Survey of Anesthesiologists’ Practices Related to Steep Trendelenburg Positioning in the USA

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Results Survey Response Rates and Speed 

We received 290 responses out of 2050 email invitations, a 14.1% response rate. We obtained 54.8% (159/290) of the total responses after the first email invitation. Nearly all survey responses arrived within two weeks of each email invitation (> 96%). Survey completion rate was 99.6%; only one respondent did not complete the survey through to the last question.

Anesthesiologist Practices 

When asked about inclination angle during steep Trendelenburg position, 32.8% (95% CI, 27.4–38.2) (95/290) of respondents picked “I do not limit the inclination angle” and 40% (95% CI, 34.4–45.6) (116/290) chose “minimum angle for optimal surgical access”. On the other hand, 69.2% (95% CI, 63.9–74.5) (200/289) did not limit the duration of steep Trendelenburg position.

As for measures taken to minimize duration of steep Trendelenburg position, 68.5% (95% CI, 63.2–73.8) (198/289) reported having a discussion with the surgeon, 44.6% (95% CI, 38.9–50.3) (129/289) documented the start and finish, 15.9% (95% CI, 11.7–20.1) (46/289) stated that they provided the surgeon with an hourly reminder, and 14.2% (95% CI,10.2–18.2) (41/289) took no action.

The most common technique used to position patients during steep Trendelenburg and prevent sliding off operating table was the use of a gel mattress (61.9% [177/286]). Other techniques employed were waist straps (36.0% [103/286]), gel or foam pads across the shoulders (33.2% [95/286]), shoulder braces (30.7% [88/286]), shoulder to hip strapping (29.7% [85/286]), bent knees (15.4% [44/286]), wrist straps (12.2% [35/286]), and ankle cuffs (2.4% [7/286]). Open-ended replies included bean bag (5.6% (16/286)), egg crate foam mattress (4.2% (12/286)), and slightly elevating patient’s back (0.7% (2/286)).

To avoid complications related to positioning, 73.9% (95% CI, 68.8–79.0) (212/287) repeatedly assessed the patient’s position during surgery, 66.9% (95% CI, 61.5–72.3) (192/287) tucked the patient’s arms to the sides, 54.0% (95% CI, 48.2–59.8) (155/287) avoided excess fluid administration, and 44.6% (95% CI, 38.8–50.4) (128/287) avoided abduction, external rotation or extension of upper extremities. Moreover, 30.7% (95% CI, 25.3–36.1) (88/287) avoided the use of shoulder braces and wristlets, 28.9% (95% CI, 23.7–34.1) (83/287) of respondents limited the angle, and 19.2% (95% CI, 14.6–23.8) (55/287) limited the duration of steep Trendelenburg position. Other comments included monitoring ventilation, application of saline ointment to the eyes, and monitoring of renal perfusion pressure.

Complications 

Sixty-three respondents out of 290 (21.7% (95% CI, 17.0–26.4)) reported encountering one or more complication related to Trendelenburg positioning. In total, 91 complications were reported (Table 1). The most common complication was airway and face edema (39.5% [36/91]), second was brachial plexus injury 16.4% (15/91), and third was corneal abrasions (13.1% [12/91]).

Institutional Policies 

Only 2.1% (6/289) reported having a policy for Trendelenburg positioning. Policies included: minimizing duration of head-down positioning (5/6), frequent discussion with surgeons regarding patient’s positioning (5/6), minimizing inclination angle (3/6), frequent assessments and documentation of patient’s position (3/6), avoiding excessive intravenous fluid administration (2/6), and avoiding shoulder braces (1/6).

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