Safe and Standardized Trendelenburg Positioning

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.

There's a correlation between the amount of fluids surgeons want administered and the degrees of Trendelenburg in which patients are positioned; the steeper the angle, the less fluids patients are typically given. Low fluid levels could result in acute renal failure, so it's important to find the right balance between maximum exposure of the surgical field and sufficient fluid use.

2. Standardize protocols

It's important to root out any inconsistencies in patient positioning practices because even minor variations can lead to major safety problems. To properly place patients in low lithotomy, first make sure the OR table is properly positioned and a non-slip positioning pad is securely attached to the table's surface. Help the patient move onto the table so their hips and buttocks align with the cutout in the surface.

After the patient is anesthetized and intubated, slowly and simultaneously place their legs in stirrups. Limit pressure on the back of the knees and make sure the heels are at the back of the stirrups, the knees are lined up with the opposite shoulder, hips are not over rotated externally and all pressure points are padded. Pad IV locations and securely wrap the patient's arms, making sure to cover the elbow, to prevent injuries to the ulnar nerve, and hands to prevent crushing or pinching injuries that can occur when the stirrups are raised and lowered. Place the patient's padded and protected arms at their sides with their thumbs up and palms facing inward. Then draw the sheet up and over the patient's arms, making sure to support the elbow, and tuck it under their body, using the patient's bodyweight to secure the sheet instead of stuffing it under the table pad.

You can also use a chest strap to secure the patient to the table, but doing so can compress the area where gravity is already pushing the abdominal cavity toward the lungs. You also need to pad the patient's head, making sure it's properly aligned and the face is protected. At my facility, we place a foam donut under the head, as this provides better non-slip friction than a regular pillow.

When the patient is fully positioned, run through a checklist of potential problem areas. Are the patient's legs aligned and positioned correctly in the stirrups? Are all sensitive areas sufficiently padded? Are the arms secured at their sides? Is the patient secure on the surface after the table has been tilted?

In the end, adding extra safeguards and standardizing your Trendelenburg protocols are well worth the effort. The last thing you want for a patient who trusts you to perform a complex surgery is to send them home with a positioning-related complication. OSM