Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients

Abstract

BackgroundIn 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates.MethodsConsecutive ASA I–IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients.ResultsCombining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; p = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; p < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; p = 0.0004; 2.3 days; p < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; p < 0.0001; 2.2 days; p < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; p = 0.0849; 2.7 days; p < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; p = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; p = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; p = 0.0246).ConclusionsThese findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes.Trial registrationClinicalTrials.gov, NCT02984657

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

“…However, authors of recently conducted studies have suggested that a head and trunk inclined (semi-Fowler) position may improve FPS through enhanced preoxygenation (denitrogenation) via increased functional residual capacity (FRC) and improved laryngeal view, and reduce the risk of clinically significant aspiration of passively regurgitated gastric contents. Seventeen studies were included that addressed this question (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23).…”

“…Evidence from a cadaveric study (13), simulation trials (14,15), and surgical patients in the OR (16)(17)(18)(19)(20)(21)(22)(23) suggest that the semi-Fowler position is beneficial for improving several intubation-related outcomes, including laryngoscopic view (16)(17)(18)(19)(20), time-to-intubation (14,15), intubation success (20), and time-to-oxygen desaturation (defined as 92% and 95%, respectively, in these studies) (21,22). In addition, studies in noncritically ill patients showed a benefit with the semi-Fowler position in patients at risk for experiencing difficult intubation (20), including those with morbid obesity (17,18,22), and patients at increased risk for aspiration (23). However, none of these studies specifically examined the semi-Fowler position in critically ill patients with these conditions.…”

Patient positioning and its impact on perioperative outcomes in children: A narrative review

“…During the pre, intra and postoperative periods patients are managed in various body positions including supine, lateral, prone, lithotomy, head up or head down (Trendelenburg), and they may require specific procedures, such as pneumoperitoneum, to facilitate surgery. These positions and procedures exert physiological effects on various organ systems 5–8 . When positioning cannot be modified (i.e., when it is a requirement for the surgery itself), an understanding of the effects of positioning allows appropriate action, to mitigate against adverse physiological effects.…”

“…While there is a body of evidence describing the effects of positioning and specific perioperative outcomes in adults 5,6,10 this evidence appears to be more limited in the pediatric population. Observational studies in adults have demonstrated various alterations to perioperative positioning that correlate with the incidence of postoperative hypoxemia, aspiration, and hospital length of stay 5,6 . Additionally, positioning is known to impact airway management in adult patients, for example, head‐elevated positioning can prolong safe apnea time 11 and improve glottic views and intubation times 10 .…”

“…While there is a body of evidence describing the effects of positioning and specific perioperative outcomes in adults 5,6,10 this evidence appears to be more limited in the pediatric population. Observational studies in adults have demonstrated various alterations to perioperative positioning that correlate with the incidence of postoperative hypoxemia, aspiration, and hospital length of stay 5,6 .…”