Evidence Based Practice Paper - Title Page



Evidence Based Practice: Trendelenburg Position

Jamie Kruger

Ferris State University

Abstract

Several research studies were examined from professional journals to determine if placing a patient in the Trendelenburg Position has merit for treatment of patients experiencing hypotension. The decades old intervention has been used in the majority of hospitals and is taught in medical and nursing schools across the United States. The positioning maneuver, after investigating the research, has been found to have to no evidence based practice.

Keywords: Trendelenburg, hypotension, evidence based practice

Evidence Based Practice: Trendelenburg Position

Placing a patient in Trendelenburg position is one of the first interventions that nurses do when their patient experiences hypotension. The positioning maneuver is easy and can be done quickly by simply tilting the patient’s head down and feet up. In fact, most hospital beds are equipped with a “Trendelenburg” button that can be pressed until the desired angle degree is reached. This intervention does not require a physician’s order and is often done before leaving the patient’s side to call the physician with the change in status.

The Trendelenburg position has been around for more than a century, having been discovered by a surgeon, Dr. Friedrich Trendelenburg, in 1890 for ease of shifting abdominal contents out of the way while he performed surgery (Bridges & Jarquin-Valdivia, 2005, p. 364). It was not “until World War I that Walter Cannon, an American physiologist, introduced the position as a treatment of shock. He promoted the technique as a way to increase venous return to the heart, increase cardiac output, and improve blood flow to vital organs” (Johnson & Henderson, 2004, p. 48). The positioning maneuver has been grand fathered in over the years, with no substantial research studies to prove that there are any detrimental effects or that it actually improves outcomes.

My practice area is critical care; I have mostly worked in a four-bed unit where there was no physician readily available. While there are protocols that are followed when a patient experiences hypotension, the first thing that is done is placing the patient in Trendelenburg. The idea is the position is used as a stopgap measure until the physician can be notified. The maneuver, which I learned in nursing school in the late 1990’s, has been an intervention that I never questioned the safety of. Every nurse placed their hypotensive patient in this position, senior nursing staff would growl if it wasn’t done.

I first questioned this intervention when I came across a journal article on the Internet that mentioned that it might not be an appropriate intervention. I brought the article to my peers, thinking that we may need to change our practice. Even though I passed this information around nobody changed their practice, even me. I felt that I was not helping the patient by letting them just lay there. Further research, however, has led me to change my mind.

Research

Research Study Number One

Study one is collected from the Journal of Clinical Anesthesia that was published in 1996. According to Fahy et al (1996), this study was completed to discover if “chest wall mechanics” had any bearing when patients were placed in a Trendelenburg position at 15 degrees when positioned for surgery. The measurements of fifteen participants, who underwent various elective laparoscopic surgeries, were taken immediately after being anesthetized prior to surgery invasively through their endotracheal tubes. The researchers concluded that Trendelenburg positioning “does increase the mechanical impedance of the lungs to inflation, probably due to decreases in lung volume, which may not be important to many patients, it may be of greater concern to those patients that are obese or have chronic lung disease” (Fahy et al. 1996, p. 243).

This study has its limitations. While a variety of patient types were chosen, each patient had its own unique criteria. There were six physical characteristics of these patients, they included gender, age, height, weight, smoking history, and procedure performed. No two patients were alike out of the criteria chosen. The conclusion would have held more weight if the sample of patients was greater and multiple patients shared the exact characteristics.

Whatever the limitations of this study, there is still valuable information that can be used. While patients that are receiving anesthesia to this degree will not be placed in the critical care unit, some will be sedated and receiving mechanical ventilation. This patient population that is also obese or have a chronic lung condition will need to be monitored more closely when placed in Trendelenburg for their hypotension.

Research Study Number Two

Research study number two was published in 1995 and is found in the American Journal of Emergency Medicine (Terai et al. 1994, p 255-258). This study was reprinted from an original research project that was completed in Japan at the National Defense Medical College in Saitama in 1994. This study’s approach was to take measurements non-invasively by using algorithmic formulas with data retrieved by ultrasonic echocardiography. The patients, who were all healthy young men, were placed in Trendelenburg position at a ten degree angle when their measurements were taken at one and ten minute intervals. The researchers concluded that at the one-minute interval the patients did have an increase in cardiac output (and with it increased blood pressures), but at the ten-minute interval all patients had a return to baseline that were reflected in control measurements (Terai et al. 1994, p. 257).

The researchers completing this study were helpful in pointing out the limitations of their study. As most people reading this study would discover, the study is limited by the use of healthy patients. The conclusions are interesting and I think important to know, however, the study would have been more beneficial if the patient population was hypotensive from the start.

The implications of this study are still important, even if the study is limited and the patient population in question is not reflected in the study. This study shows us that even in a completely healthy individual, there are no lasting effects of this positioning maneuver; this is significant, as there has to be a starting point from which further questions can be asked.

Research Study Number Three

Research study number three has the most recent data, as it was published in 2003. This study was completed on twelve mechanically ventilated patients that had known hypovolemia, and thus were experiencing hypotension, immediately post-operatively after leaving the post anesthesia care unit. These patients had all undergone elective coronary artery bypass grafting and were undergoing invasive hemodynamic monitoring. The patients had several invasive measurements taken after being placed in Trendelenburg position at 30 degrees; all measurements were taken at precisely the same time upon entering the intensive care unit. The research team concluded that there were only small increases in cardiac output without improving cardiac performance and after time cardiac output even fell below baseline numbers. (Reuter et al. 2003, p.17-20).

This study appeared to be thorough in determining the effect of Trendelenburg positioning in a specific patient population. The patients in this study were also placed at a greater angle, a more realistic angle that a nurse would place her patient in response to the hypotension. Again, the size of the study is what I feel limits it efficacy.

This study actually shows the harm done by placing hypovolemic patients in Trendelenburg. Personally, this study has limited implications in my personal practice as I do not work with this specific patient population. The evidence presented in this study would cause me to err on the side of caution, however, if any of my patients were to experience hypotenstion.

Nursing Theory

The theory that I feel best fits this clinical practice concern is Symphonological Bioethical Theory developed by Gladys and James Husted. This theory is described as a “practice-based approach to ethical decision making” (Husted & Husted, 2008). The major concern of this theory is that the nurse and the patient share an agreement, one in which the patient relies on the nurse’s judgment and the nurse relies on the patient in which there is an ethical understanding between the two (Husted & Husted, 2008).

With this theory, the nurse has a moral and ethical obligation to provide care that is practice based. Clinical practices that are not evidence based have no research to qualify their safety. If the nurse were to give care without regard to safety, this would violate the nurse-patient relationship. This relationship is a fragile bond with the expectation of the patient being that the nurse “will do unto him as she would have done unto her” (Alligood & Tomey, 2010, p 562).

With this theory in mind I’ve concluded that placing a patient in the Trendelenburg position has no evidence based practice and the maneuver should not be used. There are no research studies available to justify the use of this technique; therefore there is no proof of its safety. Until there are more studies done to examine the effects on all patient populations, this positioning maneuver should not be used in clinical practice.

References

Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work. Maryland

Heights, MO: Mosby.

Bridges, N., & Jarquin-Valdivia, A. A. (2005). Use of the Trendelenburg position as the

Resuscitation position: to T or not to T. American Journal of Critical Care, 14,

364-367.

Fahy, B. G., Barnas, G. M., Nagle, S. E., Flowers, J. L., Njoku, M. J., & Agarwal, M.

(1996). Effects of Trendelenburg and reverse Trendelenburg postures on lung and chest wall mechanics. Journal of Clinical Anesthesia, 8, 236-244.

Husted, J. H., & Husted, G. L. (2008). Ethical decision making in nursing and health

care: The symphonological approach (4th ed.). New York: Springer.

Johnson, S. & Henderson, S. O. (2004). Myth: The Trendelenburg position improves

circulation in cases of shock. Canadian Journal of Emergency Medicine, 6(1),

48-49.

Reuter, D.A., Felbinger, T.W., Schmidt, C., Moerstedt, K., Kilger, E., Lamm, P., &

Goetz, A.E. (2003). Trendelenburg positioning after cardiac surgery: effects of

intrathoracic blood volume index and cardiac performance. European Journal of

Anaesthesiology, 20, 17-20.

Terai, C., Anada, H., Matsushima, S., Shimizu, S., & Okada, Y. (1995). Effects of mild

Trendelenburg on central hemodynamics and internal jugular vein velocity, cross

Sectional area, and flow. American Journal of Emergency Medicine, 13, 255-258.

|DESCRIPTION AND ANALYSIS OF PRACTICE ISSUE |POINTS POSSIBLE |POINTS AWARDED |

|Clear Introductory Description of Practice Concern/Interest: Describes reason for |10 |10 |

|interest or concern and description of issue. | | |

|Practice Environment: |5 |5 |

|Provides clear description of practice area. | | |

|Causal Factors: Personal Perspective and Description/Analysis of Possible Contributing |10 |10 |

|or Causative Factors for the Concern | | |

|Defined Area of Research Search: Narrows down and defines a specific area for research |5 |5 |

|review and provides a clear statement of same. | | |

|RESEARCH REVIEW | | |

|Research Findings: Shares the findings of a minimum of 3 original research studies from | |20 |

|professional journals on the selected topic. Briefly describes the research approaches |20 | |

|and findings of each. | | |

|Critique of the Research: Attempts to point out any research limitations/credibility of |5 |5 |

|the studies. | | |

|Implications For Practice: Identifies potential practice implications of research. This |5 |5 |

|goes beyond implications included in the study itself, to include perceptions of | | |

|implications for personal practice. | | |

|Critical Reflection: Identifies a nursing theory that this practice concern/research |10 |10 |

|findings is an appropriate fit. Includes reflections on the significance/implications of | | |

|integrating research into practice. | | |

|STANDARDS & APA CRITERIA | | |

|APA: Attaches and adheres APA checklist and APA manual guidelines. Length appropriate |15 |14 |

|(5-6 pages of typed content excluding the reference page, abstract, and title page). | | |

|Writing: Development of a clear, logical, well-supported paper. Overall presentation: |15 |15 |

|Grammar, punctuation, clean and legible. | | |

|TOTAL POINTS |100 |99 |

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