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?"

The OR team eased the patient off Trendelenburg so the heart had room to fill, which brings Dr. Dayal to his next point: A few degrees less of Trendelenburg could reduce the risks of position-related complications without increasing the difficulty of the surgical procedure.

"Surgeons keep asking for more and more Trendelenburg, especially for laparoscopic cases," says Dr. Dayal. "If the anesthesiologist isn't paying attention, the heart can get compromised in that position."

Practical pearls

Patients can suffer everything from sheared skin and nerve damage caused by shifting and pressure, to serious injuries caused by falling, thanks to the Trendelenburg position. And all of that can leave your facility open to massive lawsuits, many of which will end in favor of the patient, says anesthesiologist Ashish Sinha, MD, PhD, DABA, MBA, professor and vice chairman of anesthesiology at Temple University School of Medicine in Philadelphia, Pa. In order to avoid patient injuries and potentially ruinous lawsuits, remember that positioning the patient carefully is everybody's job. "It's something the anesthesia provider and nursing staff are all responsible for," says Dr. Sinha.

Here are some tips for safely securing the patient during Trendelenburg positioning.

Keep time on your side. Place patients in the Trendelenburg position for the shortest amount of time possible and take them out of Trendelenburg's position slowly to let the body readjust to the change in blood volume.

Protective padding. The Trendelenburg position can cause a patient to slip down the operating table. That slippage can leave a patient with painful skin shear injuries. There are several ways to prevent that.

Place a foam or gel pad under the patient — between their skin and the table — to prevent skin shearing. The friction created by the pads, which are taped to the table or held down with straps, help hold the patient in place.

Foam padding and sponges can also serve to protect parts of the patient's body that might be injured under pressure or accidental poking. Protect the ulnar nerve with foam padding underneath the elbow, and the peroneal nerve with padding around the knee to prevent the peroneal nerve from coming in contact with anything solid, like a metal rod, that might damage it, says Dr. Sinha.

Mind your elbows. Be aware of excess pressure that's being put on vulnerable parts of a patient's body during surgery, like the femoral nerves around the groin.

"A surgeon is focused on the part that's exposed for surgery," says Dr. Sinha. "The surgeon may put elbow pressure on a (patient's) abdomen that they're not even seeing."

Prevent foot drop. During the set-up to the procedure, remember to be wary of foot drop — a gait issue that occurs when weakness in the foot prevents a patient from lifting the forefront of their foot off the ground after surgery. A patient who suffers from foot drop may have to go through physical therapy or surgery to correct the issue; or they might never be able to correct it, leaving your facility open to a potential lawsuit. Placing a footboard at the edge of the bed can keep the feet aligned and prevent foot drop.

Braces or "speed bumps." While foam pads can help keep a patient secure on the bed, you'll need to take other precautions to keep the patient from slipping during surgery with the Trendelenburg.

Braces that fit around your patient's shoulders can keep this from happening. The 4-inch wide metal braces clamp onto the edge of the bed near your patient's head and secure the tops of their shoulders from sliding off that edge, says Dr. Sinha. Thick padding between the brace and the shoulder are intended to prevent dermal injury and soreness after the surgery.

Protection like the braces are necessary to use during a long procedure, but also when the patient has a higher BMI, says Dr. Sinha. The weight of a larger patient can cause them to slide more easily.

However, recently, studies have suggested that the shoulder braces are linked to higher rates of soreness and brachial plexus injuries. Some doctors have chosen instead to opt for a "speed bump" method in which 4 pieces of foam are affixed to a frame at the head of the table, according to a poster on patient sliding by Jan Barber, BSN, RN, service educator for gynecology/urology at the University of Michigan Health System. One of the pieces fits like a roll — or a speed bump — underneath the neck, butting up against the trapezius muscle; another goes around the head in a half cylinder; and 2 final pieces of foam sit in a 45-degree angle from the shoulders for stabilization.

A study using the speed bump method for stabilization in 503 laparoscopic and robotic gynecological cases with a steep Trendelenburg position of 30 to 40-degrees produced amazing results, the poster said. None of the patients slid, suffered skin shearing or developed brachial plexus injuries.

Fitted restraints. Deep Trendelenburg positions — which are classified as 30-40 degrees — might require more in the way of support and restraint to keep your patient from shifting or sliding on the table. In these cases, beanbag restraints can help. The restraint is a bag that's placed under the patient, between their upper back and the table, and it's affixed to the table with straps. It holds your patient's upper body in a firm position throughout the course of the surgery. Hold the beanbag in place while a nurse connects suction to the bag's valve. The suction removes air from the bag, and it wraps around your patient as the Styrofoam beads inside conform to the shape of your patient's shoulders and neck. You and 2 others should help mold the bag as it deflates to ensure it fits tightly around your patient's upper back and shoulders.

Proper ventilation. Having a patient in Trendelenburg can disturb the blood flow circulating from the head, resulting in facial or laryngeal edema during and immediately following a procedure. This is especially true with longer surgeries, like robotic prostate surgery, which could leave your patient in deep Trendelenburg for 5 hours, or with patients who have intracranial lesions, says Dr. Sinha.

While edema is common during a long Trendelenburg procedure, you need to take precautions following the operation, when it might not be safe to remove the endotracheal tube due to respiratory distress caused by the swelling, says Dr. Sinha. He advises using the balloon at the end of the endotracheal tube to ensure that the patient is able to have the tube removed. If you deflate the balloon, you should hear a leak around the tube that indicates the airway is not swollen.

"You put the stethoscope on the patient's neck and as air leaks around the tube, you can hear it," says Dr. Sinha, noting that the absence of a leak is suggestive that you should leave the endotracheal tube inserted until the possible swelling goes down. OSM