Trendelenburg Position: ''Put to Bed'' or Angled Toward Use in Your Unit?

Margo A. Halm
Am J Crit Care 2012;21:449-452 doi: 10.4037/ajcc2012657
2012 American Association of Critical-Care Nurses
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Clinical Evidence Review

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TRENDELENBURG POSITION:
PUT TO BED OR ANGLED TOWARD
USE IN YOUR UNIT?
By Margo A. Halm, RN, PhD, ACNS-BC

n the mid-19th century, Friedrich Trendelenburg

pioneering German surgeon (1844-1924)
popularized the technique known in the Middle
Ages as the head-down position. In his surgical
text of 1873, Trendelenburg recognized that raising
a patients hips caused the bulk of abdominal viscera to slide toward the diaphragm, providing a less
cluttered operative field for lower abdominal and
pelvic procedures. Later in the early-20th century,
American physiologist Walter Cannon promoted
the Trendelenburg position to displace blood from
the lower extremities to enhance venous return in
the treatment of hemorrhagic shock. This action was
thought to cause an autotransfusion to the central
circulation, increasing right and left ventricular preloads, stroke volume, and cardiac output (CO)/cardiac index (CI).1-3
Despite surgeons questioning the positions
effectiveness in the 1950s because of adverse consequences,4 use of the Trendelenburg position continued as a mainstay of resuscitation.3 Although current
Advanced Cardiac Life Support and first aid guidelines from the American Red Cross (ARC)/American
Heart Association (AHA) state that patients with
evidence of shock should be positioned supine,5,6
use of the Trendelenburg position may remain a ritualistic practice in response to hypotension. Thus,
the following question was prompted: Does use of
the Trendelenburg position (head-down or passive
leg raising) cause clinically significant increases in
blood pressure and CO/CI in hypotensive patients?

Methods
The strategy included searching MEDLINE,
CINAHL, and the Cochrane database. Key words
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012657

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included Trendelenburg, head-down, passive leg raising,

hypotension, cardiac output, and hemodynamics. The
search was not limited by date in order to present
scientific evidence about this practice over time.

Results
The hemodynamic effects of the Trendelenburg
position were tested in more than 20 studies.
Although the effects on blood pressure and CO/CI
are the main focus of this review, changes in other
variables were evaluated: heart rate, blood pressure,
systemic vascular resistance, filling pressures, ventricular index, blood volume, blood flow dynamics,
and oxygenation/gas exchange. Most studies used
observational methods, enrolling small heterogeneous samples ranging from animals or healthy
volunteers to postoperative and other acute/critical
care patients. The Trendelenburg position (10-30)
and the modified Trendelenburg position with passive leg raising (45-60) were studied, with duration
of position change ranging from 1 to 30 minutes.
Table 1 outlines the predominant effect of
Trendelenburg positioning on hemodynamic and
physiological variables across studies, as well as less
common changes that were also statistically significant.7-31 First, CO/CI increased significantly in healthy
populations,12,15,23 although the effects were transient,
lasting 1 to 3 minutes. Of the 13 studies of acutely
ill patients, almost half showed significant increases
in CO/CI with a mean change of 8%, but these effects
were largely transient, lasting 3 to 5 minutes.14,17,18,25,30,31
In 1 study,17 significant increases remained at 30
minutes but CO/CI changes were only 6% to 9%.
Although CO/CI increased, the predominant effect
of use of the Trendelenburg position on blood
pressure was no change. In the few studies17,18,20,30,31
in which increased blood pressure was observed,
the mean change was only 9 mm Hg.

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449

Table 1
Primary hemodynamic and physiological effects associated with use of
the Trendelenburg position: studies spanning 1949 to 2012 (N = 25)a
Predominant effectb

Variable

Less common effectb

Decreased with 60 passive leg raising

Heart rate

No change

Stroke volume

Increased

Preload
Central venous pressure
Pulmonary artery pressure

Increased
Increased

No change
No change

Afterload
Blood pressure (systolic or mean)

No change

Increased, a mean of 9 mm Hg across

studies (range, 4-20 mm Hg)
No change, or decreased

Systemic vascular resistance

Increased

Ventricular indexes
Right ventricular end-systolic volume index
Left ventricular end-systolic volume index

Increased
Increased, or no change

Decreased when ejection fraction < 40c

Cardiac output/cardiac index

Increased, a mean of 11% across all studies

(range, 3%-25%); effect transient at 1-5
minutes

No change

Intrathoracic blood volume

Increasedc

Perfusion indexes
Carotid blood flow

Decreased when normotensive, no change

if hypotensivec
Decreasedc
Decreased at 1 minutec
Increased at 1 minutec
Decreased to apicesc
Increasedc
Decreasedc

Cerebral blood flow

Internal jugular vein velocity
Cerebral perfusion pressure
Pulmonary blood flow
Aortic blood flow
Segmental arm blood flow
Pulmonary indexes
Oxygen saturation
Partial pressure of carbon dioxide
Oxygen transport
Total elasticity/resistance
Pulmonary function
Functional residual capacity

No change

Decreased
Increasedc
No changec
Increasedc
No change
Decreasedc

Based on information from Shenkin et al,7 Guntheroth and Abel,8 Reed and Wood,9 Taylor and Weil,10 Sibbald et al,11 Gaffney et al,12 Bivins et al,13
Pricolo et al,14 Haennel et al,15 Wong et al,16 Gentili et al,17 Reich et al,18 Armstrong et al,19 Sing et al,20 McHugh et al,21 Ostrow et al,22 Terai et al,23
Fahy et al,24 Boulain et al,25 Reuter et al,26 Bertolissi et al,27 Naylor et al,28 Monnet et al,29 Mekis and Kamenik,30 and Kweon et al.31
b P < .05.
c Results of 1 study.

Normal physiology provides evidence that

changes in body position cause shifts in blood volume
that affect preload. However, Bivins et al13 reported
that only a small amount of total blood volume
(1.8%) is displaced centrally with Trendelenburg
positioning. In the face of hypovolemia, preload
changes are limited because venous capacitance

About the Author

Margo A. Halm is the director of nursing research, professional practice, and Magnet at Salem Hospital in Salem,
Oregon.
Corresponding author: Margo A. Halm, RN, PhD, ACNS-BC,
Salem Hospital, Salem, OR 97301 (e-mail: margo.halm@
salemhealth.org).

450

vessels are rapidly depleted and have little blood

volume to add to the central circulation. Thus, the
autotransfusion effect associated with use of the
Trendelenburg position is small and unlikely to
have clinical significance. Additionally, when blood
pressure is low and patients are tilted, abdominal
contents shift35 and compress the vena cava, putting pressure on and fooling baroreceptors that
blood pressure is back to normal. As a result, the
normal baroreceptor response to low blood pressureheightened sympathetic and reduced parasympathetic activity to increase systemic vascular
resistance and blood pressureis halted and instead,
vasodilatation ensues, further aggravating the
hypotensive problem.

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Additional studies reveal potential harmful

effects associated with use of the Trendelenburg
position (Table 1), such as reduced blood flow and
oxygenation. Although most of this evidence is from
1 observational study or studies with small samples,
it needs to be considered clinically. In a review of
physiological changes, Martin3 outlined the sequence
of symptoms that typically occur after a patient is
tilted into the Trendelenburg position (see Figure).
The Trendelenburg position is poorly tolerated by
conscious patients, whereas hypotensive and mentally obtunded patients may first become transiently
more alert and then subsequently lose the will to
struggle. Disease conditions set patients up for more
deleterious effects. Patients with coronary artery
disease are at risk for increased myocardial oxygen
consumption that provokes dysrhythmias, whereas
patients with lower limb ischemia may experience
more reduction in perfusion as segmental blood
flow gradually decreases the longer the position is
maintained.15 Respiratory expansion and vital
capacity also decrease, especially in obese patients,
promoting hypoventilation or atelectasis and
altered ventilation-perfusion ratios as blood gravitates to poorly ventilated apices. Patients with neurological impairment face other unfavorable effects,
including increased intraocular/intracranial pressure
and cerebral edema from increased venous congestion inside and outside the cranium.32 It is conceivable that the steeper the tiltas well as the longer it
is maintainedthe more pronounced the physiological impact will be.

Recommendations for Practice

Most of the evidence for this intervention is
grade B evidence (Table 2), indicating that use of
the Trendelenburg position does not lead to beneficial changes in blood pressure or CO/CI. As a result,
this position is probably not useful in rescue efforts.
The associated hemodynamic effects are small and
unsustained and thus are unlikely to have a clinically significant impact on hypotensive patients.
Furthermore, because use of the Trendelenburg
position may be associated with harmful cardiopulmonary, neurological, and vascular effects, especially
in the presence of disease, the position should be
used with caution even when immediate/transient
benefits are desired. Instead, clinicians should position patients flat and seek or initiate available orders
for additional interventions such as fluid boluses,
pharmacological therapies, or other devices targeted
to the cause of the hypotension.
Although the results are dated, Ostrow34 conducted a survey of nearly 500 critical care nurses
about use of the Trendelenburg position. Most of
the responding nurses reported that use of the
Trendelenburg position was an immediate and

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Anxiety and restlessness

Onset of pounding vascular headache

Nasal congestion causing mouth breathing

Progressive dyspnea

Loss of cooperation
(including overt hostility)

Struggling efforts to sit upright

Figure Sequence of signs and symptoms associated with use of the

Trendelenburg position.a
aBased

on information from Martin.3

Table 2
American Association of Critical-Care Nurses
evidence-leveling systema
Level

Description

Meta-analysis of multiple controlled studies or metasynthesis

of qualitative studies with results that consistently support
a specific action, intervention, or treatment

Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific
action, intervention, or treatment

Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

Peer-reviewed professional organizational standards, with

clinical studies to support recommendations

Theory-based evidence from expert opinion or multiple case

reports

Manufacturers recommendation only

aFrom

Armola et al,33 with permission.

independent intervention routinely used to treat

hypotension/shock almost half of the time. Despite
the limited hemodynamic effects and adverse consequences associated with use of the Trendelenburg
position, anecdotal evidence suggests that clinicians
still use this position today. Thus, use of the Trendelenburg position is an example of an intervention
that is based on tradition rather than scientific evidence.32,35,36 Perhaps tilting the patient gives clinicians
satisfaction that they have initiated some intervention until they can start other therapies such as
administration of fluid boluses or inotropic agents.
Or the explanation could be that because these
interventions are often initiated almost simultaneously, clinicians attribute a blood pressure response
to the effects of using the Trendelenburg position
and not to the other therapies. Furthermore, current
ARC/AHA first aid guidelines6 state that because the

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evidence is mixed, passive raising of the legs 6 to

12 inches (30-45) may be helpful for patients
with no signs of trauma or injury as long as the
position does not cause pain or discomfort. The
presence of such guidelines in the prehospital setting may add to the confusion among clinicians in
the acute care setting about continued use of the
Trendelenburg position.
Challenge practice in your unit with a small
test of change: Repeat Ostrows survey with your
colleagues to determine if implementation science
has been effective in changing their initial response
to hypotensive episodes. If reliance on the intervention remains, use the evidence to teach your colleagues about the limited therapeutic and potentially
harmful effects of using the Trendelenburg position.
Only with continued commitment and discipline
to access and integrate the best available evidence
at the bedside can we move our practice beyond
the confines of our initial nursing education, professional experience, and unit rituals or traditions
to evidence-based practice.
Financial Disclosures
None reported.
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