Oral gastric tube-guided insertion of the ProSeal™ laryngeal mask is an easy and noninvasive method for less experienced users.

PURPOSE: The ProSeal™ laryngeal mask airway (PLMA) can be more difficult to insert than the classic laryngeal mask, especially in patients who have a thin palate with a steep oropharyngeal curve. Here, an oral gastric (OG) tube-guided technique is considered as a method that makes it easier to successfully insert a PLMA. METHODS: Sixty patients who were scheduled to undergo general anesthesia without neuromuscular blocking were randomly allocated into two groups: 30 patients with PLMA inserted by the standard digital technique, and 30 with the PLMA inserted by an OG tube-guided technique. Most PLMA insertions were performed by less experienced users. The success rate at the first attempt, the time taken to insert the PLMA, the difficulty of the procedure, and the incidence of oropharyngeal trauma and postoperative sore throat were compared between the two groups. RESULTS: PLMA insertion was successfully achieved at the first attempt using the OG tube-guided technique in all 30 patients. The OG tube-guided insertion required fewer attempts (P = 0.04) and led to a less difficult insertion procedure (P = 0.02) than the standard digital insertion. Effective ventilation during anesthesia was achieved in all patients, with a lower mean cuff pressure in the OG tube-guided technique group (P = 0.02). The frequency of blood sticking to the PLMA tube (P < 0.001) and the incidence of postoperative sore throat (P = 0.003) were lower in the OG tube-guided group than the standard digital technique group. CONCLUSIONS: OG tube-guided PLMA insertion is easier for less experienced users, trainees, and experts as well as less invasive for patients than the standard digital insertion.

[Pre-operative smoking cessation does not always reduce the incidence of surgical site infection after gastrointestinal surgery].

BACKGROUND: Centers for Disease Control (CDC) recommend pre-operative smoking cessation to reduce the risk of surgical site infection (SSI). However, whether pre-operative smoking cessation reduces the incidence of SSI for gastrointestinal surgery is unclear. We investigated whether pre-operative smoking cessation reduces the incidence of SSI among patients undergoing gastrointestinal surgery. METHODS: The study subjects were 512 consecutive patients undergoing gastrointestinal surgery at Osaka Medical Center for Cancer and Cardiovascular Diseases. SSI occurrence was determined by the hospital SSI surveillance team. Pre-operative smoking status was obtained by interview, and the patients were divided into four groups. Information on age, sex, operation time, operational organ, American Society of Anesthesiologists physical status (ASA-PS), elective or emergency surgery, co-existing procedures, use of scopes, ileo-colostomy, properties of drain tube, use of floss, and wound contamination was obtained from the medical records. The relationship between smoking status and incidence of SSI, and risk factors associated with the incidence of SSI were investigated. RESULTS: SSI occurred in 83 patients. Pre-operative smoking status had no relation with the incidence of SSI. Operation time, gallbladder and pancreatic surgery, colon surgery, emergency surgery, co-existing procedures, ilea-colostomy, closed drain, usage of floss, and wound contamination were related significantly with SSI. CONCLUSIONS: Pre-operative smoking cessation does not reduce the incidence of SSI. However, since continuation of smoking has no benefits for the safety of surgery, anesthesiologists must advice patients to quit smoking before surgery.

[Internal jugular vein cannulation guided by pulsation].

BACKGROUND: We are accustomed to right internal jugular vein (IJV) cannulation guided by pulsation for 20 years or more. This study was conducted to evaluate whether this method is a safe and certain method. METHODS: After obtaining informed consent, 100 elective surgical patients requiring central venous catheterization during perioperative period were randomly assigned to either the pulsation group in which IJV pulsation was used for a landmark of puncture or the US group in which IJV was recognized with ultrasonography before puncture. RESULTS: Pulsation was observed in 98 patients. Successful rate of first attempt with a 23 G seeking needle was 85.7% in the pulsation group and 86% in the US group. IJV was successfully cannulated at 1 pass in the entire pulsation group and 92% in the US group. The frequency of puncture with cannula was significantly lower in the pulsation group than that of the US group. Arterial puncture with the seeking needle was recorded in 3 patients in the US group. Successful rate of first attempt in this study was comparable to other studies using ultrasonographic guidance. CONCLUSIONS: Internal jugular vein cannulation by pulsation method is a safe and certain method.

[Remifentanil provides fast recovery and hemodynamic stability in laryngomicrosurgery anesthesia].

BACKGROUND: Stressful procedures such as intratracheal intubation and direct laryngoscopy in very short operations make anesthetic management for laryngomicrosurgery difficult. This study was conducted to evaluate which anesthetic agent, remifentanil or fentanyl, is suitable in anesthesia for laryngomicrosurgery. METHODS: After obtaining informed consent prior to the study, 18 patients undergoing elective laryngomicrosurgery were randomly allocated to one of two groups to receive remifentanil (R group) or fentanyl (F group). Patients with ages above 76 years and moderate abnormalities in cardiovascular system or respiratory system were excluded. RESULTS: Average infusion rate of remifentanil was 0.24 +/- 0.02 microg x kg(-1) x min(-1) and total infused dose of fentanyl was 0.27 +/- 0.05 mg. Average bispectral index values in both groups were comparable. Cases needing sevoflurane inhalation to control blood pressure were significantly more in F group than in R group. Heart rate was significantly lower in R group than in F group. Duration from the end of operation to responses to verbal commands and extubation was significantly shorter in R group than in F group. CONCLUSIONS: Remifentanil provided faster recovery and hemodynamic stability. Therefore, remifentanil seems to be more suitable than fentanyl in anesthesia for laryngomicrosurgery.

[Prophylactic strategies for perioperative pulmonary thromboembolism in cancer patients].

BACKGROUND: Our previous reports showed that elastic stockings (ES) combined with intermittent pneumatic compression (IPC) significantly decrease the incidence of perioperative pulmonary thromboembolism (PTE). This study was conducted to investigate whether ES with IPC is useful to prevent PTE in cancer patients. METHODS: No prophylactic strategies were employed from January 1998 to December 1999 (4511 cases). ES combined with ICP apparatuses was employed from May 2000 to April 2008 (20,383 cases). Details of the methods were described in our previous reports. RESULTS: Age, anesthesia duration and operation duration increased statistically without clinical significances after the induction of prophylactic strategies. About 90 per cent of surgical patients had malignant disease. Seven patients developed PTE without any interventions and 5 patients with treatments. The incidence of PTE decreased significantly from 15.51 persons/10,000 cases to 2.45 persons/10,000 cases. Cardiac arrest occurred in two untreated patients but in no treated patient. Intervention also significantly decreased the incidence of cardiac arrest. CONCLUSIONS: The combination of ES and ICP seems to be useful to decrease the incidence and severity of perioperative PTE in cancer patients in Japan.

Dopamine D2 receptor Taq IA polymorphism is associated with postoperative nausea and vomiting.

PURPOSE: The dopamine D2 receptor (DRD2) is considered to be involved in the development of postoperative nausea and vomiting (PONV). Our aim was to examine the relationship between DRD2 Taq IA polymorphism and the occurrence of PONV. METHODS: We enrolled 1070 patients who were scheduled to undergo elective surgery under general anesthesia. Patients who vomited or required rescue antiemetics for severe nausea at two time points (within 6 and within 24 h after surgery) were defined as having early and total PONV, respectively. A polymerase chain reaction with confronting two-pair primers (PCR-CTPP) technique was adopted for DRD2 genotyping allele (A1A1, A1A2, or A2A2). The relationship between DRD2 Taq IA polymorphism and the occurrence of PONV was examined by multivariate logistic regression analysis. RESULTS: The incidences of early PONV were 9.0%, 9.3%, and 14.4% in patients with the A1A1, A1A2, and A2A2 alleles, respectively. Sex, nature of the disease, smoking status, type of surgical department, duration of anesthesia, and the DRD2 Taq IA polymorphism were related to the emergence of early PONV. On multivariate analysis, the relative risk associated with the A2A2 allele in comparison with the A1A1 or A1A2 allele was 1.58 (95% confidence interval [CI], 1.05-2.37) for early PONV. The incidences of total PONV were 12.5%, 13.6%, and 17.2% in patients with the A1A1, A1A2, and A2A2 alleles, respectively. Sex, smoking status, type of surgical department, and duration of anesthesia were related to the emergence of total PONV. On multivariate analysis, the relative risk associated with the A2A2 allele in comparison with the A1A1 or A1A2 allele was 1.27 (95% CI, 0.88-1.84) for total PONV. CONCLUSION: The DRD2 Taq IA polymorphism affected the occurrence of early PONV. Analysis of patients' genetic backgrounds may improve risk-stratification for PONV.

[Wound healing in reconstructive head and neck surgery].

BACKGROUND: Smoking cessation and shorter operative duration are known as factors to improve wound healing in reconstructive head and neck surgery. We investigated the other factors associated with wound healing. METHODS: Informations on age, sex, body mass index, smoking status, serum albumin level, diabetes mellitus, chronic obstructive pulmonary diseases, preoperative steroid therapy, preoperative chemotherapy, preoperative radiation therapy, preoperative starvation care, American Society of Anesthesiologists physical status (ASA-PS), intraoperative administration of prostaglandin E1, operative duration, and type of flap were obtained from the medical records of 370 patients. Requirements of postoperative intervention were also recorded. Factors associated with wound healing were estimated by multivariate analysis. RESULTS: Compared with smokers, 22 to 42 day smoking quitters, over 43 day smoking quitters, and non-smokers had lower incidence of wound complications; odds ratio; 95% confidence intervals (CI) were 0.20; 0.06-0.68, 0.19; 0.07-0.51, and 0.15; 0.05-0.45, respectively. Other factors and odds ratios (95% CI) associated with wound complications were preoperative chemotherapy; 3.02 (1.09-8.41), preoperative starvation; 0.23 (0.06-0.84), every one minute of operation duration; 1.01 (1.00-1.01). CONCLUSIONS: Preoperative smoking cessation, preoperative chemotherapy, preoperative starvation care, and operation duration were significantly associated with wound healings.

[Prophylactic strategies for perioperative pulmonary embolism: the second report; reevaluation of usefulness of combination of elastic stockings and intermittent pneumatic compression].

BACKGROUND: The incidence of perioperative pulmonary thromboembolism (PTE) has increased in Japan. As the mortality rate of PE is very high, its prophylaxis is important. METHODS: From January 1998 to December 1999 no prophylactic strategies were employed. From May 2000 to December 2004, elastic stockings (ES) for prevention of perioperative deep vein thrombosis were worn from the morning of the operation until the beginning of ambulation. Intermittent pneumatic compression (IPC) apparatuses were used in combination with ES right after the induction of anesthesia until leaving ICU. Sixty percent of patients stayed in ICU until the next morning after the operation and the other patients for a few hours after the end of surgery. RESULTS: We managed 4,511 patients without any preventing method and 11,688 patients with the combination of ES and IPC. Seven patients developed PTE without any prophylaxis and one with preventative methods. The incidence of PTE was significantly decreased from 15.51 persons/10,000 cases to 0.86 person/10,000 cases. Symptomatic deep vein thrombosis occurred in 3 cases in spite of preventative methods. CONCLUSIONS: Our preventive strategies with the combination of ES and IPC seem to be useful to decrease the incidence and severity of perioperative PTE.

Effects of a phosphodiesterase 3 inhibitor, olprinone, on rhythmical change in tension of human gastroepiploic artery.

The gastroepiploic artery, used widely as a conduit in coronary artery bypass grafting, has high vasospasticity. The aims of this study were to examine the vasorelaxant effects of three phosphodiesterase 3 (PDE3) inhibitors, olprinone, milrinone and amrinone, on isolated gastroepiploic arterial preparations in comparison with a calcium channel blocker diltiazem, and to confirm the mRNA expression of PDE3A isoenzyme using reverse transcription-polymerase chain reaction (RT-PCR) in the human gastroepiploic artery isolated from stomach removed in cancer surgery. In endothelium-denuded gastroepiploic arterial preparations, phenylephrine (100 microM) produced spontaneous, rhythmical changes in tension consisting of repeated contraction and relaxation. Olprinone at a concentration of 10 microM (n=6) significantly inhibited the frequency (2.7+/-1.1 times/30 min vs. 6.2+/-0.7 times/30 min in the vehicle group), maximum tension (1.7+/-0.6 g vs. 3.6+/-0.6 g in the vehicle group) and minimum tension (0.6+/-0.2 g vs. 1.7+/-0.3 g in the vehicle group) of rhythmical changes. Such potency is comparable to that of diltiazem, but is stronger than milrinone and amrinone. RT-PCR using PDE3A- or PDE3B-specific oligonucleotide primer demonstrated the existence of PDE3A sequence in the gastroepiploic artery. These results suggest that olprinone, a potent PDE3A inhibitor, would be suitable for protecting against perioperative spasm during coronary artery bypass graft surgery.

[Prophylaxis of perioperative pulmonary thromboembolism in a patient with anti-phospholipid antigen syndrome].

A 68-year-old woman with anti-phospholipid antigen syndrome (APS) was proposed to undergo partial pulmonary resection for lung cancer. She suffered from mild cerebellar ataxia. Exercised 201Tl myocardial scintigraphy was performed due to abnormal Q wave in preoperative electrocardiography and showed old myocardial infarction in inferior-to-posterior area without myocardial ischemia. Cardiac function was marginally decreased in cardiac echographic evaluation. Arterial thrombosis by APS might cause cerebellar ataxia and myocardial infarction. Low molecular weight heparin (LMWH) was continuously infused from 1 hour prior to arrival in an operation room. Elastic stockings (ES) were worn from the morning of the operation in combination with the use of intermittent pneumatic compression apparatus (IPC). Significant bleeding was not observed perioperatively. Hypothermia was avoided by forced-air-warming therapy. She was transferred to ICU after the end of the operation. She was returned to her ward without IPC on the first postoperative day. Warfarin was given with the beginning of ambulation on the second postoperative day to keep PT-INR about 2. On the third postoperative day LMWH was discontinued and ES were taken off. The postoperative course was uneventful.

Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery.

BACKGROUND: Preoperative smoking cessation has been suggested to be effective in reducing various postoperative complications. However, the optimal duration of preoperative smoking cessation for reducing wound complications is unclear. METHODS: One hundred eighty-eight consecutive patients who underwent reconstructive head and neck surgery at the authors' institution were included in this retrospective study. Information on preoperative smoking habits was obtained from the patients' medical records. Smokers were defined as having smoked within 7 days before surgery. Late, intermediate, and early quitters were defined as patients whose duration of abstinence from smoking was 8-21, 22-42, and 43 days or longer before the operation, respectively. Patients who required postoperative debridement, resuture, or reconstruction of their flap before hospital discharge were defined as having had impaired wound healing. RESULTS: The incidences (95% confidence intervals) of impaired wound healing among the late, intermediate, and early quitters and nonsmokers were 67.6% (52-83%), 55.0% (33-77%), 59.1% (47-71%), and 47.5% (32-63%), respectively, and the incidence of impaired wound healing was significantly lower among the intermediate quitters, early quitters, and nonsmokers than among the smokers (85.7% [73-97%]). After controlling for sex, age, American Society of Anesthesiologists physical status, operation time, history of diabetes mellitus, chemotherapy, radiation therapy, and the type of flap, the odds ratios (95% confidence intervals) for development of impaired wound healing in the late, intermediate, early quitters, and nonsmokers were 0.31 (0.08-1.24), 0.17 (0.04-0.75), 0.17 (0.05-0.60), and 0.11 (0.03-0.51), respectively, compared with the smokers. CONCLUSIONS: Preoperative smoking abstinence of longer than 3 weeks reduces the incidence of impaired wound healing among patients who have undergone reconstructive head and neck surgery.

[Short-term bed rest as a cause of deep vein thrombosis in a patient with a huge abdominal tumor].

A 43-year-old female with a huge myoma uteri was scheduled for a simple total hysterectomy. However, there was massive penetration of the tumor into the retroperitoneum, and her first operation failed because we had no advance information on its posterior aspect. Angiography was done to obtain this information. She rested on bed until the day after the first operation and angiography. MRI, performed again due to early growing tumor, revealed deep vein thrombi in the left iliac vein to the left femoral vein which the last MRI had not shown. Therefore, just before the second operation a temporary vena-cava filter was inserted, to prevent acute pulmonary thromboembolism. The operation was performed without incident. The filter captured some thrombi, and these were resolved by urokinase postoperatively. No symptomatic pulmonary thromboembolism was recognized during the perioperative period. The postoperative course was uneventful.

[A case of silent rupture of a cerebral arteriovenous malformation during laparotomy].

A 52-year-old female, scheduled for rectal cancer resection, had no history of central nervous system abnormality. Anesthesia was maintained with general anesthesia combined with epidural anesthesia. Her only hemodynamic change was a rise in arterial pressure to 140 mmHg just after the start of the operation. However, postoperatively she failed to be aroused and she exhibited a positive Babinski's sign, anisocoria, an absent light reflex and paresis of the left lower extremity. Cerebral vascular accident was suspected and a CT scan revealed a cerebral hematoma which was immediately removed surgically. Upon exploration, abnormal vessels were recognized and we diagnosed an acute rupture of arteriovenous malformation. She fully recovered consciousness immediately after the operation. Her postoperative course was uneventful, except for a residual paresis of the left lower extremity.

[Anesthetic management of a patient with squeezed heart by huge sternal tumor].

We experienced perioperative management for excision of a huge sternal chondrosarcoma squeezing the heart. A 46-year-old woman could not sleep due to dyspnea for 6 months. Dyspnea increased in the right decubitus and disappeared in the left decubitus. This suggested that the heart was squeezing the tumor. MRI and echocardiography revealed no invasion to the heart. Surgical removal was proposed. Anesthesia was induced with propofol and fentanyl. As this tumor composed of bone-like tissue and was tightly connected with thoracic cage, we thought that the use of muscle relaxant at the induction of anesthesia would not cause cardiovascular collapse and ventilation insufficiency even if the tumor was huge. Vecuronium was administered to facilitate endotracheal intubation. Hemodynamic variables were stable and mask ventilation was uneventful. Anesthesia was maintained with propofol, sevoflurane, supplemental dose of fentanyl and epidural anesthesia. The tumor had invaded the myocardium and was successfully flaked off from the myocardium without using any assisted devices. The tumor was excised including thoracic wall (sternum and parts of 3rd to 12th ribs, 20 cm in diameter). Thoracoplasty was performed using Marlex Mesh. Muscle relaxant was reversed after the end of the operation. Respiration was stable without flail chest. Endotracheal tube was successfully removed in the operation room. The postoperative course was uneventful.

[Prophylactic strategies for perioperative pulmonary embolism].

BACKGROUND: Incidence of perioperative pulmonary embolism (PE) has increased in Japan probably due to the modernized life style. As the mortality rate of PE is very high, its prophylaxis is important. Therefore, prophylactic strategies for PE were instituted in the entire hospital. METHODS: Elastic stockings (ES) for preventing perioperative deep vein thrombosis in lower extremities were worn from the morning of the operation until the beginning of ambulation. Intermittent pneumatic compression (IPC) apparatuses were used in combination with ES. IPC apparatus was employed right after induction of anesthesia until leaving postanesthetic care unit (PACU). Seventy percent of patients stayed in PACU until the morning after the operation and the other patients for a few hours after the end of surgery. RESULTS: We managed 4,200 patients with this method. We experienced one symptomatic deep vein thrombosis but not severe or moderately severe PE. However, it is difficult to evaluate the incidence of mild PE because it is usual that symptom such as chest discomfort is thought as an indefinite complaint and its cause is not investigated further. CONCLUSIONS: Our preventive strategies seem to be useful to decrease the incidence and severity of perioperative PE.

[A successfully treated case of intraoperative latex anaphylaxis during abdominal aorta aneurysm resection].

We experienced resuscitation from latex anaphylaxis induced by surgical gloves during elective abdominal aorta aneurysm resection in a low risk adult with latex allergy. The patient developed severe circulatory collapse 10 minutes after the start of surgery. Although administration of dopamine, norepinephrine, and a large amount of fluid could not normalize this circulatory collapse, but addition of famotidine and chlorpheniramine could restore blood pressure. After resuscitation, we decided to postpone the operation. The re-operation was planned in the latex free setting one month later. All products, containing latex, had been excluded from operating room one day before the re-operation, and the patient entered operating room earlier than other patients to avoid latex-polluted powder from surgical gloves of other staffs. Y-shaped graft replacement was performed, and the perioperative course was uneventful. Latex is the second leading cause of intraoperative anaphylaxis, and the high-risk cases could be easily detected through the questionnaires, focusing on latex and other tropical fruits allergy. Moreover, because it is easy to get latex-free products, we recommend that a set of latex free products should be prepared at least for a high-risk case of latex allergy.

[Anesthetic management of two patients with hypertrophic obstructive cardiomyopathy for percutaneous transluminal septal myocardial ablation].

We experienced anesthetic management of two patients with hypertrophic obstructive cardiomyopathy (HOCM) for percutaneous transluminal septal myocardial ablation (PTSMA). PTSMA had been performed more than a year earlier in both cases, and symptoms and exercise tolerance were improved after PTSMA. Laparotomy for suspected ovarian cancer in one patient and thoracotomy for metastatic lung cancer in the other patient were proposed. Preoperative echocardiography showed reduced left ventricular outflow tract pressure gradient (from 90 mmHg before PTSMA to 10 mmHg and from 81 mmHg to 17 mmHg, respectively) and decreased septal wall thickness. Systolic anterior movement of mitral valve apparatus had disappeared. General anesthesia in the former and general anesthesia combined with epidural anesthesia in the latter were employed. Anesthesia was induced with propofol and fentanyl. A laryngeal mask was used to minimize hemodynamic fluctuations during induction and emergence in the former. Anesthesia was maintained with propofol, sevoflurane and supplemental fentanyl. Epidural anesthesia was also used to maintain anesthesia in the latter. The postoperative course was uneventful in each case. PTSMA for HOCM might be useful to prevent perioperative cardiac events.

Infiltration anesthetic lidocaine inhibits cancer cell invasion by modulating ectodomain shedding of heparin-binding epidermal growth factor-like growth factor (HB-EGF).

Although the mechanism is unknown, infiltration anesthetics are believed to have membrane-stabilizing action. We report here that such a most commonly used anesthetic, lidocaine, effectively inhibited the invasive ability of human cancer (HT1080, HOS, and RPMI-7951) cells at concentrations used in surgical operations (5-20 mM). Ectodomain shedding of heparin-binding epidermal growth factor-like growth factor (HB-EGF) from the cell surface plays an important role in invasion by HT1080 cells. Lidocaine reduced the invasion ability of these cells by partly inhibiting the shedding of HB-EGF from the cell surface and modulation of intracellular Ca2+ concentration contributed to this action. The anesthetic action of lidocaine (sodium channel blocking ability) did not contribute to this anti-invasive action. In addition, lidocaine (5-30 mM), infiltrated around the inoculation site, inhibited pulmonary metastases of murine osteosarcoma (LM 8) cells in vivo. These data point to previously unrecognized beneficial actions of lidocaine and suggest that lidocaine might be an ideal infiltration anesthetic for surgical cancer operations.

Intravenous anesthetic, propofol inhibits invasion of cancer cells.

Intravenous anesthetic, propofol (2,6-diisopropylphenol), is extensively used for general anesthesia without knowing the effects on cancer. We found here that clinically relevant concentrations of propofol (1-5 microg/ml) decreased the invasion ability of human cancer cells (HeLa, HT1080, HOS and RPMI-7951). In the HeLa cells treated with propofol, formation of actin stress fibers as well as focal adhesion were inhibited, and propofol had little effect on the invasion ability of the HeLa cells with active Rho A (Val(14)-Rho A). In addition, continuous infusion of propofol inhibited pulmonary metastasis of murine osteosarcoma (LM 8) cells in mice. These results suggest that propofol inhibits the invasion ability of cancer cells by modulating Rho A and this agent might be an ideal anesthetic for cancer surgery.

[Evaluation of cardiac load by measuring brain natriuretic peptide after thoracic esophagectomy and gastric tube in place].

A small dose of dopamine has been routinely infused for hemodynamic stabilization and diuresis in patients undergoing esophagectomy and gastric tube in place until the seventh postoperative day in our hospital. The timing of discontinuing infusion of dopamine was determined by our experience. However, there was no rationale to determine the timing of discontinuing it. Therefore, eight patients with ASA physical status I or II, undergoing esophagectomy and gastric tube in place were studied to evaluate postoperative cardiac load using brain natriuretic peptide, which is a biochemical detector of left ventricular dysfunction. There were no hemodynamic and cardiac events including myocardial ischemia and infarction in any patients. The postoperative course was uneventful in all patients. Serum BNP increased gradually and significantly until the third postoperative day with increasing urine volume. Serum BNP returned to the baseline level on the fourth postoperative day. However, serum BNP was still high in 3 patients on the sixth postoperative day in spite of dopamine. We conclude that cardiac overload was recognized until the third postoperative day.