Best Practice
Why don’t we use Trendelenburg?
When I used to be starting my nursing profession within the early Nineteen Nineties, I remember my intensive care unit teacher reflexively placing her patient within the Trendelenburg position during episodes of acute hypotension and shock. She explained that lowering the patient’s head and elevating the legs above the chest helped move blood from the lower extremities to the center, brain and other vital organs. It actually made logical sense and appeared to work, at the least temporarily. I quickly integrated Trendelenburg into my each day practice. However, researchers have found that the usage of Trendelenburg doesn’t improve blood pressure and shock and as an alternative can have harmful effects in certain patient populations.
The origins of Trendelenburg date back to the late nineteenth century, when surgeon Dr. Friedrich Trendelenburg pioneered the technique to realize higher access to the pelvic organs for surgery. During World War I, this position was used to treat shock to extend circulation to the center, increase cardiac output (CO), and improve blood flow to vital organs (Shammas and Clark, 2007). Also often called autotransfusion, the Trendelenburg method has change into common practice in a wide range of healthcare settings reminiscent of emergency rooms, operating rooms, post-anesthesia units, and intensive care units. Additionally, the Trendelenburg with a ten–15 degree head-down tilt significantly increases the diameter of the jugular vein and is now really helpful because the optimal position for central line insertion when clinically appropriate and feasible to facilitate cannulation and reduce the chance of venous air embolism ( Heffner and Androes, 2022). Healthcare staff also use this position briefly to realize intravenous access to start out quick fluid boluses. However, although this system has long been used to treat hypotension, medical and nursing associations haven’t developed guidelines to support the usage of Trendelenburg within the treatment of shock.
Physiological Effects of Trendelenburg Position (Welch, 2024)
Controversy surrounds whether blood flow from the extremities to the central body contributes to hemodynamic stability and whether there are harmful effects that outweigh the potential advantages. The Trendelenburg position causes significant changes within the body reminiscent of:
- Increased central blood volume, venous return to the center, and mean arterial pressure, which could also be tolerated in healthy people but may cause cardiovascular disorders in patients with heart disease
- Shifts of the abdominal organs toward the diaphragm reduce functional residual capability and lung compliance, which can contribute to atelectasis
- Increased intracranial pressure
- Increased intraocular pressure
- Potential damage to the respiratory tract as a consequence of swelling and swelling of the face, tongue and laryngeal tissues
- Higher risk of passive regurgitation
Tests
Shammas and Clark (2007) and Bridges and Jarquin-Valdivia (2005) reviewed several studies examining the consequences of Trendelenburg items. The research results are summarized below.
- Sibbald, Paterson, Holliday, and Baskerville (1979) found that the Trendelenburg didn’t consistently improve hemodynamic outcomes in critically ailing hypotensive patients.
- Ostrow, Hupp and Topjian (1994) found no significant effects on CO, cardiac index (CI), partial pressure of oxygen (PO2), systemic vascular resistance (SVR) or MAP with Trendelenburg or modified Trendelenburg (legs elevated at an angle of 30 degrees).
- Terrai, Anada, Masushima, Shimizu, and Okada (1995) evaluated the consequences of the Trendelenburg position with a 10-degree head-down tilt on central hemodynamics and internal jugular vein flow. The results showed a rise in left ventricular end-diastolic volume (LVEDP), stroke volume (SV), and CO (16% increase) with a decreased heart rate after 1 minute of the 10-degree Trendelenburg position. After 10 minutes, hemodynamic changes returned to preintervention levels.
- Fahy et al. (1996) investigated the effect of Trendelenburg on lung mechanics. They concluded that Trendelenburg doesn’t increase intrathoracic pressure, but affects the movement of the lung and chest wall, leading to a discount in lung volume. They speculated that the intervention might need a greater hostile effect on patients with the next body mass index and people with lung disease.
- Reuter et al. (2003) found that the Trendelenburg position barely increased preload volume and produced a small autotransfusion effect but didn’t significantly improve cardiac function.
Although these studies had small samples and were quasi-experimental in nature, without randomization or control groups, several conclusions could be drawn (Shammas and Clark, 2007).
- Studies don’t support the usage of Trendelenburg as a way of treating hypotension.
- The use of Trendelenburg needs to be avoided until more extensive studies are performed as it could increase the patient’s risk of hemodynamic disturbances and abnormal lung mechanics.
- Certain groups of patients shouldn’t be admitted to the Trendelenburg, including patients with:
- Decreased right ventricular ejection fraction (RVEF)
- Lung disorders
- Unprotected airways and aspiration risk (London, 2023)
- Increased intracranial pressure
- HEAD INJURIES
- Bleeding in areas that change into dependent when the top is turned down (London, 2023)
- Interventions effective within the treatment of hypotension include inotropes, intravascular volume, and cardiac assist devices.
Trendelenburg versus passive leg raises
Note that the Trendelenburg position is different from the passive leg raise or passive leg raise (PLE), during which the legs are raised and held at a 45-degree angle for one minute while the top and torso remain in a horizontal position (not lowered). Several studies have shown that a ten% increase in cardiac output during PLE predicts a patient’s response to fluids (Mikkelsen, Gaieski & Johnson, 2023). Therefore, the term PLE is used briefly to explain treatment options for hypotension.
Abandoning outdated practices
Trendelenburg isn’t any longer a part of my routine practice. It is significant for clinicians to not sleep to this point with the most recent research and ensure they will not be perpetuating outdated patient management techniques which can be potentially harmful. Further research is required to guage the use and safety of Trendelenburg before it’s included in practice guidelines and as an ordinary of care. Do you continue to use Trendelenburg to treat hypotensive patients?
Bridges, N., & Jarquin-Valdivia, A. A. (2005). Using the Trendelenburg position as a resuscitation position: To T or to not T? (5), 364-368.
Fahy, B. G., Barnas, G. M., Nagle, S. E., Flowers, J. L., Njoku, M. J., & Agarwal, M. (1996). Effect of the Trendelenburg position and reverse Trendelenburg position on lung and chest wall mechanics. (3), 236-244.
AND
Heffner, A. C. and Androes, M. P. (2022, April 20). Inserting catheters into the jugular vein. Current. https://www.uptodate.com/contents/placement-of-jugular-venous-catheters
AND
London, M. J. (2023, July 13). Hemodynamic management during anesthesia in adults. . https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults
AND
Mikkelsen, M. E., Gaieski, D. F. & Johnson, N. J. (2023, December 8). Novel tools for hemodynamic monitoring in critically ailing patients with shock. . https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-residents-with-shock
AND
Ostrów, C. L., Hupp, E., & Topjian, D. (1994). Effects of Trendelenburg and modified Trendelenburg positions on cardiac output, blood pressure, and oxygenation: a preliminary study. (5), 382-386.
Reuter, D. A., Felbinger, T. W., Schmidt, C., Moerstedt, K., Kliger, E., Lamm, P., & Goetz, A. E. (2003). Trendelenburg positioning after cardiac surgery: effect on thoracic blood volume index and cardiac performance. (1), 17-20.
AND
Shammas, A., & Clark, A. (2007). Legal and ethical: Trendelenburg position within the treatment of acute hypotension: helpful or harmful? Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 21(4), 181-187
Sibbald, W. J., Paterson, N. A., Holliday, R. L., & Baskerville, J. (1979). Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. (5), 218-224.
Terrai, C., Anada, H., Masushima, S., Shimizu, S., & Okada, Y. (1995). Effects of Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. , 255-258.
AND
Welch, M. B. (2024, January 10). Patient positioning during surgery and anesthesia in adults. . https://www.uptodate.com/contents/patient-positioning-for-surgery-and-anesthesia-in-adults#H551043064
 Â