Protect Patients in Steep Trendelenburg

Patient Safety

By: Kendal Gapinski | Contributing Editor

Published: 9/13/2021

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Risks of complications go up as soon as the patient's head goes down.


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.

Prevent sliding and shearing

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.

Monitor intraocular pressure

POINT PERSON Anesthesiologists should document the amount of time patients spend in Trendelenburg and communicate with the surgeon about the possibility of minimizing the angle of incline.

Increased intraocular pressure that leads to serious ocular injuries, including postoperative vision loss, is one risk associated with the Trendelenburg position that some providers might not address. Dr. Van Wicklin published a systematic review and meta-analysis to estimate the magnitude of the increase in intraocular pressure in patients undergoing surgery in Trendelenburg, and found that the pressure increased “significantly.” 

“We found that in 95% of all patient populations, intraocular pressure could increase by as much as 28.1 mmHg. Normal intraocular pressure is 10 mmHg to 20 mmHg,” she says. “If a patient’s preoperative baseline intraocular pressure was 15 mmHg, it could increase to 43.1 mmHg, which is more than double the upper limit of what is considered normal. Increases in intraocular pressure of this magnitude can lead to serious ocular injury.”

There are several simple things you can do to help prevent the occurrence of postoperative blindness or other ocular injuries in patients undergoing surgery in the Trendelenburg position, says Dr. Van Wicklin. The first is monitoring intraocular pressure at established intervals during the procedure. “You can use a tonometer to obtain a preoperative baseline intraocular pressure measurement, and then periodically check the pressure throughout a procedure to see if it’s increasing — and by how much it’s increasing,” she explains. 

How often this measurement should occur depends on the health of the patient and their preexisting comorbidities such as chronic obstructive pulmonary disease, diabetes, cardiovascular disease or uncontrolled hypertension. You should also closely monitor physical signs. For example, if the patient suffers facial edema or chemosis, check their intraocular pressure more frequently. In most cases, these pressure-checking intervals should occur every 60 to 90 minutes, according to Dr. Van Wicklin, who suggests working with the surgical team to determine intervals that are appropriate for your patient populations. 

If a patient’s intraocular pressure is steadily increasing during surgery, consider leveling out the table to provide the patient with a rest period for about 10 to 15 minutes, suggests Dr. Van Wicklin. This rest period, again, will likely be patient specific. A large, obese patient might require more frequent breaks than a small, lightweight person.

Additionally, research indicates some medications may be helpful in preventing or treating intraocular pressure increases. For example, two studies have found that dorzolamide-timolol drops can be applied prophylactically to prevent an increase in intraocular pressure or preoperatively when a patient’s pressure begins to increase, with the authors concluding that “treatment with dorzolamide-timolol eyedrops significantly reduces elevated intraocular pressure of patients who undergo lengthy laparoscopic surgery in the steep Trendelenburg position.” 

Reduce the degree of incline

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.

Added responsibility

You’re already used to treating patients as individuals with specific clinical needs, but that’s especially important to do when they’ll be placed in the Trendelenburg position in order to determine if they’ll require extra care. As more advancements in technology occur — including the boom of robotic procedures — Trendelenburg is being used more often, points out Dr. Van Wicklin. “Surgical teams need to do everything they can to protect patients from harm and reduce their risks of post-op complications as this technology continues to advance,” she says. “Every perioperative team member, from nurses to surgeons to anesthesia professionals, has the power to ensure — or at least suggest — that necessary precautions are taken to help prevent devastating injuries that can occur when patients are placed in this high-risk position.” OSM

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