Positional change under the anesthesia may cause marked hypotension, particularly in the critically ill patient. Therefore, positional change must be accomplished slowly and gently, and blood pressure observed throughout the procedure. Basic components for the safe positioning is knowledge, forethought, teamwork and housekeeping. Patients with paraplegia, quadriplegia, or a critical illness may require intravenous vasopressor drug before turning, and the lightest possible level of anesthesia is used. The authors experienced a case of cardiac arrest after changing position of a paraplegic patient under general anesthesia. The patient was resuscitated.