Trendelenburg’s Position

The Trendelenburg Position is a position in which the patient is laid supine, with the head declined to an angle between 30-45 degrees.

The Trendelenburg position is most often used in surgical procedures of the lower abdomen, pelvis and genitourinary system as it allows gravity to pull the abdominal contents away from the pelvis. The position is also very effective in reducing and preventing the exacerbation of both abdominal and inguinal hernias. This is because it avoids putting downward pressure on the hernia^​1​, which in turn reduces stress on the weakened tissues.

The Trendelburg position is also often used as part of a Modified-Valsalva Maneuver when cardioverting Supraventricular-Tachycardia^​2​.

Because gravity’s can be effectively reversed relative to the body, the Trendelenburg position is also useful in assisting with the placement of central venous catheters in the internal jugular or subclavian veins, due to the veins filling and distending.

Nursing Considerations

The position can often be rather uncomfortable for patients. Many will experience a sensation of falling backwards, or of sliding off the bed head first. The nurse should be vigilant in ensuring the patient is well informed and aware of the details of of the position.

The patient may lose their reference to level ground, and the declined angle may be greater than they anticipate, causing them panic as their head drops further beyond their comfort levels. It is recommended that the nurse instructs the patient to hold the bed rails for added security and peace of mind, and if possible, allow the patient to look sideways where they can see the floor or a bench to reorient themselves to level ground.

The final position may be quite uncomfortable for the patient due to distention of the jugular veins. They may also find it more difficult to perform adequate respirations as the abdominal organs put pressure on the diaphragm.

It is important to remember the position cannot be rapidly reversed. Rapid reversal of the trendelenburg position can cause severe disorientation, sudden onset of postural hypotension, nausea and fainting spells. If the patient panics, halt any movement of the bed and try to reassure them. If they continue to panic or are extremely uncomfortable, slowly return the bed to level, or the semi-fowlers position.

Contraindications

The Trendelenburg position is contraindicated in patients with acute neurological issues^​3​, with the exception of suspected pneumocranium, in which case it is recommended to place the patient in a flat or slight trendelenburg position to promote absorption of intracranial air.

Patients with suspected or confirmed increased intracranial pressure (IIP) should not be placed in the Trendelenburg position for any reason, as it will reduce venous blood return to the heart, and increase cerebral congestion^​3​ as fluids are unable to drain from the cranium.

The position should also be avoided in pregnant woman as the position may interfere with the mothers ability to perform adequate respirations.

Controversy

The Trendelenburg’s use in a variety of clinical situations is heavily debated, mainly due to the “archaic” reasoning for its use. For example; The Trendelenburg position is traditionally recommended for patients in hypovolemic shock, because gravity will draw blood to the brain and heart. While true to an extent, the efficacy is still debated in light of recent medical advancements.

The controversy seems to centre around the American physiologist Walter Cannon, who popularised the use of the trendelenburg position to treat patients in shock during the first world war. He promoted it as a way to increase venous return to the heart, increase cardiac output, resulting in increased organ perfusion. the position became increasingly popular, but was also heavily criticised. Cannon would eventually reverse this opinion a decade later, but this did not deter its already widespread use.

Variants of Trendelenburg’s Position

Steep Trendelenburg Position

Table Break Trendelenburg Position

Reverse Trendeleburg