Protect Patients in Steep Trendelenburg

A lot can go wrong when patients are placed in steep Trendelenburg. This high-risk position has many well-known dangers, such as shearing injuries that occur when patients slide down the surface of the table, as well as many lesser-known risks, such as detached retinas or postoperative blindness caused by increased intraocular pressure. When placing patients in the head-down position, implement whatever measures are necessary to protect them from harm. Fortunately, there are several straightforward steps you can take to reduce the risks of injuries and complications.

One of the more well-known injuries that can occur with the Trendelenburg position is shearing of the skin caused by sliding, says Sharon Ann Van Wicklin, PhD, RN, CNOR, CRNFA(E), CPSN-R, PLNC, FAAN, ISPAN-F, a perioperative and legal nurse consultant. “Finding a solution to this problem can be tough,” says Ms. Wicklin, “but pads and positioning aids designed to reduce shearing and pressure injuries are available.”

However, says Dr. Wicklin, it’s important to remember that none of these solutions are 100% successful in preventing a patient from sliding. “To help reduce the patient’s risk for injury, the devices should be used in combination with other preventative measures,” she says. (More on those later.)

For many years, according to Dr. Van Wicklin, it was standard practice to extend the patient’s arms on arm boards while placing them in the Trendelenburg position. However, it’s now recognized that extending and securing a patient’s arms, combined with the downward force inherent to the position, leads to excessive abduction that can cause brachial neuropathy. For this reason, she notes, a patient’s arms should be secured at their sides with a draw sheet or arm guards.

One of the key things you can do to help prevent injuries associated with the Trendelenburg position is to keep the degree of incline the patient is placed in to the minimum necessary to complete the surgery. Though there is no agreement in the literature as to what constitutes “steep” Trendelenburg, most surgical professionals define it as a 30- to 45-degree angle. However, that amount of steepness places undo strain on the patient’s body and increases the risk for complications, according to AORN’s guideline for positioning the patient.

Reducing the degree of Trendelenburg, whenever possible, is one of the simplest preventative measures that you can take to prevent complications associated with the position. The AORN guideline recommends against placing patients who have a BMI over 40 in Trendelenburg, if possible. However, if using the position is absolutely necessary, conduct regular monitoring of the patient’s airway, skin condition and intraocular pressure levels. You should implement regular Trendelenburg rest periods and minimize the degree of Trendelenburg as much as possible. 

Dr. Van Wicklin says many surgical teams have a false belief that placing patients in steep Trendelenburg is necessary to help shift their organs out of the surgical field in order to give surgeons the exposure and access they need to operate effectively. However, research has shown that this maximum tilt is not always necessary. In one study, researchers slowly moved patients undergoing robotic-assisted gynecologic surgery into increasing degrees of Trendelenburg until surgeons said the position provided sufficient visualization to perform the procedure (osmag.net/3ykddb2). The researchers found that, on average, the surgeons needed about 17 degrees of tilt for sufficient visualization and access — quite a difference from the 45 degrees that’s commonly used. 

"Surgical teams need to do everything they can profect patients from harm."
— Dr. Sharon Ann Van Wicklin

“Robotic-assisted benign gynecologic surgery can be effectively performed without use of the steep Trendelenburg position,” say the study’s authors. “The practice of routine adherence to this positioning in gynecologic robotic surgery should be questioned.”

The American Society of Anesthesiology’s practice advisory related to the Trendelenburg position recommends documenting how long patients remain in the position, conducting frequent checks of their condition throughout surgery, avoiding the use of shoulder braces and limiting abduction of upper extremities. A recent survey of 290 anesthesiologists about their practices and facilities’ polices related to use of the Trendelenburg position shows 33% of the respondents do not limit the inclination angle and 40% set the angle at the minimal level needed for surgical access. Nearly 70% of the anesthesiologists said they do not limit the time patients spend in steep Trendelenburg.

Close to 70% of the providers have had discussions with surgeons about minimizing the use of steep Trendelenburg and 45% documented the start and finish times of the position’s use. Only 16% of the anesthesiologists say they provide surgeons with hourly reminders about the risks patients face in the position. It’s somewhat encouraging that 74% of the respondents reassess the patient’s position during surgery, but 14% of the respondents said they take no action to minimize use of the position.

The survey’s authors say facility-based policies and protocols addressing how to care for patients in the Trendelenburg position would help to prevent related complications and adverse outcomes. However, only 2% of the respondents said their facilities have policies in place that address shortening the duration of the position, discussions with surgeons about patient positioning risks, minimizing the inclination angle and frequent intraoperative checks of the patient.