Trendelenburg position in the ED: many critically ill patients in the emergency department do not tolerate the Trendelenburg position.

OBJECTIVES: Critically ill patients in emergency departments (ED) frequently require catheterization of the internal jugular vein. For jugular insertion, the Trendelenburg position (TP) is recommended. However, many patients in the ED do not tolerate lying in the supine or even the head-down position, or TP is contraindicated for other reasons. The aim of our trial was to investigate to which extent TP is either not tolerated or contraindicated in the target population of patients admitted to the ED.

PATIENTS AND METHODS: This was a clinical observational trial, carried out in an ED of a Tertiary Healthcare Hospital, including critically ill patients. From October 2015 to January 2016, we enrolled 117 nonintubated patients over 18 years admitted to the ED of Jena University Hospital, a Tertiary Healthcare Facility. Patients were positioned in TP (15° head-down) for a maximum of 10 min. If the position had to be abandoned for any reason, time to abandonment and reason for ending the position were recorded. 38.5% of all enrolled patients could not be positioned in TP because of contraindications (17.9%) or intolerance of the positioning (20.5%).

RESULTS AND CONCLUSION: For central venous catheterization, TP remains the gold standard. Our trial shows the limitations of this positioning for critically ill patients. Almost 40% of the patients could not be tilted 15° head-down. Therefore, guideline recommendations should be reconsidered and alternatives should be sought.