elevate feet or tilting the entire body with hypotensive pt

[paris]

In report recently we where discussing a patient with an acute hypotensive episode: the practice here is apparently to tilt the foot end of the bed so that the entire body is tilted with head down.

Managers says that we should elevate feet rather than tilt the entire body.


What are your views on this?

[Varied A]

Perhaps the managers' risk assessment concluded that only the feet should be raised because of the risk of the patient sliding head-first off the bed if the whole body is tilted too far?

[Bex x]

If legs raised, all blood would go to internal organs (as body flat.) If whole body tilted, all blood would go to head. It's a guess, but...

[andy2]

This is something that constantly annoys me - the only time that elevating the legs or placing the patient head down for hypotension is indicated is following vaso-vagal syncope where there is a loss of arteriolar and venous tone leading to lower limb blood pooling.

For any other cause of hypotension it is both illogical and dangerous to place patients head down/elevate the legs. First the illogicality - the venous system is high capacitance system and if the patient is hypovolaemic the veins will be maximally vasoconstricted then all non-essential blood will be shunted to the core organs without the need to elevate the legs/tip patient head down.
The dangers are several - firstly the increased intra-thoracic pressure caused by upward shift of the abdominal organs makes breathing harder. Similarly the diaphragm is unable to function as effectively so further worsening the breathing problems, thirdly it increases cerebral venous presure so can increase intra-cranial pressure. So an unecessary and dangerous procedure which is performed for ritualistic reasons - please stop using this totally outdated "treatment" for hypotension.

Head down positions should only be used for
1) vasovagal syncope (and even then lying flat is probably as effective)
2) for a vomiting patient who cannot be turned on their side
3) insertion of central venous lines.

[pilly84]

Wow! That's a really comprehensive post. Thank you andy2

[Spencer Wells]

And for the record it's called the Trendellenburg position.

[andy2]

for those who want evidence
(from Canadian journal of emergency medicine)
Prospective studies

In a 1967 prospective study, Taylor and Weil tested the effectiveness of the Trendelenburg position in 6 hypotensive patients in clinical shock and 5 normotensive controls.3 In 9 of the 11 of patients, Trendelenburg positioning was ineffective, causing reductions in systolic, diastolic and mean arterial pressures. These authors noted that, in the head-down position, the viscera weigh down the diaphragm and compromise lung volumes. They also suggested that patients were at higher risk of cerebral edema, retinal detachment and brachial nerve paralysis.3

In 1994, Sing and colleagues4 assessed the impact of the Trendelenburg position on oxygen transport in 8 hypovolemic postoperative patients and found that it was associated with higher mean arterial blood pressure but not with improved cardiac output. Therefore, despite increases in blood pressure and left ventricle filling, there do not appear to be changes in tissue oxygenation during body tilting.4,5

In 1985, Bivins and coworkers6 studied the effect of the Trendelenburg position on blood distribution, finding that only 1.8% (99% confidence interval, -1.3% to 4.7%) of the total blood volume was displaced centrally when normovolemic patients were placed in the head-down position. They concluded that the autotransfusion effect produced by Trendelenburg positioning was small and unlikely to have an important clinical effect.6

Sibbald and cohorts investigated the effect of the Trendelenburg position on systemic and pulmonary hemodynamics in 76 critically ill patients (61 normotensive and 15 hypotensive) with acute cardiac illness or sepsis.7 In the normotensive group there was no change in pre-load or mean arterial pressure, but cardiac output increased slightly. In hypotensive patients there was no increase in preload or mean arterial pressure, but cardiac output decreased, suggesting that Trendelenburg positioning may be detrimental. These authors, like others, concluded that there were no demonstrable beneficial hemodynamic effects in hypotensive patients.1,3,7



1. Martin JT. The Trendelenburg position: a review of current slants about head down tilt. AANA J 1995;63:29-36.
2. Ostrow CL. Use of the Trendelenburg position by critical care nurses: Trendelenburg survey. Am J Crit Care 1997;6:172-6.
3. Taylor J, Weil MH. Failure of the Trendelenburg position to improve circulation during clinical shock. Surg Gynecol Obstet 1967;124:1005-10.
4. Sing RF, O'Hara D, Sawyer MA, Marino PL. Trendelenburg position and oxygen transport in hypovolemic adults. Ann Emerg Med 1994;23:564-7.
5. Terai C, Anada H, Matsushima S, Shimizu S, Okada Y. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. Am J Emerg Med 1995;13:255-8.
6. Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med 1985;14:641-3.
7. Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979;7:218-24.