Archive January 2018 XIX, No. 1

Tips for Safer Trendelenburg Positioning

Keep patients safe and secure during head-down tilting positions during surgery.

Outpatient Surgery Editors


DANGER ZONE It can be dangerous for patients when you place them head down and elevate their feet.

The usual hazards of Trendelenburg positioning are sheared skin, pinched nerves, overextended limbs, and crushing injuries to hands and arms. But as these actual cases illustrate, patients can also slide off the table and their hearts can stop pumping blood when you place patients head down and elevate their feet.

  • Trendelenburg slide. Consider the extreme but not uncommon case of Coley Purvis, a Florida man who 10 years ago went into the West Jefferson Medical Center in New Orleans, La., for surgery but claims he left with herniated discs and a traumatic brain injury, among other ailments. He alleges that he slid off the table while in the Trendelenburg position. Mr. Purvis sued the surgical facility, claiming it had failed to properly secure him on the tilted operating table, leading him to slide off and fall on the floor while he was under anesthesia. After a 9-year legal battle, the medical center last year admitted its error and settled out of court with the patient.
  • Pulseless electrical activity. Another cautionary tale from anesthesiologist Jayesh Dayal, MD, owner of the White Flint Surgery Center in Rockville, Md., serves as a reminder to check your patient's radial pulse during surgery, particularly longer cases. During his residency, he remembers the case of an obese 22-year-old woman in Trendelenburg for a tubal ligation. Her EKG and blood pressure both looked perfectly normal on the monitor, but when Dr. Dayal happened to check the patient's pulse, there was none. The weight of the woman's internal organs was pressing against her heart and "wringing it like a rag, literally squeezing the life out of it." This caused the heart to beat but not pump any blood, a condition known as pulseless electrical activity — cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. If it went unrecognized for long, the patient likely would have been brain dead, says Dr. Dayal.

"This happens commonly enough, but most people aren't aware of it," he says. "I just happened to check the pulse — everything else looks perfectly normal. How many times do you check a pulse during a case?"

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