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Archive August 2020 XXI, No. 8

Safe and Standardized Trendelenburg Positioning

Avoid skin tears, pressure injuries and other complications by paying extra attention to common problem areas.

Emma Greene

Emma Greene, BSN, RN, CNOR


FULL TILT A test run in the Trendelenburg position is a good way to easily spot positioning problems that could affect the patient during the surgery.

Putting patients in steep Trendelenburg is arguably one of the most challenging positioning tasks your OR staff faces. With the number of robotic urologic and gynecological procedures on the rise, the steep version of this position will be more frequently used moving forward. To prevent all-too-common issues such as skin tears, pressure injuries and other complications associated with this gravity-defying, slide-inducing position, let's look at everything that goes into keeping the patient as safe as possible every time you tilt them head down.

Understand all of the risk factors

The risks associated with the Trendelen-burg position increase the steeper patients are angled and the longer they remain in the position. If a procedure is taking longer than three hours, consider flattening the patient out for a few minutes to give their body a break from the physical stressors of the position. Gravity increases intraocular and intracranial pressures and increases risks of airway and facial edema. I've seen a few patients emerge from anesthesia with significant swelling around the eyes. In one case we had to keep the patient intubated to let the swelling go down. Gravity can also cause the patient to slide down the surface of the table, which could result in skin tears or the patient falling to the floor. Some facilities still use shoulder braces to prevent patients from slipping, but this practice is not recommended because the supports can cause brachial plexus injuries. Putting patients with higher BMIs in Trendelenburg can also cause pressure on the chest, which could lead to ventilation difficulties.

The lithotomy-Trendelenburg position — supine with both legs separated, flexed and supported in stirrups — can compress the lateral side of the legs, which could ultimately result in peroneal neve injury. Other potential complications associated with this position: injury to the obturator nerve, which causes pain in the inner thigh; injury to the sciatic nerve from over external rotation of the hips; and injury to the popliteal nerve, which can be caused by the stirrups pressing on the back of the knee.

Surgeons at my facility perform a lot of robotic prostatectomies, during which patients are placed in the low lithotomy Trendelenburg position. Some surgeons prefer to place patients in a steep angle for the duration of the procedure, while others want patients in a steep angle until the bowel moves out of the way before decreasing the table's tilt.

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