Safe and Secure in Steep Trendelenburg

When you place patients head down with their stirrup-supported legs reaching skyward at a 30- to 45-degree angle, there is a laundry list of things that could go wrong, ranging from sheering injuries and problematic sliding to potentially blinding intraocular pressure injuries. While there are certainly many inherent dangers to steep Trendelenburg, the shifting of organs and neurovascular structures provides adequate visualization of key areas of the patient’s anatomy surgeons need to perform surgery.

With the increased use of less-invasive surgical procedures, strategic patient positioning such as steep Trendelenburg is only likely to be more commonplace in outpatient facilities — especially in those that use robotics. It’s therefore essential to ensure adequate planning takes place, positioning aids are available and regular monitoring occurs whenever patients are placed in the position.

The best way to prevent unnecessary risks and complications when the patient is in steep Trendelenburg is with clear policies in place that are based upon industry guidelines and, if you’re using positioning aids, the manufacturers’ instructions for use (IFU). This can get tricky when surgeons want to do things “the way they’ve always been done” — even when that way doesn’t align with relevant IFUs. For instance, I once worked with a surgeon who wanted to use an IV bag as a positioning aid. When I told him he couldn’t, he said, “Show me a policy that says I can’t.” For this reason, I always include overarching language in all our policies clearly stating that “all equipment and supplies can be used only as intended and recommended by the manufacturer.” This disclaimer is key because even though most surgeons won’t argue about improperly using an IV bag, many have a natural tendency to only use the positioning and supplies with which they trained.

When it comes to physically moving the patient into Trendelenburg, staff should do it the same way every time. That’s why I recommend simulation training. The hands-on nature of this type of training allows everyone involved in patient positioning to get a feel for exactly how the process will play out and ensures no details are missed. Simulation training should involve the entire interdisciplinary team — including the surgical care technicians who often play a critical role in gathering and maintaining the devices used to position patients properly. All too often, these individuals are left out of the equation, and that’s a mistake.

Another important factor to keep in mind with simulation training is variation. Make sure to factor in different-sized patients and the varying degrees of mobility and fragility they might have. You also want to stay vigilant when you have patients with existing or previous health problems, whether it’s diabetes, high blood pressure or a history of cancer treatments that did significant damage to their bodies. You can’t manage all risk factors with these patients, but you can position them very carefully, check them more frequently and change their positioning when needed. For instance, if the surgery lasts longer than two hours, you might want to move the head a bit, and check the ears and other anatomy you can see for skin redness. When possible, you should peek under the drapes every once in awhile to make sure their arms are still secured and positioned where they’re supposed to be.

I’ve always relied on AORN’s recommended positioning guidelines and its “Positioning at a Glance” tool when putting together the checklist I’ve created to standardize my facility’s Trendelenburg positioning protocols. Regardless of how steep you go, be sure to keep the patient’s head and neck in a neutral position, and take the necessary precautions to protect their eyes when they’re under general anesthesia. Tape the eyelids and use a transparent dressing or eye lubrication to prevent corneal abrasions. 

Increased intraocular pressure is one of the more serious risks of Trendelenburg positioning, and complications even include postoperative vision loss. You can monitor patients during surgery with a tonometer and, if the intraocular pressure is climbing steadily, move the patient back to a level position for about 10 to 15 minutes.

When positioning the patient’s arms, consider the physical limitations of the patient and the needs of the OR staff. You can secure the arms at the patient’s side in a neutral position, flex and secure them across the body or extend them on arm boards. When the patient’s arms are extended and secured to arm boards, make sure the palms are facing up and the arm boards are padded, level with the OR table’s mattress and abducted less than 90 degrees.

Place padding or a pillow on the patient’s lumbosacral region to prevent postoperative back pain and position the knees with approximately five to 10 degrees of flexion to prevent popliteal vein compression and reduce risk of venous thromboembolism. Make sure the legs are parallel to each other with ankles uncrossed and secure them in place with a safety strap approximately two inches above the flexed knees.

Because the heels present a major pressure injury risk, keep them elevated in a way that allows the patient’s weight to be distributed along the calf. This prevents excess pressure on the Achilles tendon and avoids hyperextension of the knee. There are heel-suspension devices or pressure-redistributing surfaces created for this task. Position the patient’s feet in a neutral position without hyperflexion or hyperextension. Positioning devices on the market are specifically designed to prevent the patient from sliding down the surface of the OR table and protect against skin tears and pressure injuries.

Like all purchasing decisions, consider the cost and storage requirements of positioning aids. The upfront expense of reusable products and devices can be considerable. When you factor limited storage space into the equation, you might find that disposable positioning aids are the way to go. Of course, on top of the environmental issues associated with disposables, these items can become costly over time if you aren’t reimbursed for them as a line item. These types of decisions are best made by a seasoned, well-represented purchasing committee.

Of course, the principal factor in Trendelenburg positioning is patient safety. That comes down to properly training everyone — from patient care technicians to surgeons — who’s involved in the positioning process and empowering them to speak up whenever anything seems amiss. OSM