Clinical trial NCT02984657: Reverse Trendelenburg Positioning and Its Effect on Outcomes: a Retrospective Study of Consecutive Patients
Official title: Evaluation of Operating Room Reverse Trendelenburg Positioning and Its Effect on Postoperative Hypoxemia, Aspiration, and Length of Stay: a Retrospective Study of Consecutive Patients
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Aspiration, Respiratory
Hypoxia
Perioperative Period
Supine Position
Keywords: Hypoxemia
Reverse Trendelenburg
Lead sponsor: Mercy Health Ohio
Sponsor class: OTHER
Collaborators: name: St. Elizabeth Youngstown Hospital
First posted: 2016-12-07
Enrollment: 1500
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: RETROSPECTIVE
Sampling method: PROBABILITY_SAMPLE
Study population: Surgical patients from an urban hospital

Brief summary: The purpose of this study is to investigate whether intraoperative reverse Trendelenburg positioning decreases postoperative hypoxemia and perioperative pulmonary aspiration rates.

Detailed description: Intraoperative pulmonary aspiration can cause death and lead to morbidity. In addition, reliable estimates of aspiration rates are uncertain. In part, this ambiguity relates to the lack of prospective data. Relevant studies are retrospective chart reviews or results from voluntary reporting databases. Furthermore, aspiration diagnosis can be imprecise. The finding is certain when there is aspiration of bile or particulate matter from the tracheobronchial tree or there is endoscopic visualization. However, the diagnosis is presumptive when there is intraoperative or postoperative development of a new chest x-ray infiltrate and attendant tachypnea, hypoxia, wheezing, or changes in ventilator airway pressures.

Most patients undergoing general endotracheal anesthesia are in the supine or horizontal position. However, evidence from the literature demonstrates that the supine position in mechanically ventilated patients is a risk for aspiration and ventilator associated pneumonia (VAP). During intensive care unit (ICU) mechanical ventilation, the Institute for Healthcare Improvement recommends elevating the head of the bed to prevent pulmonary aspiration and VAP. Other investigations have shown a profound relationship between horizontal positioning and intra-operative aspiration. There is substantial operating room, ICU, and animal investigative evidence that aspiration occurs despite the presence of a cuffed endotracheal tube. Likewise, previous work by this group showed a 30% perioperative hypoxemia rate, which was significantly associated with horizontal positioning. The post-operative length of hospital stay was 2 days longer with hypoxemia, compared to no hypoxemia (p \<0.0001) and this represented a total of 300 additional days for the 2 months of the study.

The purpose of this retrospective study is to repeat the investigation after adopting a recent policy change of 10-degree Reverse Trendelenburg position as the routine for surgical patients, unless deemed inappropriate by either the anesthesiology or operating room nursing staff.

Eligibility criteria: Inclusion Criteria:

* Patients undergoing endotracheal intubation and general anesthesia
* Age ≥18 years
* Glasgow Coma Scale score ≥13 (prior to tracheal intubation)
* American Society of Anesthesiologists classification I-IV
* Pre-operative pulmonary stability

Exclusion Criteria:

* Tracheal intubation prior to emergency department arrival
* Cardiac and thoracic surgical patients

Primary outcomes:
measure: Postoperative hypoxemia
timeFrame: 48 hours postoperatively
Secondary outcomes:
measure: Perioperative pulmonary aspiration
timeFrame: 48 hours postoperatively
Other outcomes:
Locations:
city: Youngstown
country: United States
facility: St. Elizabeth Youngstown Hospital
state: Ohio
Study officials:
affiliation: St. Elizabeth Youngstown Hospital
name: C. Michael Dunham, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Dunham CM, Hileman BM, Hutchinson AE, Chance EA, Huang GS. Perioperative hypoxemia is common with horizontal positioning during general anesthesia and is associated with major adverse outcomes: a retrospective study of consecutive patients. BMC Anesthesiol. 2014 Jun 9;14:43. doi: 10.1186/1471-2253-14-43. eCollection 2014.
citation: Cotton BR, Smith G. The lower oesophageal sphincter and anaesthesia. Br J Anaesth. 1984 Jan;56(1):37-46. doi: 10.1093/bja/56.1.37. No abstract available.
citation: Tiret L, Desmonts JM, Hatton F, Vourc'h G. Complications associated with anaesthesia--a prospective survey in France. Can Anaesth Soc J. 1986 May;33(3 Pt 1):336-44. doi: 10.1007/BF03010747.
citation: Kozlow JH, Berenholtz SM, Garrett E, Dorman T, Pronovost PJ. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000. Crit Care Med. 2003 Jul;31(7):1930-7. doi: 10.1097/01.CCM.0000069738.73602.5F.
citation: Kluger MT, Short TG. Aspiration during anaesthesia: a review of 133 cases from the Australian Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia. 1999 Jan;54(1):19-26. doi: 10.1046/j.1365-2044.1999.00642.x.
citation: Ewig S, Torres A. Prevention and management of ventilator-associated pneumonia. Curr Opin Crit Care. 2002 Feb;8(1):58-69. doi: 10.1097/00075198-200202000-00010.
citation: Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, Lomena F, Rodriguez-Roisin R. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992 Apr 1;116(7):540-3. doi: 10.7326/0003-4819-116-7-540.
citation: Reali-Forster C, Kolobow T, Giacomini M, Hayashi T, Horiba K, Ferrans VJ. New ultrathin-walled endotracheal tube with a novel laryngeal seal design. Long-term evaluation in sheep. Anesthesiology. 1996 Jan;84(1):162-72; discussion 27A. doi: 10.1097/00000542-199601000-00019.
citation: Petring OU, Adelhoj B, Jensen BN, Pedersen NO, Lomholt N. Prevention of silent aspiration due to leaks around cuffs of endotracheal tubes. Anesth Analg. 1986 Jul;65(7):777-80.
citation: Seegobin RD, van Hasselt GL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J. 1986 May;33(3 Pt 1):273-9. doi: 10.1007/BF03010737.
citation: Smith G, Ng A. Gastric reflux and pulmonary aspiration in anaesthesia. Minerva Anestesiol. 2003 May;69(5):402-6.
citation: Ferrer R, Artigas A. Clinical review: non-antibiotic strategies for preventing ventilator-associated pneumonia. Crit Care. 2002 Feb;6(1):45-51. doi: 10.1186/cc1452. Epub 2001 Jan 11.
citation: Keenan SP, Heyland DK, Jacka MJ, Cook D, Dodek P. Ventilator-associated pneumonia. Prevention, diagnosis, and therapy. Crit Care Clin. 2002 Jan;18(1):107-25. doi: 10.1016/s0749-0704(03)00068-x.
citation: Koeman M, van der Ven AJ, Ramsay G, Hoepelman IM, Bonten MJ. Ventilator-associated pneumonia: recent issues on pathogenesis, prevention and diagnosis. J Hosp Infect. 2001 Nov;49(3):155-62. doi: 10.1053/jhin.2001.1073. No abstract available.
citation: Fernandez-Crehuet R, Diaz-Molina C, de Irala J, Martinez-Concha D, Salcedo-Leal I, Masa-Calles J. Nosocomial infection in an intensive-care unit: identification of risk factors. Infect Control Hosp Epidemiol. 1997 Dec;18(12):825-30.
citation: Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999 Nov 27;354(9193):1851-8. doi: 10.1016/S0140-6736(98)12251-1.
citation: Kollef MH. Ventilator-associated pneumonia. A multivariate analysis. JAMA. 1993 Oct 27;270(16):1965-70.
citation: Institute for Healthcare Improvement: Prevent ventilator-associated pneumonia. Institute for Healthcare Improvement. 2012. http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx; Accessed 9 Dec 2013.
citation: Blitt CD, Gutman HL, Cohen DD, Weisman H, Dillon JB. "Silent" regurgitation and aspiration during general anesthesia. Anesth Analg. 1970 Sep-Oct;49(5):707-13. No abstract available.
citation: McEwen DR. Intraoperative positioning of surgical patients. AORN J. 1996 Jun;63(6):1059-63, 1066-79; quiz 1080-6. doi: 10.1016/s0001-2092(06)63293-6.
citation: Adedeji R, Oragui E, Khan W, Maruthainar N. The importance of correct patient positioning in theatres and implications of mal-positioning. J Perioper Pract. 2010 Apr;20(4):143-7. doi: 10.1177/175045891002000403.
citation: Smith KA. Positioning principles. An anatomical review. AORN J. 1990 Dec;52(6):1196-202, 1204, 1206-8. doi: 10.1016/s0001-2092(07)69197-2. No abstract available.
citation: Mulier JP, Dillemans B, Van Cauwenberge S. Impact of the patient's body position on the intraabdominal workspace during laparoscopic surgery. Surg Endosc. 2010 Jun;24(6):1398-402. doi: 10.1007/s00464-009-0785-8. Epub 2010 Jan 7.
citation: Abdulla S. Pulmonary aspiration in perioperative medicine. Acta Anaesthesiol Belg. 2013;64(1):1-13.
citation: Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth. 1999 Sep;83(3):453-60. doi: 10.1093/bja/83.3.453. No abstract available.
citation: Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg. 2001 Aug;93(2):494-513. doi: 10.1097/00000539-200108000-00050.
citation: Kalinowski CP, Kirsch JR. Strategies for prophylaxis and treatment for aspiration. Best Pract Res Clin Anaesthesiol. 2004 Dec;18(4):719-37. doi: 10.1016/j.bpa.2004.05.008.
citation: Michael Dunham C, Hileman BM, Hutchinson AE, Antonaccio T, Chance EA, Huang GS, Szmaj G, Calabro K, Bishop C, Schrickel TT. Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients. Perioper Med (Lond). 2017 Aug 22;6:10. doi: 10.1186/s13741-017-0067-2. eCollection 2017.