Do you use the trendelenberg position?

jnette, ASN, EMT-I · Oct 14, 2003

I can't speak for areas other than my own, but in dialysis we use the trendelenburg position dailey... on multiple patients ! It is used whenever they become hypotensive, (unless they have co-morbidities such as COPD and would then find it difficult to breathe)...along with a NS bolus and/or a volume expander such as mannitol. With so much blood "out" of their body and having even more fluid "pulled" over 3-4 hours, becoming hypotensive is quite common, and trendelenburg is a helpful and common intervention. They are kept in this position until the B/P rebounds and they are feeling better... could be half an hour or longer.. many stay in this position for the last hour or two of their treatment.

Our patients know the score, and even joke about it.."going down to the dungeon"... "counting the specks on the ceiling", etc.

wishingmary · Oct 14, 2003

Thanks jnette. We use a slow dialysis in the MICU called SLED with one on one care. Didn't even think of dialysis and of course I'm asking about this position in addition to other interventions like fluids you mentioned if not contraindicated, etc. Thanks for the post! I wonder about the use of modified Trendelenberg, meaning patient flat with legs up.

wishingmary · Oct 14, 2003

I have posted this under critical care but I do want nurses in research to see it too...

I am a nursing student and a nurse aide in the MICU. My last semester of nursing school requires I do a teaching project so I asked my manager if she could think of a teaching need in the units. She suggested the use of trendelenberg. Evidently there is some controversy about its appropriate use in the units. I have done some research and I don't find anything in nursing journals off the web specifically addressing its use. I have found trendelenberg used when inserting an art line to reduce chances of a PE and of course there is some operating room instances. My clinical adviser told me I could use this board as a reference

So......

When do nurses in the units use trendelenberg and how long do you maintain this position? I also want to know if you use it in cases of hypotension along with hypotensive drugs and whether it's benefit outweighs the risk of increased intracranial pressure in non-head trauma patients? Oh, another question I have is do your units allow its' use as a nursing intervention or is it treated as a collaborative intervention with an order from a physician?

By the way, I'm not doing an inservice since I would feel queer standing in front of seasoned ICU nurses so I'm doing a poster board. In order to evaluate the effectiveness of this teaching I'm leaving a quiz of 5 multiple choice questions. Hopefully I'll get some response by those who remember nursing school.

:)

gwenith, BSN, RN · Oct 15, 2003

The full trendelenberg postion has a LOT of medical dissention surrounding it. Obviously it is never used for head injuries or patients who may have increased intracranial pressure. A head down position is somtimes used in placing central venous lines especially the sublclavian approach as not only does this minimise the risk of air embolus but it also engorges the vein a little to make cannulation easier.

To be exact you should differentiate between Trendelenberg, head down and the "modified" trendelenberg. One of the reasons this is so contentious is that some articles when refering to the Trendelenberg position refer to the specific position where the head is down but the legs are bent other articles use the term Trendelenberg as synonomous to any head down position.

Any head down position in an ICU patient will increase the rsk of reflux and therefor aspiration - it may also increase the risk of displacement/migration of the naso-gastric tube as well. The main concern in a non-neuro patient is ocf course the splinting of the diaphram by the abdominal contents leading to diminished respiratory effort. Head down positions are usually (not always) associated with poorer gas exchange.

Usually the recommendations these days is to lie the person flat and raise the legs so the old first aid adage of "face red raise the head face pale raise the tail" still has some merit.

Oh! and if you go to the google search option at the bottom of the page you will find the merck manual in the drop down menu. hope this helps.

WhyO · Oct 15, 2003

Great to see this here...

I have always been taught that if you have a very hy potensive pt (especially symptomatic) you dump them into trendelenburg and go from there. We have a new MD (just done with residency) who says there is no clinical evidence which supports this, however I SWEAR it helps (at least the numbers--grin). Obviously if it is a patient with intracranial issues you would not do this or make a clinical decision either way. I would LOVE to hear what you come up with--please post it! thanks

sjoe · Oct 15, 2003

What would informatics have to do with it? Why would computer people have an opinion about it?

zambezi, BSN, RN · Oct 15, 2003

I have also heard that there is no clinical evidence that support this...it seems like I read something about this not too long ago on the boards...i use it if my patients bp dumps, I have used it in conjunction with pressors to get that pressure back up...have used it when patient is tamponading...between fluids, pressors, and trendellenburg...pressure and svo2 came back up...dr almost didn't take pt back to surgery because numbers looked so good when he got there...we convinced him too, good thing because pt had huge clot behind heart...as whyo said...i think it helps too, at least numbers wise...obviously the goal is to correct the problem asap though...

wishingmary · Oct 15, 2003

Gwenith,

Thanks for the post. I was wondering if the literature was calling a spade a spade or Trendelenberg a Trendelenberg. Only my Black Med/Surg text brought up modified Trendelenberg. The Merck manual search turned up nothing but that doesn't surprise me. I wish there was some research on the subject rather than just finding Trendelenberg mentioned in articles that have nothing to do with the position as a topic. I'm glad this research project is informal. The cons you listed (actually, I'll put your post in full on my poster board) will be reflected in my written report. Thanks.

Mary

gwenith, BSN, RN · Oct 16, 2003

Try searching hypotension instead or syncope you will see it's use mentioned there. I did a literature search some years ago on this and there is just so much dissention even in research literature over it's effectiveness. Some authors argue that the slight rise in BP is offset by the poorer gas exchange in a true head down position others argue against this. My literature search was done a couple of years ago and there may have been some more definitive research since then.

Two systematic review sites are the Cochrane database http://www.update-software.com/cochrane/abstract.htm (medicine) and the Joanna Briggs Institute

http://www.joannabriggs.edu.au/about/home.php

Try those sites but use broad categories such as patient position or hypotension etc - lots of luck!!!

wishingmary · Oct 20, 2003

Thanks Gweneth,

I checked them out. I didn't find anything with a quick search. The second one has a list of topics I can look through. There are alot of interesting things in them.

Zinnia · Oct 20, 2003

Trendelenberg position puts pressure on the carotid sinus and you get a false improvement. Yes, the numbers 'look' better.

http://www.jems.com/jems/e0302k.html