybutyrate or acetone and sulfonylurea measurements Then give oral fast-acting carbohydrate followed by a meal If the patient is confused or unable to take oral agents, then administer 50 mL of 50% dextrose intravenously over 3 to 5 minutes Do not conclude a fast based simply on a capillary blood glucose measurement wait for the laboratory glucose value unless the patient is very symptomatic and it would be dangerous to wait

It is imperative that the surgeon be convinced that the diagnosis of insulinoma has been unequivocally made by clinical and laboratory findings Only then should surgery be considered, as there is no justification for exploratory operation just as there is none for the use of current localization techniques as a preoperative diagnostic tool Resection by a surgeon with previous experience in removing pancreatic B cell tumors is the treatment of choice In patients with a single benign adenoma, 90 95% have a successful cure at the first surgical attempt when intraoperative ultrasound is used by a skilled surgeon Blood glucose should be monitored throughout surgery, and 10% dextrose in water should be infused at a rate of 100 mL/h or faster In cases where the diagnosis has been established but no adenoma is located after careful palpation and use of intraoperative ultrasound, it is no longer advisable to blindly resect the body and tail of the pancreas, since a nonpalpable tumor missed by ultrasound is most likely embedded within the fleshy head of the pancreas that is left behind with subtotal resections Most surgeons prefer to close the incision and schedule a selective arterial calcium stimulation with hepatic venous sampling to locate the tumor site prior to a repeat operation Laparoscopy using ultrasound and enucleation has been successful with a single tumor of the body or tail of the pancreas, but open surgery remains necessary for tumors in the head of the pancreas

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