Abstract
BackgroundSteep Trendelenburg during surgery has been associated with many position-related injuries. The American Society of Anesthesiology practice advisory recommends documentation, frequent position checks, avoiding shoulder braces, and limiting abduction of upper extremities to avoid brachial plexopathy. We conducted a web-based survey to assess anesthesiologists’ practices, institutional policies, and complications encountered when using steep Trendelenburg.MethodsTwo thousand fifty randomly selected active members of the American Society of Anesthesiology were invited via email to participate in a 9-item web-based survey. Results are reported as absolute numbers and proportions with 95% confidence interval (CI).ResultsSurvey response rate was 290 of 2050 (14.1%). 44.6% (95% CI, 38.9–50.3) of the respondents documented anesthesia start and finish, 73.9% (95% CI, 68.8–79) frequently checked positioning during surgery, 30.8% (95% CI, 25.4–36.2) reported using shoulder braces, 66.9% (95% CI, 61.5–72.3) tucked patients’ arms to the side, 54.0% (95% CI, 48.2–59.8) limited fluid administration, and more than two-thirds did not limit the duration or inclination angle. Notably, 63/290 (21.7%) reported a complication and only 6/289 (2.1%) had an institutional policy. The most common complication was airway and face edema, second was brachial plexus injury, and third was corneal abrasions. Most institutional policies, when present, focused on limiting duration of steep Trendelenburg and communication with surgical team. Only 1/6 policies required avoiding use of shoulder braces.ConclusionBased on survey results, practices related to steep Trendelenburg varied among USA anesthesiologists. Differences included protective measures, documentation, positioning techniques, fluid management, and institutional guidelines. The singular commonality found among all respondents was lack of institutional policies. Survey results highlighted the need for institutional policies and more education.
Highlights
Steep Trendelenburg during surgery has been associated with many position-related injuries
Using SurveyMonkeyR (Portland, OR), we developed a web-based survey following guidelines to survey research in anesthesiology [9]
Anesthesiologist practices When asked about inclination angle during steep Trendelenburg position, 32.8% (95/290) of respondents picked “I do not limit the inclination angle” and 40% (116/290) chose “minimum angle for optimal surgical access”
Summary
Steep Trendelenburg during surgery has been associated with many position-related injuries. First linked by name to the 19th century German surgeon Freidrich Trendelenburg, steep Trendelenburg positioning describes the head-down tilting (25°-45°) of an otherwise supine patient [1, 2]. This mode of positioning provides optimal field exposure for a wide variety of surgeries performed using laparoscopic, robotic, or other techniques [2, 3]. It is associated with physiological changes and complications that span the majority of organ systems [3,4,5]. The American Society of Anesthesiology (ASA) and others have issued recommendations about patient positioning during steep Trendelenburg, Souki et al BMC Anesthesiology (2018) 18:117 there is limited published information as to what constitutes routine practice [6,7,8]
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