From the Guidelines
Trendelenburg positioning is not recommended for hypotensive patients due to its potential to cause harm and lack of effectiveness in improving blood pressure. The most recent and highest quality study, published in 2024 1, suggests avoiding the Trendelenburg position and instead recommends elevation of the upper body ≥ 40° in intubated patients, considering possible haemodynamic side effects.
Alternative Management Strategies
- Hypotensive patients should receive prompt fluid resuscitation with isotonic crystalloids (typically 500-1000 mL boluses of normal saline or lactated Ringer's solution), with reassessment after each bolus, as suggested by a 2019 study 1.
- Vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be needed if fluids alone are insufficient.
- A better alternative for improving venous return is passive leg raising, which can temporarily elevate blood pressure while diagnostic workup and definitive treatment are initiated, as recommended by a 2019 study 1.
- Always identify and treat the underlying cause of hypotension rather than relying on positioning alone.
Rationale for Avoiding Trendelenburg Positioning
- The Trendelenburg position can compromise respiratory function by pushing abdominal contents against the diaphragm, potentially worsening oxygenation in critically ill patients.
- It may also increase intracranial pressure and worsen cerebral perfusion.
- The 2024 study 1 suggests avoiding upper body elevation with flexion of the knees and hips in patients with elevated intraabdominal pressure or at its risk and suggests favouring the anti-Trendelenburg position for upper body elevation.
From the Research
Hemodynamic Effects of the Trendelenburg Position
- The Trendelenburg position has been studied for its effects on hypotensive patients, with mixed results 2, 3, 4, 5, 6.
- One study found that placing a donor in the Trendelenburg position and rapid infusion of 1,000 mL saline was an effective procedure for resolving severe acute hypotension associated with donor plasmaphereses 2.
- However, another study suggested that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive, due to a lack of strong evidence 3.
- A meta-analysis compared the hemodynamic effects of the Trendelenburg position and passive leg raising, finding that both increased cardiac output, but only passive leg raising sustained this effect after one minute 4.
- A study from 1979 found that the Trendelenburg position did not increase preload, slightly increased afterload, and decreased cardiac output in hypotensive patients 5.
- A more recent systematic review and meta-analysis found that the Trendelenburg position significantly increases stroke volume and improves multiple hemodynamic parameters in adult patients 6.
Clinical Relevance
- The use of the Trendelenburg position in hypotensive patients is a topic of ongoing debate, with some studies suggesting its potential benefits and others highlighting its limitations 2, 3, 4, 5, 6.
- The decision to use the Trendelenburg position should be based on individual patient needs and careful consideration of the potential risks and benefits 3, 4, 5, 6.
- Further research is needed to fully understand the effects of the Trendelenburg position in different clinical settings and to determine its optimal application 3, 4, 6.