The Reverse Trendelenburg position is a specialized patient positioning technique where the entire body, while supine (lying on the back), is placed on an incline. This inclination raises the head above the level of the feet, utilizing gravity to achieve specific therapeutic or procedural goals. This position is employed across operating rooms, intensive care units, and general patient care to optimize patient physiology and facilitate various medical procedures.
Visualizing the Position
The head of the bed or operating table is elevated, while the foot of the surface is lowered. This creates an angle where the head is positioned higher than the lower limbs.
The degree of tilt typically ranges from 15 to 30 degrees, although a 10-degree incline is common for certain applications. This positioning contrasts directly with the standard Trendelenburg position, where the head is lowered below the feet, reversing the effects of gravity on the patient’s body systems.
Because the entire body is tilted, the patient’s torso is not bent at the hips, distinguishing this from a semi-seated position like the Fowler’s position. Patients require secure placement with straps or footrests to prevent them from sliding downward on the tilted surface, especially during prolonged surgical procedures.
How Gravity Affects the Body in This Position
The intentional use of gravity in the Reverse Trendelenburg position has several direct effects on the patient’s internal physiology. By elevating the head, the position promotes venous drainage from the brain and upper body, helping to lower intracranial pressure (ICP). This process can begin within one minute of positioning.
A decrease in venous pressure within the jugular veins is an immediate consequence, which directly contributes to the reduction in ICP. Studies show that an incline of approximately 10 degrees can significantly reduce subdural pressure and dural tension without negatively affecting cerebral perfusion pressure (CPP).
The position also influences the cardiovascular system by reducing the venous return of blood to the heart from the lower body. This reduction in preload can lead to a slightly lower mean arterial blood pressure (MABP). However, this effect is often managed and remains therapeutically useful in certain procedures to decrease bleeding in the head and neck regions.
Furthermore, the downward pull on the abdominal organs shifts them away from the diaphragm, the main muscle of breathing. This physical shift allows for improved diaphragmatic movement and lung expansion, which is particularly beneficial for patients with obesity or those undergoing general anesthesia. Enhanced respiratory function and oxygen exchange facilitate unobstructed breathing.
Key Clinical Applications
In the management of gastroesophageal reflux disease (GERD), the position uses gravity to reduce the backflow of stomach contents into the esophagus. This application is often recommended for patients experiencing chronic acid reflux, especially at night, as it reduces the risk of aspiration.
The position is routinely employed in various types of surgery, particularly laparoscopic procedures involving the upper abdomen, such as gallbladder removal. Tilting the patient allows the abdominal organs to naturally fall inferiorly, which provides the surgeon with a clearer field of view and better access to the surgical site. This gravitational retraction is safer and less invasive than using mechanical retractors.
In neurocritical care and neurosurgery, the position is a standard protocol for managing elevated ICP. The promotion of cerebral venous drainage is a direct therapeutic action that helps to relieve pressure on the brain. This is especially useful during craniotomies, where a slight incline can improve operating conditions by relaxing the brain tissue.
Finally, the position is intentionally used in head and neck procedures to minimize bleeding at the surgical site. By reducing the hydrostatic pressure in the veins of the head, the position decreases blood pooling, leading to less blood loss during surgery.