From speed bumps and sticky pads to arm tucks and tilt tests, you pull out all the stops to protect patients when you place them in the Trendelenburg position. Here are 6 tips to keep their bodies from sliding and their skin from shearing.

1. Lithotomy-Trendelenburg. Anytime you go into a lithotomy-Trendelenburg position — supine with the legs separated, flexed and supported in raised stirrups — you need to worry about positioning injuries. Most of the time it's a peroneal nerve injury, caused by being up in the stirrups that puts pressure on the lateral side of the legs and peroneal nerve. Check to see that the stirrups are in the right place and that the patient is positioned at the bottom of the bed.

"I make sure that the articulating aspect of the stirrup that's attached to the bed is at the level of the hip joint of the patient," says Taylor Brueseke, MD, of St. Joseph Hospital in Orange, Calif. "So, when I move the foot up, the leg is rotating from that same point of rotation."

When positioning patients, Dr. Brueseke thinks about the skeleton rather than the skin. He uses the ischial tuberosity — the bony part of the buttocks — as a guide to make sure it's supported and located at the edge of the table so that the lower back will stay neutral and not hyperextend, which can cause back pain after surgery. Also, keeping the legs in an ergonomically appropriate position while in the stirrups helps prevent injuries.

"As we move the legs, from high lithotomy to low lithotomy, we're not damaging any nerves and we're keeping the patient in the appropriate physiological position," says Mini "Dr. Mini" Somasundaram, MD, of Comprehensive Women's Care in Columbus, Ohio.

When adjusting or re-positioning one side of the patient, be sure to check the opposite side for potential problems.

"When the patient position has been adjusted, whether this is due to table, patient or purposeful staff movement, always check the contralateral side for any issues that may cause an injury," says Brent Klev, MBA, MSN, RN, surgical services nurse manager at South Jordan Health Center in Utah.

2. Tuck and check. When tucking the arms of the lithotomy patient down to her side, between the thigh and where the stirrups are attached to the bed, you can cause pinching injures to the hands and fingers if you start moving the stirrups around.

Proper tucking technique will prevent the pinching. When tucking the hands, check the patient's fingers to make sure they're out of the way of the stirrup attachments, says Mr. Klev. "Once you've got the patient's arms tucked, move the stirrups around before the patient is draped, to make sure the fingers aren't being pinched," he says. "If the patient has wide hips and you start moving the stirrups around, you can pinch the fingers."

Remember, the anesthesia provider usually runs the bed control from the head of the table, so he can't see the patient's hands at the end of the bed. He could injure the patient's hand when bringing the foot of the bed back up at the end of the case, says Dr. Brueseke.

Another key point to tucking is to make sure the arm is not pinned underneath the body. Wrap the sheet around the arm and then push the sheet underneath the patient's body to provide resistance so the arm doesn't fall off the bed.

"That sheet is holding the arm on the bed," says Dr. Brueseke, "so if you just tuck, tuck, tuck, you can accidentally tuck the arm under the body."

After you're done tucking the arms, you'll want to look at the patient's shoulders to make sure they're still relatively neutral. If you tuck a little too hard, says Dr. Brueseke, with the patient's hand too high or low, you could end up with the patient's shoulders misaligned.

3. Do a tilt test. Before you prep and drape, get the patient properly positioned and tilt the table into the Trendelenburg position. You want the patient in a good position for the procedure and the tilt test will let you know if the patient is sliding, says Mr. Klev.

It only takes an extra minute or two. Because once you start the procedure and get the patient prepped and draped, if you have problems with sliding, you may have to stop the procedure and re-position and re-drape the patient. That costs you some time as well as money with having to open new supplies.

The tilt test also helps you check if there are any problems with the patient's ventilation, which also can be an issue in steep Trendelenburg. When you get the patient in that position, you're placing significant weight onto the diaphragm, and consequently the lungs, and that could cause breathing problems.

But the tilt test is beneficial for a few other reasons as well, according to Mr. Klev. You can tell right away how the patient is going to respond to the steep Trendelenburg and it also lets the patient get into the position that they're going to be resting in during the procedure. And it's not out of the question to do a second tilt test after seeing what happens in the first tilt test.

"Once you tilt that patient back, you can tell how far they're going to slide," says Mr. Klev. "They've already slid that distance and rested into that spot. So, if there are any adjustments that need to be made, we'll do a second tilt test to make sure the patient is in a good spot."

4. Speed bumps and sticky pads. You can place axial skeleton stabilizers around the neck and shoulders of patients to help keep them stabilized while in the Trendelenburg position. Dr. Brueseke calls these devices "speed bumps."

"It sits right in the small of the neck, and as the patient is put into steep Trendelenburg, the speed bump is against the spine — the spine is resting on it — and the whole load of the body is kept on the spinal column," says Dr. Brueseke. "That's essentially what happens when we're upright and walking. That's what the skeleton is built to do, to hold the weight of the body."

The patient is upside down, but all the weight, pressure, tension and heaviness are on the thing that's built to hold that kind of weight.

"It's remarkably effective. It's pretty impressive how you can put that little speed bump right there underneath the neck and you put the patient in steep Trendelenburg and she sits right on that spot," says Dr. Brueseke.

You can also keep Trendelenburg patients stable and pressure-ulcer free with a combination of speed bumps and a pad that molds and conforms to the patient's contour to prevent unwanted patient sliding. A strap across the chest adds extra stability.

"My rule is if the patient weighs more than 250 pounds, I use the sticky pad and the (speed bump) device because I want the security of knowing for sure that if one device fails, the other is going to make up for it," says Dr. Mini. "A lot of times, especially now that we're conscious of cost, people will say, "Isn't that (using both the pad and the speed bump device) more expensive?' Well, it's more expensive if you injure your patient."

5. Chest strap or not? Some surgeons like to use a chest strap to help secure the patient to the table while in Trendelenburg. But this can create a ventilation problem for larger patients.

"Not only are you pushing their abdomen contents toward their lungs by tilting them on their head," says Mr. Klev, "but now you're strapping their chest to the bed and potentially creating more problems."

Adds Dr. Mini: "The restriction on ventilating the patient when the chest straps were in place bothered anesthesia, especially in our larger patients. This was why other methods of supporting the patient on the operative tables arose."

6. Experience it for yourself. Dr. Brueseke believes that many surgeons underappreciate the physiological changes that the patient experiences from being in Trendelenburg for extended procedures. Years ago, Dr. Mini found out for herself. She put herself into steep Trendelenburg while awake. "And 25 degrees Trendelenburg is pretty steep. You have blood rushing to your head. It gives you a perspective on why Trendelenburg worries people," she says. "You just assume that the patient is asleep, what's the big deal? But no, you feel what's happening to their physiology when you're awake and in that extreme Trendelenburg." OSM