The neuropeptide neuromedin U promotes inflammation by direct activation of mast cells.

Neuromedin U (NMU) is a neuropeptide that is expressed in the gastrointestinal tract and central nervous system. NMU interacts with two G protein-coupled receptors, NMU-R1 and NMU-R2. Whereas NMU-R2 localizes predominantly to nerve cells, NMU-R1 is expressed in peripheral tissues including lymphocytes and monocytes, suggesting a role of NMU in immunoregulation. However, the functions of NMU in peripheral tissues have not been clarified. In this study, using NMU-deficient mice, we first demonstrated that NMU plays an important role in mast cell-mediated inflammation. Complete Freund's adjuvant-induced mast cell degranulation as well as edema and neutrophil infiltration, which occurred weakly in mast cell-deficient WBB6F(1)-W/W(v) mice, did not occur in NMU-deficient mice. Moreover, intraplantar injection of NMU into paws induced early inflammatory responses such as mast cell degranulation, vasodilation, and plasma extravasation in WT mice but not in WBB6F(1)-W/W(v) mice. NMU-R1 was highly expressed in primary mast cells, and NMU induced Ca(2+) mobilization and degranulation in peritoneal mast cells. These data indicate that NMU promotes mast cell-mediated inflammation; therefore, NMU receptor antagonists could be a novel target for pharmacological inhibition of mast cell-mediated inflammatory diseases.

[Factors that affect the mortality in patients receiving emergency surgery for ruptured abdominal aortic aneurysms].

This retrospective study was performed to identify the perioperative factors affecting the mortality rate in 28 patients, who had received emergency surgery for ruptured abdominal aortic aneurysms from January, 2005 to June, 2008. Five (17.9%) of these 28 patients died of massive bleeding, sepsis, or multiple organ failure during or within 11 days after surgery. Various factors which might influence the outcomes were compared between the survivors and non-survivors. Preoperative hypotension defined as a systolic blood pressure < or = 80 mmHg associated with hemorrhagic shock was the only significant factor affecting the mortality. There were no significant differences in age, gender, the time from the admittance to the hospital to aortic cross clamping, duration of surgery, and the amount of blood products transfused and intraoperative blood loss, between the two groups. Of great importance is that preoperative hypotension should be corrected before the onset of hemodynamic deterioration.

Role of adrenoceptors in the regulation of dopamine/DARPP-32 signaling in neostriatal neurons.

Studies in animal models of Parkinson's disease have revealed that degeneration of noradrenaline neurons is involved in the motor deficits. Several types of adrenoceptors are highly expressed in neostriatal neurons. However, the selective actions of these receptors on striatal signaling pathways have not been characterized. In this study, we investigated the role of adrenoceptors in the regulation of dopamine/dopamine- and cAMP-regulated phosphoprotein of M(r) 32 kDa (DARPP-32) signaling by analyzing DARPP-32 phosphorylation at Thr34 [protein kinase A (PKA)-site] in mouse neostriatal slices. Activation of beta(1)-adrenoceptors induced a rapid and transient increase in DARPP-32 phosphorylation. Activation of alpha(2)-adrenoceptors also induced a rapid and transient increase in DARPP-32 phosphorylation, which subsequently decreased below basal levels. In addition, activation of alpha(2)-adrenoceptors attenuated, and blockade of alpha(2)-adrenoceptors enhanced dopamine D(1) and adenosine A(2A) receptor/DARPP-32 signaling. Chemical lesioning of noradrenergic neurons mimicked the effects of alpha(2)-adrenoceptor blockade. Under conditions of alpha(2)-adrenoceptor blockade, the dopamine D(2) receptor-induced decrease in DARPP-32 phosphorylation was attenuated. Our data demonstrate that beta(1)- and alpha(2)-adrenoceptors regulate DARPP-32 phosphorylation in neostriatal neurons. G(i) activation by alpha(2)-adrenoceptors antagonizes G(s)/PKA signaling mediated by D(1) and A(2A) receptors in striatonigral and striatopallidal neurons, respectively, and thereby enhances D(2) receptor/G(i) signaling in striatopallidal neurons. alpha(2)-Adrenoceptors may therefore be a therapeutic target for the treatment of Parkinson's disease.

[Anesthetic management for gastrectomy in two gastric cancer patients after coronary artery bypass grafting using right gastroepiploic artery].

We report two cases for anesthetic management of gastrectomy for gastric cancer which took place after receiving coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). The first patient was a 75-year-old man after CABG using the RGEA 14 years before. He was diagnosed with gastric cancer and was scheduled for total gastrectomy. Preoperative coronary angiography (CAG) showed complete occlusion of the right coronary artery (RCA), whereas RGEA was patent. Because percutaneous coronary intervention (PCI) was hard to perform on the occluded RCA, proximal gastrectomy was carried out without lymph node dissection. The surgeons judged the surgery enough for radical treatment. Surgery was accomplished without any problems. The second patient was a 76-year-old man after CABG using the RGEA 15 years before. He was diagnosed with advanced gastric cancer and was scheduled for distal gastrectomy. Preoperative CAG showed the RCA partially occluded and the RGEA remaining patent. He received the scheduled surgery after confirmation of the success of PCI, performed preoperatively for reperfusion of the occluded segments. Although the RGEA was incised during the surgery, gastrectomy was accomplished without any problems in the cardiac function.

[Retrospective investigation and analysis of dental injuries during endotracheal intubation].

BACKGROUND: The objective of this study is to clarify the causes of dental injuries (DIs) developed during the direct laryngoscopy for the endotracheal intubation (EI) in our hospital. METHODS: Subjects are 4173 patients who had the EI from April 1, 2006 to March 31, 2007. Mallampati's classification and Miller's classification were used for the evaluation of difficult airway and the dental unsteadiness, respectively. RESULTS: There was no case between 10 and 40 years of age. Twelve cases (0.3%) had the DIs during the observation period. In 8 out of 12 cases (67%), EI was carried out by the residents with less than 3 months of the training period. Three cases (25%) were classified to the II or III grade. The dissociation of the evaluations by a dental anesthesiologist and medical anesthesiologists were found in two cases. Eight cases received temporary treatment by a dental anesthesiologist. CONCLUSIONS: Temporary treatment in the operating room was carried out by a dental anesthesiologist. Careful inquiry is needed for the proper preoperative teeth evaluation, especially in the schoolchild with milk teeth and elderly patients. A precise educational system for the residents is required for the prevention of DIs during the EI.

Gradient of bronchial end-tidal CO2 during two-lung ventilation in lateral decubitus position is predictive of oxygenation disorder during subsequent one-lung ventilation.

PURPOSE: Hypoxemia is one of the major problems during one-lung ventilation (OLV). During two-lung ventilation (TLV) using a double-lumen bronchial tube, bronchial endtidal carbon dioxide partial pressure (ETbr(CO2)) can be determined on both sides, independently. The ETbr(CO2) is mainly dependent on the pulmonary perfusion to each lung. If the degree of oxygenation disorder during OLV were to be predictable before starting OLV, this could provide time to prepare for any subsequent hypoxemia. The aim of this study was to investigate whether the difference of ETbr(CO2) (D-ETbr(CO2)) between the dependent and the nondependent lungs during TLV in the lateral decubitus position (LP) could be a predictive factor for the severity of oxygenation disorder under subsequent OLV. METHODS: Eighteen patients undergoing lung surgery were enrolled in this study. Anesthesia was induced with intravenous thiopental and fentanyl, supplemented by the inhalation of sevoflurane. A left-sided double-lumen bronchial tube was placed. The ETbr(CO2) was independently determined on each side during TLV in the supine position (SP) and at 10 min after changing the position from SP to LP. PaO2/inspiratory fraction of oxygen (FIO2) was taken at 15 min after switching from TLV to OLV in LP. RESULTS: The decrease of PaO2/FIO2 at 15 min during OLV in LP correlated with the reduction of the D-ETbr(CO2) predetermined during TLV in LP (r = 0.698; P < 0.01). CONCLUSION: The D-ETbr(CO2) predetermined during TLV in LP could be a predictive factor for the severity of oxygenation disorder after starting OLV in LP.

Cuff occlusion on the left upper arm increases flow of the left internal mammary artery and bypass flow to the left anterior descending artery.

PURPOSE: Changes in vascular resistance in the left forearm may affect the flow of left internal mammary artery (LIMA)- to left anterior descending artery (LADA) bypass, because the LIMA is a major branch of the subclavian artery. We studied the effects of occlusion of the left upper arm on blood flow of LIMA-to-LADA bypass in patients undergoing coronary artery bypass grafting (CABG). METHODS: In ten patients, the blood volume shed from LIMA with the distal end open (LIMA free flow) was stored for 1 min before and during cuff inflation in CABG surgery. LIMA-LADA bypass flow was measured with ultrasonic flow-metry before and after cuff inflation on the left upper arm in an other ten patients. Mean arterial blood pressure (MAP), heart rate (HR), and electrocardiograms (ECGs) were monitored throughout the studies. RESULTS: LIMA free flow (ml x min(-1)) increased from 50.3 +/- 7.1 to 60.9 +/- 8.4 (P < 0.01) at the end of 1-min cuff inflation. LIMA-LADA bypass flow (ml x min(-1)) increased from 31.4 +/- 3.7 to 39.7 +/- 4.0 (P section sign 0.05) at 1 min after cuff inflation. MAP, HR, and ST segments on ECGs did not show any significant changes related to measurement times. CONCLUSION: LIMA-LADA bypass flow increased after cuff inflation on the left upper arm and returned to the baseline values after cuff deflation. Anesthesiologists should be aware of this relationship between local vascular resistance and bypass flow for the evaluation of LIMA-LADA anastomosis.

Effects of nasal application of an epinephrine and lidocaine mixture on the hemodynamics and nasal mucosa in oral and maxillofacial surgery.

PURPOSE: Our purpose was to investigate the influences of nasal pretreatment with a mixed solution of epinephrine and lidocaine (E-L pretreatment) on the systemic hemodynamics and the mucosa of the inferior nasal concha, which is carried out for expansion of the nasal cavity and the prevention of mucosal injury before nasotracheal intubation. PATIENTS AND METHODS: Subjects included 29 adult patients undergoing oral and maxillofacial surgery. This study consisted of 2 parts. In part 1 (n = 18), the effects of E-L pretreatment on the systemic hemodynamics were studied before (pre-Anesth group, n = 10) and after (post-Anesth group, n = 8) induction of anesthesia. Changes of the mucosal volume and the blood flow of the inferior nasal concha also were observed by optic bronchoscopy and noncontact type laser-Doppler flowmetry, respectively. In part 2 (n = 11), changes in the serum concentrations of epinephrine and lidocaine after the E-L pretreatment were determined by high performance liquid chromatography and enzyme immunoassay, respectively. RESULTS: The heart rate increased at 2 and 3 min after E-L pretreatment in pre-Anesth group (P < .05), but not in post-Anesth group. The cross section of the nasal cavity decreased from 66% to 42% (n = 8, P < .05). The mucosal blood flow decreased from 60 to 22 AU (n = 8, P < .01). The serum epinephrine concentration increased from 24 to 185 pg/mL. CONCLUSIONS: The E-L pretreatment provided characteristic evidence for useful expansion of the nasal cavity and for reduction of the nasal mucosal blood flow with less systemic hemodynamic effects, although further investigation is needed for the determination of the proper epinephrine concentration in E-L pretreatment.

[Combination of spinal and inhalation anesthesia for nephrectomy in a cirrhotic patient].

We report a 75-year-old man with the liver cirrhosis of Child-Pugh B who underwent nephrectomy. Preoperative serum examination revealed increases in GOT, GPT, LDH and total bilirubin, decreases in cholinesterase and albumin, and prolongation of prothrombin time. We selected spinal anesthesia using bupivacaine and fentanyl rather than epidural anesthesia in combination with isoflurane inhalation anesthesia to supplement intra-operative anesthesia and post-operative pain relief. We explained the risks of blood coagulopathy and the predictable venous dilatation in the epidural space to the patient and relatives on obtaining informed consent. The surgery was completed uneventfully in 2.5 hours. Post-operative pain control was satisfactory and hepatic dysfunction did not deteriorate in the postoperative period.

[Cesarean section for case with preoperatively-suspected placenta accrete followed by hysterectomy due to uncontrollable massive bleeding].

A 42-yr-old pregnant woman highly suspicious of the placenta accreta was scheduled for cesarean section (c-section) under general anesthesia. She had received emergency c-section for the placenta previa at 36 years of age and three episodes of intrauterine curettage for spontaneous abortion. While the possibility of placenta accreta was pointed out and the risks accompanying with it were explained at the 7th week of pregnancy, she insisted on having a baby. C-section was intended at around the 30th week of pregnancy and 1,200 ml of autologus blood was stored for the predictable massive bleeding. Bilateral embolization of the internal iliac artery was also planned. The baby was delivered uneventfully. However, the adherence of the placenta was so tight that the placenta could not be separated from the uterine wall. The arterial embolization immediately after the delivery did not work as effectively as to control massive bleeding. It took about 1 hour to control the massive bleeding of up to 9000 ml by difficult hysterectomy. Since we had prepared for such a situation, we could well catch up with the massive bleeding. The mother and baby were discharged well from the hospital 29th day after the c-section.

Moderate cerebral venous congestion induces rapid cerebral protection via adenosine A1 receptor activation.

Stroke is a devastating complication in cardiovascular surgery, and neuronal damage is worsened by intracranial pressure elevation caused by cerebral venous circulatory disturbances (CVCD). However, we have previously reported that CVCD before cerebral ischemia decreases the infarct area. In the present study, focal cerebral ischemia was induced in spontaneously hypertensive rats by filament insertion through the carotid artery. Rats were divided into the following four groups: sham-operated, mild or severe venous congestion (VC), and DPCPX. The DPCPX group received the adenosine A1 receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine (DPCPX) prior to mild VC. Behavior, infarct volume, edema and S-100 protein were evaluated among the four groups. The infarct volume rates in mild VC and severe VC groups were significantly less than that in sham-operated and DPCPX groups. However, the mortality of the severe VC group worsened in a time-dependent manner. We observed a significant decrease in edema in the mild VC group compared to the DPCPX group. Behavioral scores also indicated that the mild VC group had fewer neurological deficits than the other three groups, including the DPCPX group. We were able to induce rapid cerebral protection via adenosine A1 receptor activation by administering an appropriate degree of VC prior to cerebral ischemia produced by middle cerebral artery occlusion. Our work suggests possible mechanisms by which such effective VC may lead to cerebral protection and adenosine A1 receptor activation.

Effects of systemic deep hypothermia and subarachnoid block on the longitudinally conducting evoked spinal cord potentials in man.

The present study reports the effects of systemic deep hypothermia (SDH) and subarachnoid block (SAB) on the longitudinally conducting evoked spinal cord potential (conducting ESCP) in man. Before induction of anesthesia, a pair of bipolar catheter electrodes was introduced to the epidural space: one at the level of the cervical enlargement and the other at the lumbosacral enlargement. The conducting ESCP was produced by electrical stimulation through the upper electrode and recorded through the lower electrode, and vice versa. SDH Study: Subjects were 6 patients who underwent replacement surgery of an aortic aneurysm with deep hypothermia anesthesia. The peak latency of the ESCP was gradually prolonged and the duration was widened with cooling via extracorporeal circulation. The amplitude of ESCP showed a biphasic change over the course of cooling with a turning point of around 30 degrees C in esophageal temperature. The ESCP was well observed until blood temperatures as low as near 10 degrees C. The result shows that ESCP is available as an intra-operative monitoring parameter of the spinal function even under SDH. SAB Study: Subjects were 7 patients, 6 of whom had SAB and the remaining 1 intravenous application of a local anesthetic. The conducting ESCP was markedly depressed or disappeared completely even after SAB with clinical doses of various local anesthetics, while it was hardly affected by the intravenous application. The result implies that SAB causes, at least partially, the conduction block within the spinal cord.

[Intra-operative monitoring of EEG].

The fundamentals and clinical applications of intra-operative EEG monitoring are described. EEG monitored on line at bedside is useful for the evaluation of the depth of anesthesia and sedation, and also for the early detection of cerebral ischemia and seizure. However, EEG monitoring is not easy in the operating room, where a number of electrical machines and medical personnel are working. The authors have introduced a basal lead for the recording of brain-stem electrical activity and a fiberoptic EEG instrument for the exclusion of electrical noises. Recently, EEG instruments with computer-processing function, which are small in size and easy to manage, have been developed one after another. Computer-processed EEG is sequentially expressed as a digitalized value. Today, computer-processed EEG is more popular than raw EEG as an intra-operative monitoring of cerebral function, while raw EEG is superior to computer-processed EEG in the detection of seizure waves. The authors recommend multi-modality monitoring including non-invasive measurements of oxygen saturation and blood flow for the safe maintenance of cerebral

[Labor management using epidural anesthesia in a gravida patient with high spinal injury].

Since autonomic hyperreflexia (AH) is a serious complication during labor in a gravida with spinal cord injury, anesthetic measures should be taken for the suppression of AH even in a sensory-loss condition. Several reports have described various methods for the suppression of AH, in which epidural anesthesia has been advocated as a useful means for the prevention or amelioration of AH. However, it is difficult to evaluate the efficacy of epidural anesthesia due to the lack of sensory and motor functions. We report a primipara who had spinal cord injury below the T 3 level at the age of 17 due to a traffic accident and underwent successful vaginal delivery twice under epidural anesthesia at the ages of 30 and 32. For the first delivery, we placed two epidural catheters. We controlled the rate and the content of epidural infusion through the two different injection sites so as to meet delivery process. For the second delivery we did epidural anesthesia in the same way. Tubal-ligation was also performed under epidural anesthesia after the second delivery. No major obstetric complication including AH occurred in either of delivery. The woman with high spinal injury could have two healthy children without major complications during labor by the cooperation of gynecologists and anesthesiologists.

A novel method of detecting rCBF with laser-Doppler flowmetry without cranial window through the skull for a MCAO rat model.

BACKGROUND AND PURPOSE: In a rat model of middle cerebral artery occlusion (MCAO) with intraluminal technique, lesion volume and its reproducibility vary among laboratories. Although laser-Doppler flowmetry (LDF) is useful to optimize the reliability, conventional methods require a craniotomy and special apparatus. The purpose of this study was to evaluate a novel approach for LDF monitoring of rCBF through lateral aspect of the skull without a craniotomy. METHODS: SD rats were subjected to 45 min of MCAO using an intraluminal thread. MCAO was achieved by an examiner who had been trained 4 weeks for making the model with no LDF monitoring (Group-1, n = 12), while in the other group, the same examiner induced MCAO using a novel approach of LDF monitoring (Group-2, n = 12). rCBF was detected through an LDF probe attached to the lateral aspect of the skull. The survival rate and the infarct volume were estimated for comparison between the two groups 2 days after MCAO. RESULTS: The mortality rate was 25% in Group-1 and 0% in Group-2. The lesion volume of the cortex in Group-2 was 167.21 +/- 48.54 mm(3) (mean +/- SD), which was larger than that in Group-1 (112.77 +/- 36.03 mm(3), P = 0.026). The coefficient variation of the lesion volume was smaller in Group-2 (29%) than in Group-1 (35%), indicating better reproducibility of the lesion volume in Group-2 than in Group-1. CONCLUSIONS: The approach of LDF monitoring through the lateral aspect of skull was useful for making large consistent infarct with reducing intraanimal variability and unexpected animal death for rat MCAO model.

Induction of neuronal tolerance by electroconvulsive shock in rats subjected to forebrain ischemia.

We have examined ischemic tolerance induced by electroconvulsive shock before exposure to forebrain ischemia. Subjects were 40 rats, which were randomly allocated to control, single ECS (sECS), repeated ECS (rECS) or sham group. sECS group and rECS group received ECS only once 2 days before the subsequent 8-min forebrain ischemia and once a day for 9 consecutive days until 2 days before the exposure to ischemia, respectively. Forebrain ischemia was produced by modified bilateral carotid artery occlusion technique. Control group underwent brain ischemia without ECS pretreatment. Sham group received ECS without following exposure to ischemia. Pyramidal cell injury of the hippocampal CA1 sector was microscopically examined on the 7th day after the ischemic exposure or the sham operation. Damage of the pyramidal cells was assessed by the injury ratio, which was ratio of non-viable pyramidal cells to the whole pyramidal cells. The injury ratios of CA1 pyramidal cells in sECS, rECS and control groups were 30.5 +/- 10.8 (n=10), 42.3 +/- 18.4% (n=10) and 90.4 +/- 2.9% (n=9), respectively. The injury ratios in sECS and rECS groups were lower than the ratio in control group (p<0.01), while the ratios of sECS and rECS groups were not different. The pyramidal cells in sham group were intact. Our results indicate that both preconditionings of sECS and rECS have a potency to induce delayed tolerance against temporary forebrain ischemia, though the potency was not different between sECS and rECS. Electroconvulsive shock may be added to the list of preconditioning stimuli to protect brain against ischemic neuronal damage.

[Anesthetic management for a patient with multiple sclerosis].

A 49-year-old woman with multiple sclerosis (MS) received emergency laparotomy for panperitonitis. She had been suffering from MS for 13 years, and her main clinical symptoms were disorders in sight, walking and touch sensation below T 7. We used propofol and fentanyl for induction and maintained anesthesia with nitrous oxide, sevoflurane and additional fentanyl. Intubation was carried out without muscle relaxant. Train of four ratio was monitored during surgery. Thus the use of muscle relaxant was suppressed to the minimum requirement. Circulatory function was stable and no cardiovascular agent was used throughout the surgery. Awakening from anesthesia was smooth and exacerbation of the neurological abnormalities was not observed after surgery. She was transferred uneventfully to a recuperative hospital on the 13th postoperative day.

Bupivacaine, but not tetracaine, protects against the in vitro ischemic insult of rat hippocampal CA1 neurons.

Neuroprotective actions of local anesthetics, bupivacaine and tetracaine, against the irreversible membrane dysfunction induced by in vitro ischemia were investigated. Intracellular recordings were made from hippocampal CA1 neurons in rat brain slice preparations. Oxygen and glucose deprivation (in vitro ischemia) produced a rapid depolarization after approximately 5 min of exposure. When oxygen and glucose were reintroduced, the membrane depolarized further and reached at 0 mV: the membrane showed no functional recovery (irreversible membrane dysfunction). Pretreatment with tetracaine or bupivacaine significantly prolonged the latency of rapid depolarization. Bupivacaine, but not tetracaine, restored the membrane potential after the reintroduction of oxygen and glucose. Tetracaine and bupivacaine depressed both field postsynaptic potentials and presynaptic volleys. The drugs also reduced the dV/dt of Ca(2+)-dependent spikes and the rapid rise of [Ca(2+)](i) induced by in vitro ischemia. Compared with tetracaine, bupivacaine markedly suppressed the resting K(+) conductance and the ATP-sensitive and Ca(2+)-dependent K(+) conductances. Moreover, in the presence of tetraethylammonium (TEA), a majority of CA1 neurons impaled with Cs acetate-filled electrodes showed complete or partial recovery of the membrane potential after reintroducing oxygen and glucose. These results suggest that the neuroprotective action of bupivacaine is mainly due to the suppression of the K(+) conductances.

[Citizen's understanding of anesthesia from a questionnaire survey].

BACKGROUND: In order to know general understanding or impression of anesthesia by citizens, we performed a questionnaire survey. MATERIALS AND METHODS: The participants for the survey were 218 citizens including 118 healthy persons with previous attendance to Kurume University Public Lecture for Citizens (group A) and 100 patients hospitalized in Kurume University Medical Center (group B). Their answers were collected prior to the lecture planned on the 39th Annual Meeting of Kyushu Society of Anesthesiologists. RESULTS: The recovery of the survey was 78.9%. The percentages of persons who wanted to know "How and by whom I am anesthetized" were 93.2% and 72.6% in groups A on B, respectively. The percentage of persons who wanted to know the name of surgeon was 91.7%. The answers to the question; "Which doctor do you think is responsible for the treatment of an intraoperative adverse event such as acute myocardial infarction?"; were in the order of an internist 37.5%, a surgeon 29.7% and an anesthesiologist 18.0%. CONCLUSION: We have realized through the questionnaire survey that the majority of citizens still consider an anesthesiologist as a technician merely putting patients into sleep for surgery. At the preoperative examination or round, we have to explain procedures and potential risks related to anesthesia to a patient and also have to answer patient's questions fully. We anesthesiologists should do more efforts to enlighten citizens at every opportunity so that citizens would understand our work fields and evaluate anesthesiologists correctly.

[Two cases of gravity dependent atelectasis after laparoscopic nephrectomy].

Two patients developed postoperative pulmonary atelectasis after receving laparoscopic nephrectomy in the lateral kidney position. In both patients, the trachea was intubated with a single lumen tube and the lateral kidney position was kept over 9 hours. Because the pulmonary atelectasis had developed on the lower side of the lungs, we considered it as the gravity dependent atelectasis (GDA). We have also described treatments and prophylaxis for GDA in this case report.