title: Role of the reverse-Trendelenberg patient position in maintaining low-CVP anaesthesia during liver resections.
abstract: OBJECTIVE
  The Trendelenberg position is recommended during liver resection, to decrease the risk of venous air embolism. However, this position raises the central venous pressure and may increase blood loss. We propose that the reverse-Trendelenberg position can be safely and effectively used to maintain a low central venous pressure during liver surgery.
  
  
  METHODS
  Fifty consecutive patients underwent elective liver resection at a single centre during a 17-month period. Patients were positioned with a head-up tilt during division of the liver parenchyma.
  
  
  RESULTS
  Patients had a mean central venous pressure of 9.2 mmHg when supine, despite fluid restriction. The central venous pressure fell consistently and rapidly when they were tilted head-up, to a mean of 1.7 mmHg. The resections were completed with a median operative blood loss of 600 mL. No patient developed a clinically apparent venous air embolism. Postoperative renal dysfunction that could be attributed to low central venous pressure anaesthesia occurred in only one case.
  
  
  CONCLUSIONS
  The reverse-Trendelenberg position effectively lowers the CVP during liver surgery. It is easy to monitor, titrate and reverse, and avoids the need for complex pharmacological interventions. We recommend this position to liver surgeons and anaesthetists who have found it difficult to maintain a low CVP with the supine or Trendelenberg positions.
authors.affiliation: Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK.
authors.forename: Zahir F
authors.initials: ZF
authors.lastname: Soonawalla
authors.forename: Charalabos
authors.initials: C
authors.lastname: Stratopoulos
authors.forename: Mark
authors.initials: M
authors.lastname: Stoneham
authors.forename: Douglas
authors.initials: D
authors.lastname: Wilkinson
authors.forename: B Julian
authors.initials: BJ
authors.lastname: Britton
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Friend
mesh_terms: D000768:Anesthesia, General; D001650:Bile Duct Neoplasms / Q000601:surgery; D001653:Bile Ducts, Intrahepatic; D006528:Carcinoma, Hepatocellular / Q000601:surgery; D002496:Central Venous Pressure / Q000502:physiology*; D018281:Cholangiocarcinoma / Q000601:surgery; D015179:Colorectal Neoplasms / Q000601:surgery; D004618:Embolism, Air / Q000503:physiopathology / Q000517:prevention & control; D005260:Female; D005440:Fluid Therapy; D018475:Head-Down Tilt / Q000502:physiology*; D006470:Hemorrhage / Q000503:physiopathology / Q000517:prevention & control; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D007431:Intraoperative Complications / Q000503:physiopathology / Q000517:prevention & control; D008113:Liver Neoplasms / Q000556:secondary* / Q000601:surgery*; D008297:Male