Tredelenburg Position and Hypotension

Topics: Blood pressure, Shock, Hypotension Pages: 7 (2270 words) Published: November 14, 2013
Abstract
Hypotension is one of the top three most frequent causes of cardiac arrests in the United States. One early intervention used in treating hypotension is placing patients in Trendelenburg position. The purpose of this research was to review information on the use of the Trendelenburg position or variations of it to determine whether this position has an impact on hemodynamic status, to describe historical practices of the Trendelenburg position, state the reasons and need for possible change, described current best evidence, and define pros and cons for making the practice changes. Research material included scholarly peered articles, Internet Resources, and nursing textbooks revealing many studies which question the benefit of the Trendelenburg position. Research also showed great diversity of therapeutic indications. Current evidence is too inconsistent to allow us to state that the Trendelenburg position is beneficial in hemodynamically compromised patients.

Key words: Head-down tilt. Shock. Patient positioning. Trendelenburg. Hypotension.

Fig. 1 Fig. 2
In the late 19th century, Friedrich Trendelenburg (1844-1924) (Fig. 2), a German urologic surgeon, popularized the use of a supine position, with the feet raised higher than the head to facilitate surgical access to the abdominal and pelvic viscera. This position was coined the Trendelenburg position which to this day still bears his name. Years later, during the First World War, the American physiologist Walter B. Cannon adopted this position to displace blood from the lower extremities to enhance venous return in the treatment of hemorrhagic hypovolemic shock. This action was thought to cause an “autotransfusion” to the central circulation, increasing right and left ventricular pre-loads, stroke volume, and cardiac output or cardiac index. Although Cannon changed his opinion on the benefits of the Trendelenburg position, a decade later, its use continued to spread. Friedrich Trendelenburg neither originated the position nor first described it. This position had already been described by Bardenhaur of Cologne but was extensively used and taught by Trendelenburg after 1860. He found the supine, elevated pelvic position particularly useful in providing operative visualization for surgical repair of vesicovaginal fistulas. After 1860, many surgical journals and Physicians made reference to the position, which was also referred to as a “high pelvic posture.” Trendelenburg himself depicted the posture for the first time in 1890. “If one places the body of a patient on the operating table in such a way that the symphysis pubis forms the highest point of the trunk and the long axis of the trunk forms an angle of at least 45° with the horizontal, then the various organs “fall into the concavity of the diaphragm by virtue of their weight” (Wilcox & Vandam, 2008). As shown in many journals, the high pelvic posture was first achieved by dangling the patient’s legs over the shoulders of an attendant while the surgeon operated (Fig. 1). The weight of the legs rotated the pelvis toward a horizontal but elevated position. By the 1920’s, a table attachment for producing the head-down, knee-flexed position was available, with the additional support of padded shoulder rests. This position was illustrated in the practical surgery texts of its time and still is illustrated in current texts. Over time, the description of the position has become varied. The International Dictionary of Medicine and Biology describes the Trendelenburg position accurately, except for the requisite 45° tilt. “A position in which the subject was supine – with the knees higher than the rest of the body, hanging over the edge of a supporting surface and forming the apex of a right angle so that the body forms an inverted V with the pelvis elevated above the head. Also called high pelvic position” (Wilcox & Vandam, 2008). Research finds that many similar definitions are given in several...

Cited: Clark, A. & Shammas, A. (2008). Trendelenburg Positioning to Treat Acute Hypotension:
Helpful or Harmful? Clinical Nurse Specialist
Halm, M. (2012). Trendelenburg Position: “Put To Bed” or Angled Toward Use In Your Unit?
American Journal of Critical Care
Pena, S. & Larrad, A. (2012). Does the Trendelenburg Position Affect Hemodynamics? A
Systemic Review
Sheppard, R. Personal Communications, June 28, 2013.
Wilcox, S. & Vandam, L. (2008). Alas, Poor Trendelenburg and His Position! A Critique of Its
Uses and Effectiveness
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