Trendelenburg Position for the Hypotensive Patient

A 28 year-old female has hypovolaemic shock from a ruptured ectopic pregnancy. Her blood pressure is 68/35, pulse 124, and GCS 13/15. She has received 2 litres of Normal Saline with minimal response.

The senior registrar in the emergency department requests the patient be given 0.5mg IV metaraminol, and asks you to tilt the bed into the Trendelenburg position as a temporising measure untill blood products arrives and the patient is taken to the operating theatre.

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.

"Trendelenburg Position" (Source: nurseweb.ucsf.edu)

History of the Trendelenburg position

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 1 , 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.

Friedrich Trendelenburg 1844-1924

What the Literature tells us about the Trendelenburg position

Shammas & Clark (2007) summarised the state-of-play regarding the use of the Trendelenburg position to treat acute hypotension as follows:

  • Trendelenburg position is widely used by nurses and other healthcare providers as a first-line intervention in the treatment of acute hypotension and/or shock.
  • 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.
  • Adverse consequences were found in certain patient populations who were obese, had compromised right ventricular ejection fraction, a pulmonary disorder, or a head injury.
  • The Trendelenburg position should be avoided as a treatment of acute hypotension/shock until definitive research with larger sample sizes is conducted that support its use as safe and effective.

Ostrow’s 1997 study of critical care nurses’ beliefs about the Trendelenburg position showed 99% of respondents had used the position, 28% believed it was always beneficial and 61% believed it was somewhat beneficial although they also recognised the complications from it.

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.

Summary:

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.

Complications of the Trendelenburg position in the hypotensive patient

  • Anxiety and restlessness
  • Progressive dyspnea
  • Hypoventilation and atelectasis caused by reduced respiratory expansion
  • Altered ventilation/perfusion ratios from gravitation of blood to the poorly ventilated lung apices
  • Increasing venous congestion within and outside the cranium leading to increased intracranial pressure
  • Pressure from abdominal organs is transmitted into the thoracic cavity, which can impair venous return to the heart, leading to a further decreased cardiac output and hypotension
  • Increase risk of aspirating gastric contents

When the Trendelenberg position should, and should not, be used

The Trendelenburg position is clinically useful for:

  • Insertion or removal of central venous catheters
  • Certain spinal anaesthetic techniques

The Trendelenburg position is probably not indicated or may have harmful effects in:

  • Resuscitation of patients who are hypotensive
  • Patients in whom mechanical ventilation is difficult, or patients with decreased vital capacity
  • Patients who have increased intracranial pressure
  • Patients who have cerebral oedema
  • Patients who have increased intraocular pressure
  • Patients with ischaemia of the lower limbs

What does the future hold for the Trendelenburg position?

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…

“It is the mark of an educated mind to be able to entertain a thought without accepting it”.

Aristotle

Reference

Boulain, T. et.al. (2002). Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 121(4), 1245-1252. PMID: 11948060

Bridges, N.& Jarquin-Valdivia, A. (2005). Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T. American Journal of Critical Care. 14(5). 364-368. PMID: 16120887

Johnson, S. & Henderson, S. (2004). Myth: The Trendelenburg position improves circulation in cases of shock. Canadian Journal of Emergency Medicine. 6(1), 48-49. PMID: 17433146

Kettaneh, N. & Jones, J. (2008). Use of the Trendelenburg Position to Improve Haemodynamics during Hypovolaemic Shock. Accessed on 12, May, 2010 Bestsbets.org.

Ostrow, C. (1997). Use of the Trendelenburg position by critical care nurse: Trendelenburg survey. American Journal of Critical Care. 6, 172-176. PMID: 9131195

Shammas, A. & Clark, A. (2007). Trendelenburg Positioning to Treat Acute Hypotension: Helpful or Harmful? Clinical Nurse Specialist. 21(4), 181-188. PMID: 17622805

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Comments

  1. 22won11race says

    I am doing a self directed course at the moment, which has been updated recently.It has supposedly just been updated.
    Yet as part of the treatment of anaphylatic patients it instructs the nurse to place the failing patient into trendelenberg position.
    This cann’t be good!

  2. Jtparsons8 says

    Hey Kane, I appreciate your compilation of information, and it does appear that the Trendelenburg position’s use in hypotension issues is a complex one, but I would tell you that I am a survivor of septic shock in an ER and that the position instantly helped me feel better. I would be reluctant to discontinue the effort at least in shock victims at least in the initial wave of shock -- unless specific aspects of their shock would weigh against its use.

    I presented in the ER in 2008 with a fever (101) and a high bp (159/105), an elevated wct (16,000), and the upper left quadrant of the colon extremely sensitive to the touch. They determined it was diverticulitis, and put me on Cipro IV and morphine. After that my bp had dropped a little (148/95), I was feeling ok, and they had given me a contrast die for the MRI to see if there was an abscess/necrotic tissue (which required about 1 hour to absorb). They had me in a gurney with my head propped up.

    About 40 minutes into the absorption period, I started feeling bad -- nauseous, dizzy, and just not right. The hospital did not have a bp cuff on me or a call button in the ER room I was in, and no staff were around so my wife (who was with me) went to get the nurse. It took her about 3-4 minutes to come in, and at that point it felt like my body was being burned alive, and I felt the worst and in the most pain I have ever felt. The ER nurse put the gurney into the supine position, and took my bp (71/50). Even in the supine position I felt no better and had been on Cipro and Morphine for about 45 minutes. Her concern was whether it was anaphylactic shock from the Cipro (although it turned out to be septic shock from the diverticulitis). It was only when my wife instantly suggested that they kick my feet up (we did not know it was callled the Trendelenburg position) that I INSTANTLY felt better -- instantly!!

    Everything calmed down and my blood pressure improved and in about 5 minutes they lowered my feet and I did much better after that (kept in the supine position). Their concern was that maybe there had been a rupture, but the MRI showed that there was not -- and there was no necrotic tissue. I was admitted, and hospitalized for 3 more days to monitor my kidney output and other vitals to ensure that there was not going to be a cascade of organ failures or any kidney damage. There was not.

    While I know medical professionals are quick to look for “diagnostic” evidence of why something helps, I think the doctors that are discounting the T position so pervasively are missing the point. I have been looking at this issue recently since I had a friend die in an ICU after heart surgery and I think she probably went into shock while she was unconscious. With her situation, given the heart issues, the T position may or may not have helped. However, after reviewing all the postings on the internet by research doctors about shock and the T position, I am surprised that so many doctors discount it in so many settings.

    I might suggest that medical professionals investigate its benefits among conscious patients who have had the position used, and determine if there seems to be a obvious trend for those that it helped. If my wife had not suggested that it be used with me -- when nothing else was helping on my septic shock, I hate to think how I might have ended up. As it is, again I INSTANTLY felt better and I “walked out” (ok rolled out in a wheel chair for precaution) from the hospital and have relatively minor issues given the fatality rate from septic shock. I might ask doctors and medical professionals to disprove that the T position assisted in my situation, since all the vitals and empirical data and anacdotal information from my case show otherwise.

    Just something to consider.
    jtp.
    http://jamestparsons.blogspot.com/2008/05/always-always-take-someone-with-you-to.html

  3. Michael Barts says

    Well…after treating hypotension (in initial, temporizing mode) for the past 35 years (trauma stabilization, anesthesia and central IV placement) I was quite interested to see the discussion above in the body of this thoughtful piece. But, no matter how one cogitates low BP treatment, lowering the head (whether it be from Fowler’s position to flat…or flat to Trendelenburg’s position) follows not only the laws of physics but also the heart and head. I feel better when I physically act to help my patient as I wait for my rescue medications to arrive, my fluids to infuse, the OR to open with an accepting surgeon and crew…hopefully while the patient is still awake enough to ask me: Hey! Why did you just do that? See what I mean? The academics and their slave set can whup on the precise science for the next few generations and might never get it correct….but the past larger number of generations have been serving patients well with this excellent expedient. Besides, I always get a bit of a kick when the patient asks me: Hey! What did you do that for!?!

  4. Lynn Magnuson says

    Interesting article. I’m an EMT Basic candidate, and we were taught about the Trendelenberg position relating to shock treatment. I got curious and looked up the doctor who invented it, along with quite a few other procedures. He and his whole family were very intelligent and creative.

  5. Elliot Williams says

    Very iconoclastic. Anything that challenges us to reconsider historically accepted points of practise in health care is important and can only lead to healthy debate of nothing else.
    And besides, you can’t argue with evidence. Only fools do that.

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