Hostname: page-component-7c8c6479df-27gpq Total loading time: 0 Render date: 2024-03-28T08:11:29.841Z Has data issue: false hasContentIssue false

Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance

Published online by Cambridge University Press:  02 June 2005

D. A. Reuter
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
T. W. Felbinger
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
C. Schmidt
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
K. Moerstedt
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
E. Kilger
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
P. Lamm
Affiliation:
Ludwig-Maximilians-University, Department of Cardiac Surgery, Munich, Germany
A. E. Goetz
Affiliation:
Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
Get access

Extract

Summary

Background and objective: The efficacy of the Trendelenburg position, a common first step to treat suspected hypovolaemia, remains controversial. We evaluated its haemodynamic effects on cardiac preload and performance in patients after cardiac surgery.

Methods: Twelve patients undergoing mechanical ventilation of the lungs who demonstrated left ventricular ‘kissing papillary muscles’ by transoesophageal echocardiography, thus suggesting hypovolaemia, were positioned 30° head down for 15 min immediately after cardiac surgery. Cardiac output by thermodilution, central venous pressure, pulmonary artery occlusion pressure, left ventricular end-diastolic area by transoesophageal echocardiography and intrathoracic blood volume by thermo- and dye dilution were determined before, during and after this Trendelenburg manoeuvre.

Results: Trendelenburg's manoeuvre was associated with increases in central venous pressure (9 ± 2 to 12 ± 3 mmHg) and pulmonary artery occlusion pressure (8 ± 2 to 11 ± 3 mmHg). The intrathoracic blood volume index increased slightly (dye dilution from 836 ± 129 to 872 ± 112 mL m−2; thermodilution from 823 ± 129 to 850 ± 131 mL m−2) as did the left ventricular end-diastolic area index (7.5 ± 2.1 to 8.1 ± 1.7 cm2 m−2), whereas mean arterial pressure and the cardiac index did not change significantly. After supine repositioning, the cardiac index decreased significantly below baseline (3.0 ± 0.6 versus 3.5 ± 0.8 L min−1 m−2) as did mean arterial pressure (76 ± 12 versus 85 ± 11 mmHg), central venous pressure (8 ± 2 mmHg) and pulmonary artery occlusion pressure (6 ± 4 mmHg). The intrathoracic blood volume index and left ventricular end-diastolic area index did not differ significantly from baseline.

Conclusions: Trendelenburg's manoeuvre caused only a slight increase of preload volume, despite marked increases in cardiac-filling pressures, without significantly improving cardiac performance.

Type
Original Article
Copyright
© 2003 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Stedman's Medical Dictionary, 24th edn. Baltimore, USA: Williams & Wilkins 1982: 1125.
Reich DL, Konstadt SN, Raissi S, Hubbard M, Thys DM. Trendelenburg position and passive leg raising do not significantly improve cardiopulmonary performance in the anesthetized patient with coronary artery disease. Crit Care Med 1989; 17: 313317.Google Scholar
Kyriakides ZS, Koukoulas A, Paraskevaidis IA, et al. Does passive leg raising increase cardiac performance? A study using Doppler echocardiography. Int J Cardiol 1994; 44: 288293.Google Scholar
Wilcox S, Vandam LD. Alas, poor Trendelenburg and his position! A critique of its uses and effectiveness. Anesth Analg 1988; 67: 574578.Google Scholar
Pricolo VE, Burchard KW, Singh AK, Moran JM, Gann DS. Trendelenburg versus PASG application – hemodynamic response in man. J Trauma 1986; 26: 718726.Google Scholar
Mangano DT. Biventricular function after myocardial revascularization in humans: deterioration and recovery patterns during the first 24 hours. Anesthesiology 1985; 62: 571577.Google Scholar
Hoeft A, Schorn B, Weyland A, et al. Bedside assessment of intravascular volume status in patients undergoing coronary bypass surgery. Anesthesiology 1994; 81: 7686.Google Scholar
Goedje O, Peyerl M, Seebauer T, et al. Central venous pressure, pulmonary capillary wedge pressure and intrathoracic blood volumes as preload indicators in cardiac surgery patients. Eur J Cardiothorac Surg 1998; 13: 533539.Google Scholar
Buhre W, Weyland A, Schorn B, et al. Changes in central venous pressure and pulmonary capillary wedge pressure do not indicate changes in right and left heart volume in patients undergoing coronary artery bypass surgery. Eur J Anaesthesiol 1999; 16: 1117.Google Scholar
Reuter DA, Felbinger TW, Schmidt C, et al. Intrathoracic blood volume index measured by thermodilution for preload monitoring after cardiac surgery. J Cardiothorac Vasc Anesth 2002; 16: 191195.Google Scholar
Sakka SG, Rühl CC, Pfeiffer UJ, et al. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 2000; 26: 180187.Google Scholar
Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979; 7: 218224.Google Scholar
Jennings T, Seaworth J, Howell L, Tripp L, Goodyear C. Effect of body inversion on hemodynamics determined by two-dimensional echocardiography. Crit Care Med 1985; 13: 760762.Google Scholar
McHugh GJ, Robinson BJ, Galletly DC. Leg elevation compared with Trendelenburg position: effects on autonomic cardiac control. Br J Anaesth 1994; 73: 836837.Google Scholar
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: 255258.Google Scholar
Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med 1985; 14: 641643.Google Scholar
Lichtwarck-Aschoff M, Zeravik J, Pfeiffer UJ. Intrathoracic blood volume accurately reflects circulatory volume status in critically ill patients with mechanical ventilation. Intensive Care Med 1992; 18: 142147.Google Scholar
Sakka SG, Bredle DL, Reinhart K, Meier-Hellmann A. Comparison between intrathoracic blood volume and cardiac filling pressures in the early phase of hemodynamic instability of patients with sepsis or septic shock. J Crit Care 1999; 14: 7883.Google Scholar
De Hert SG, Gillebert TC, Ten Broecke PW, et al. Contraction–relaxation coupling and impaired left ventricular performance in coronary surgery patients. Anesthesiology 1999; 90: 748757.Google Scholar
Johnson MR. Low systemic vascular resistance after cardiopulmonary bypass: are we any closer to understanding the enigma? Crit Care Med 1999; 27: 10481050.Google Scholar