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Steep Trendelenburg: Risks

Trendelenburg positioning is often used during abdominal and pelvic operations in order to optimize exposure, as well as during central line placement in order to facilitate cannulation while avoiding air embolism, and during episodes of hypotension in order to increase venous return. The following physiologic consequences and risks have been associated with Trendelenburg positioning:

1. Increased risk of postoperative airway obstruction due to upper airway edema.

2. Increased central venous pressure, intracranial pressure, and intraocular pressure.

3. Decreased FRC and pulmonary compliance due to compression from the abdominal viscera. Increased airway pressures in mechanically ventilated patients, increased work of breathing in spontaneously breathing patients.

4. Increased pulmonary edema and atelectasis, leading to V/Q mismatch and increased A-a gradient.

5. Increased risk of nerve damage due to stretching or compression as the torso shifts during inclination and new pressure points are created.

6. Increased risk of mainstem intubation due to cephalad displacement of the trachea.

7. Increased risk of aspiration if airway is not secured.