The Trendelenburg position: a review of current slants about head down tilt

The steep head down tilt surgical posture, popularized in the 1870s by Trendelenburg as a means of improving access to pelvic pathology and espoused by the American physiologist, Walter Cannon, during World War I as a resuscitative position with which to treat shock, has a history of widespread, ritualistic acceptance. An awake patient placed in steep head down tilt usually objects to the posture after only a short time. Now recognized as potentially harmful in the presence of cardiac, pulmonary, ocular, and central nervous system pathology and essentially useless for vascular resuscitation, steep tilt should be limited to selected circumstances in which alternatives are unacceptable. Shallow head down tilt, a more recent variety, also offers serious questions about its surgical usefulness as well as its applicability for patients with diseased hearts, lungs, and heads. As an aid to resuscitative procedures, the contoured supine position offers assets that merit serious consideration. Means of restraining a tilted patient on an operating table include wristlets, shoulder braces, and bent knees with ankle restraints. Considerations that aid in the selection of head down tilt are presented, as is a plea for the abandonment of the Trendelenburg eponym and a suggestion for future investigation.