title: Haemostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt.
abstract: BACKGROUND
  The aim of the study was to identify whether Trendelenburg position helps detect any further bleeding points following Valsalva manoeuvre in order to achieve adequate haemostasis in head and neck surgery.
  
  
  METHODS
  Fifty consecutive patients undergoing major head and neck surgical procedures were included. The protocol consisted in performing Valsalva manoeuvre to check haemostasis and treated any bleeding points identified. The operating table was tilted 30 degrees and haemostasis was checked again and treated accordingly. The number of vessels identified and the treatment was recorded.
  
  
  RESULTS
  Twelve male and 38 female patients were included. The median age was 53 years and 74% had an ASA of 1. Twelve patients had complicating features such as retrosternal extensions or raised T4 levels pre-operatively. Thyroid resections were the most common operations performed. The total number of bleeding vessels identified in Trendelenburg tilt was significantly greater than when using Valsalva manoeuvre (P < 0.0001). All bleeding points found on Valsalva manoeuvre were minor (< 2 mm) and dealt with using diathermy. In Trendelenburg position, 11% of bleeding vessels required ties or stitching. The time taken during Valsalva manoeuvre was 60 s on average and 360 s in Trendelenburg position.
  
  
  CONCLUSIONS
  The results show that the Trendelenburg position is vastly superior to the Valsalva manoeuvre in identifying bleeding vessels at haemostasis. It has become our practice to put patients in Trendelenburg tilt routinely (we have discontinued the Valsalva manoeuvre), to check its adequacy before closing the wound. We have not noticed any intracranial complications using a tilt angle of 30 degrees .
authors.affiliation: Department of Otolaryngology, Cambridge Teaching Hospitals, Addenbrooke's Hospital, Hills Road, Cambridge, UK.
authors.forename: I
authors.initials: I
authors.lastname: Moumoulidis
authors.forename: M
authors.initials: M
authors.lastname: Martinez Del Pero
authors.forename: L
authors.initials: L
authors.lastname: Brennan
authors.forename: P
authors.initials: P
authors.lastname: Jani
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control; D005260:Female; D006258:Head and Neck Neoplasms / Q000601:surgery*; D018475:Head-Down Tilt; D006488:Hemostasis, Surgical / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning / Q000379:methods; D013965:Thyroidectomy; D014636:Valsalva Maneuver; D055815:Young Adult