reverse trendelenburgtrendelenburg positions

How the Reverse Trendelenburg Position Aids Surgeons

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By Johnny Bevers

History and Overview of the Reverse Trendelenburg Position

The Trendelenburg position was first invented by the German doctor, Friedrich Trendelenburg and was designed to be used in different surgical procedures to improve access to certain parts of the body during different procedures.  The Trendelenburg is a position where the patient is laid flat and then maneuvered into a position that lowers their head and upper part of the body downwards so that it is approximately fifteen to thirty degrees lower than the upper part of the body.  This is commonly used by surgeons and used to be the standard first aid position when someone was thought to be suffering from shock.

The Reverse Trendelenburg Position was also invented by the same doctor, Friedrich Trendelenburg and is also sometimes referred to as the “Anti Trendelenburg.”  It is the exact reverse of the Trendelenburg Position.  The patient is positioned so that the bottom part of their body is approximately fifteen to thirty degrees lower than the head and neck.  Both of these positions are now commonly used during various surgical procedures as gravity helps pull the intestines down away from the pelvis and it is easier for the surgeon to access parts of the patient’s body.  The position is being used more and more due to the massive increase in laparoscopic surgeries.

The position is now commonly used in many different surgical operations due to the many benefits that it brings, although there are also some risks.

Benefits of the Reverse Trendelenburg Position and Why its Used

The aim of the Reverse Trendeleburg position is to allow the best access possible for the surgeon, but ensuring that any potential risks to the patients are minimized.

There are many medical situations where the Reverse Trendelenburg position is of benefit:

• Using this position can improve cerebral (brain) blood flow

• Increase the effectiveness of a spinal anesthetic or epidural

• Allows easier placement of a central venous catheter as it decreases the risk of pulmonary aspiration by vomiting and engorged cervix vessels.

• The Reverse Trendelenburg position has been proven to be particularly effective when operating on morbidly obese (bariatric) patients. If the patient is positioned in this way during an operation, the oxygenation is improved due to minimal arterial blood pressure changes.

• The position is often used during prostrate operations as it offers better exposure of the area.

• Gynalogical procedures are often carried out in this position as the blood flow to this area is reduced.

• It is beneficial for neck and head surgery as it increases the venous drainage in the area along with reducing intracranial pressure. The position also decreases the chance of passive regurgitation (vomiting)

• The Reverse Trendelenburg Position is often used when removing a central line from a patient, as it makes the removal of the line a lot less bloody. This is due to the gravity of the patient’s position reducing the blood flow to the heart as well as the internal jugular/subclavian vein.

When it wouldn’t be good to use this position and Precautions to Take When using the Reverse Trendelenburg Position

The Reverse Trendelenburg Position is not without its risks.  While it brings many benefits, particularly for bariatric patients, there are a number of precautions that should be taken before, during and after using the Reverse Trendelenburg Position.

To position the patient correctly into the Reverse Trendeleburg Position, the patient should first be laid flat on the surgical table or bed.  The legs must never be crossed.  This is very important as crossing of the legs will increase the risk of thrombosis (blood clots) which can travel to the brain and cause serious brain injury or even death.

The patient must also be restrained to prevent them from slipping off the table. As the patient will not be lying flat, it is very important to ensure that they are properly secured, or there is a real risk that they will slide down the bed or table resulting in serious injury.  This is done by special restraining straps round the arms and legs as well as a tightly wrapped sheet around the body of the patient.There should also be a foot board as well as foot restraints to help stabilize the patient and stop them from slipping downwards.  It is important that the patient feels comfortable as well as secure whilst in the Reverse Trendelenburg Position.  Elderly patients may also require some extra protection for their heels.  This can be in the form of padding or maybe some soft bootees.

It is important to avoid any sudden changes in blood pressure, which can easily occur when a patient is being moved into a position where the head is at a different level to the heart.  To try and avoid this, the bed or table should be tilted very slowly into and out of the Reverse Trendelenburg Position.

Patients in this position may have an increased risk of hypotension due to decreased venous return, so it is advisable to monitor arterial blood pressure on a frequent basis.  As the patient’s head is positioned above the heart, it is important to take the resultant reduction of perfusion pressure to the brain into account when working out their optimal blood pressure.

Bear in mind that the Reverse Trendelenburg is not a natural position for a patient to be in and obviously complications are possible. Whilst they are in this position, a medical professional should be with them at all times to monitor vital signs, such as temperature, heart rate, blood pressure and pulse.  These can drop quickly due to the excessive pressure, so it is important that the patient is constantly monitored.

Breathing is not normally affected whilst in the Trendelenburg Position, but blood circulation can be compromised as gravity can mean that blood gathers in the lower extremities of the body, causing reduced cardiac output.

The Reverse Trendelenburg Position is not recommended in the following situation:  When a patient is suffering from Hypovolemic shock (shock caused by severe blood or fluid loss.

Sources:

http://www.ncbi.nlm.nih.gov/pubmed/11094011

http://medical-dictionary.thefreedictionary.com/reverse+Trendelenburg

http://ceaccp.oxfordjournals.org/content/4/5/160.full

https://www.inkling.com/read/basics-of-anesthesia-miller-pardo-6th/chapter-19/specific-positions

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