Reviewed and updated by Myrna Buiser Schnur, MSN, RN: March 20, 2024

When I first started my nursing career in the early 1990’s, I remember watching my preceptor in the critical care unit reflexively place her patient in the Trendelenburg position during episodes of acute hypotension and shock. She explained that lowering the patient’s head and elevating the legs above the chest helped to move blood from the lower extremities to the heart, brain, and other vital organs. It certainly made logical sense and seemed to work, at least transiently. I quickly integrated Trendelenburg into my everyday practice. However, researchers found that the use of Trendelenburg does not improve blood pressure and shock and instead, could have detrimental effects on specific patient populations.

The origins of Trendelenburg trace back to the late 1800s, when Dr. Friedrich Trendelenburg, a surgeon, pioneered this technique to gain better access to pelvic organs for operative purposes. During World War I, the position was utilized in the treatment of shock to increase circulation to the heart, increase cardiac output (CO), and improve blood flow to the vital organs (Shammas & Clark, 2007). Also known as autotransfusion, Trendelenburg became common practice in various healthcare settings such as emergency rooms, operating rooms, post-anesthesia care units, and critical care. In addition, Trendelenburg at a 10 to 15 degree head-down-tilt significantly increases the jugular vein diameter and is currently recommended as the optimal position for central line insertion, when clinically appropriate and feasible, to facilitate cannulation and reduce the risk of venous air embolism (Heffner & Androes, 2022). Health care providers also use the position briefly when obtaining IV access to start rapid fluid boluses. However, while the technique has been historically employed to treat hypotension, medical and nursing societies have not developed guidelines supporting the use of Trendelenburg to treat shock. 

Physiologic Effects of Trendelenburg Positioning (Welch, 2024)

The controversy lies in whether blood moving from the extremities to the central part of the body contributes to hemodynamic stability and if there are harmful effects that outweigh the potential benefits. Trendelenburg position creates significant changes in the body such as:

• Increased central blood volume, venous return to the heart, and mean arterial pressure that may be tolerated in healthy individuals but could cause cardiovascular compromise in patients with cardiac disease
• Shifts in abdominal organs toward the diaphragm decreases functional residual capacity and pulmonary compliance of the lungs which may contribute to atelectasis
• Increased intracranial pressure
• Increased intraocular pressure
• Potential airway compromise from edema and swelling of the face, tongue, and laryngeal tissues
• Higher risk of passive regurgitation

Research

Shammas and Clark (2007) as well as Bridges and Jarquin-Valdivia (2005) reviewed several studies that evaluated the effects of Trendelenburg positioning. Research findings are summarized below.

• Sibbald, Paterson, Holliday, and Baskerville (1979) found that Trendelenburg did not consistently improve hemodynamic effects in critically ill hypotensive patients.
• Ostrow, Hupp and Topjian (1994) found no significant effect on CO, cardiac index (CI), partial pressure of oxygen (PO₂), systemic vascular resistance (SVR) or MAP from either Trendelenburg or modified Trendelenburg (legs elevated 30 degrees).
• Terrai, Anada, Masushima, Shimizu, and Okada (1995) evaluated the effects of a 10-degree head-down-tilt Trendelenburg position on central hemodynamics and flow through the internal jugular vein. Results showed an increase in left ventricular end-diastolic volume (LVEDP), stroke volume (SV), and CO (increased 16%) with a reduced heart rate after 1 minute of 10-degree Trendelenburg position. After 10 minutes, the hemodynamic changes returned to pre-intervention levels.
• Fahy et al. (1996) studied the effect of Trendelenburg on lung mechanics. They concluded that Trendelenburg did not increase intrathoracic pressures but did affect lung and chest wall movement that resulted in reduced lung volumes. They surmised that the intervention may have a greater adverse effect on patients with increased body mass index and those with lung disease.
• Reuter et al. (2003) found that Trendelenburg positioning slightly increased preload volume and caused a small autotransfusion effect, but it did not significantly improve cardiac function.

While these studies consisted of small sample sizes and quasi-experimental designs without randomization or control groups, several conclusions can be made (Shammas & Clark, 2007).

• The research does not support the use of Trendelenburg as an intervention for hypotension.
• Trendelenburg should be avoided until larger studies are conducted as it may increase a patient’s risk for hemodynamic compromise and impaired lung mechanics.
• Specific patient populations should not be placed in Trendelenburg including those with:
  • Decreased right ventricular ejection fraction (RVEF)
  • Pulmonary disorders
  • Unprotected airway and risk for aspiration (London, 2023)
  • Increased intracranial pressure
  • Head injuries
  • Bleeding in areas that become dependent when head is positioned downward (London, 2023)
• Interventions that are successful in treating hypotension include inotropic agents, intravascular volume, and cardiac assist devices.

Trendelenburg versus Passive Leg Raise

It’s important to note that the Trendelenburg position is different from the passive leg raise or passive leg elevation (PLE) in which the legs are raised and held at 45 degrees for one minute, while the head and torso remain in a horizonal position (not lowered). Several studies have shown that a 10 percent rise in cardiac output during PLE is predictive of a patient’s fluid responsiveness (Mikkelsen, Gaieski & Johnson, 2023). PLE is therefore used briefly to help determine treatment options for hypotension.

Shedding Outdated Practices

Trendelenburg is no longer a part of my routine practice. It is important for clinicians to stay up to date on the latest research and be sure they are not perpetuating outdated patient management techniques that are potentially harmful. Further research is needed to evaluate the utilization and safety of Trendelenburg before it is incorporated into practice guidelines and as a standard of care. Are you still using Trendelenburg to treat your hypotensive patients?

References
Bridges, N. & Jarquin-Valdivia, A.A. (2005). Use of the Trendelenburg position as the resuscitation position: To T or not to T? American Journal of Critical Care, 14(5), 364-368.

Fahy, B.G., Barnas, G.M., Nagle, S.E., Flowers, J.L., Njoku, M.J. & Agarwal, M. (1996). Effects of Trendelenburg and reverse Trendelenburg postures on lung and chest wall mechanics. Journal of Clinical Anesthesia, 8(3), 236-244.
 
Heffner, A.C. & Androes, M.P. (2022, April 20). Placement of jugular venous catheters. UpToDate. https://www.uptodate.com/contents/placement-of-jugular-venous-catheters
 
London, M.J. (2023, July 13). Hemodynamic management during anesthesia in adults. UpToDate. https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults
 
Mikkelsen, M.E., Gaieski, D.F. & Johnson, N.J. (2023, December 8). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock
 
Ostrow, C.L., Hupp, E. & Topjian, D. (1994). The effect of Trendelenburg and modified Trendelenburg positions on cardiac output, blood pressure, and oxygenation: a preliminary study. American Journal of Critical Care, 3(5), 382-386.

Reuter, D.A., Felbinger, T.W., Schmidt, C., Moerstedt, K., Kliger, E., Lamm, P. & Goetz, A.E. (2003). Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. European Journal of Anaesthesiology, 20(1), 17-20.
 
Shammas, A. & Clark, A. (2007). Legal and Ethical: Trendelenburg positioning to treat acute hypotension: Helpful or harmful? Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 21(4), 181-187

Sibbald, W.J., Paterson, N.A., Holliday, R.L. & Baskerville, J. (1979). The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Critical Care Medicine, 7(5), 218-224.

Terrai, C., Anada, H., Masushima, S., Shimizu, S., & Okada, Y. (1995). Effects of Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. American Journal of American Medicine, 13, 255-258.
 
Welch, M.B. (2024, January 10). Patient positioning for surgery and anesthesia in adults. UpToDate. https://www.uptodate.com/contents/patient-positioning-for-surgery-and-anesthesia-in-adults#H551043064

 

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