Why trendelenburg position

A 28 year-old female has hypovolaemic shock from a ruptured ectopic pregnancy. She has received 2 litres of Normal Saline with minimal response.

The senior registrar in the emergency department requests the patient be given 0. As the patient is then rushed off to theatre, you wonder what does the Trendelenburg position actually do, and what is the evidence for it. The Trendelenburg position involves placing the patient head down and elevating the feet. It is named after German surgeon Friedrich Trendelenburg , who created the position to improve surgical exposure of the pelvic organs during surgery.

In World War I, Walter Cannon, the famous American physiologist, popularized the use of Trendelenburg position as a treatment for shock. It was promoted as a way to increase venous return to the heart, increase cardiac output and improve organ perfusion. A decade later, Cannon reversed his opinion on the benefits of the Trendelenburg position but that did not deter its widespread use. Today, the Trendelenburg position remains a time honoured tradition in the early management of the hypotensive patient.

As we shall see, this is despite a flimsy evidence base. Studies that have demonstrated an increase blood pressure and cardiac output are limited. When observed, the increase is generally short lived, lasting less than 10 minutes.

Current data to support the use of the Trendelenburg position during shock are limited and do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output. Until further large randomised control studies show a benefit from the use of the Trendelenburg position, it should not be a part of routine practice. When confronted with a hypotensive patient your time and attention may be better spent thinknig about evidence limited, time honoured practices and dilemmas like whether to resuscitate the patient with crystalloid or colloid, or whether dopamine or noradrenaline should be used as a vasopressor….

Emergency nurse with ultra-keen interest in the realms of toxicology, sepsis, eLearning and the management of critical care in the Emergency Department LinkedIn. This site uses Akismet to reduce spam. Learn how your comment data is processed. History of the Trendelenburg position The Trendelenburg position involves placing the patient head down and elevating the feet.

A review of the results of 5 research studies did not provide overwhelming support for its use as a treatment of hypotension. When Trendelenburg positioning improved cardiac parameters, it was brief and was followed by haemodynamics deterioration that led to negative consequences.

The Trendelenburg position is a topic that crops up regularly when it comes to beds in hospitals. However, it is now something that is also being discussed in the care home sector. In this article, we will cover what the Trendelenburg position is, how it is used today and how it fits into care homes. Well-established across various fields of medicine, it is a method that places a patient on a 15 to 30 degree incline, positioning the legs higher than the head.

There is also a modified version where only the legs are raised. The Anti-Trendelenburg position involves a patient being placed on the same incline, but the head is higher than the legs. Friedrich Trendelenburg was a prominent German surgeon in the late 19th and early 20th century, and came up with the method initially to improve exposure of the pelvic organs during surgery. He has had a huge influence on modern surgery, having founded and taught at the German Surgical Society, as well as having a number of procedures named after him.

These include the Brodie-Trendelenburg percussion test used to identify incompetent valves in superficial veins and the Trendelenburg position.

Since it was first established, the Trendelenburg position has been used to treat numerous conditions. In its infancy, it was used to treat shock and hypotension, including during World War I, where it was hoped it would increase blood perfusion to vital organs. Medical professionals now focus on using it for specialist uses. This includes surgical air embolisms, aiding abdominal hernia reduction, and helping placement of catheters in the internal jugular or subclavian veins.

One of its main benefits in modern healthcare is its use to stimulate blood perfusion in patients with respiratory problems. Brachial Plexus Neuropathy — The approximation of the clavicle and first rid threatens compression of the subclavian vessels and brachial plexus. Perioperative complications from extreme Trendelenburg positioning — Keeping a patient in Trendelenburg for a long period of time may lead to a risk in various injuries, including ocular trauma due to increased blood pressure in the head including corneal abrasion, retinal detachment, ischemic optic neuropathy, as well as respiratory distress.

Clinical recommendations for repositioning patients — Steep Trendelenburg patient position present risk for intraoperative injury. Injury prevention begins with awareness. Several mitigations can be deployed including; anesthesia administered crystalloids to reduce the risk for neural edema, surgeons should use the least amount of pneumoperitoneum needed for the surgery, and using the least amount of Trendelenburg needed for the procedure.

The nursing team should monitor the patient position. Second timeouts involving checking patient positioning and making adjustments based on the patient physiological and physical status have been proposed for cases taking longer than 4 hours. It is standard for the nursing staff to check the safety of patient position during the case every hour when feasible.

Introducing pauses for positioning checks and relieving Trendelenburg for even brief periods of time can reduce the risk for the most common injuries sustained while patients are in this position. A modified version of Trendelenburg, Reverse Trendelenburg position is used for laparoscopic surgeries including gallbladder, biliary tract, and stomach procedures, as well as head and neck surgeries.

In Reverse Trendelenburg, their head is up, and feet are positioned down. Positioning a patient for a surgical procedure involves reducing risk of injury and increasing comfort.

The Trendelenburg position allows a surgeon greater access to pelvic organs, helpful for procedures like colorectal, gynecological, and genitourinary surgery. As with all surgical positions, risks must be assessed prior to positioning a patient in Trendelenburg position.