Patient repositioning during percutaneous nephrolithotomy: a mortality report

We present a case of anesthesia complication during percutaneous nephrolithotomy which ended in mortality.
Case report: A 16 years old man,during percutaneous nephrolithotomy deteriorated with hypotension, hypoxia, bradyarythmia and then ventricular fibrilation and cardiovascular arrest occurred. Unwanted changing bag/ventilator sector switch of anesthesia machine (Drager: model Fabius) from ventilator mode to spont mode during changing position was recognized as etiology of apnea and cardiopulmonary arrest of the patient.
During prone PCNL one of the critical steps is changing position from lithotomy to prone considering that respiratory complications may occur not only during intubation but also after the ETT is in place.