A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and fetal compromise.

BACKGROUND: Studies in healthy patients undergoing elective caesarean delivery show that, compared with phenylephrine, ephedrine used to treat spinal hypotension is associated with increased fetal acidosis. This has not been investigated prospectively in women with severe preeclampsia. METHODS: Patients with preeclampsia requiring caesarean delivery for a non-reassuring fetal heart tracing were randomised to receive either bolus ephedrine (7.5-15mg) or phenylephrine (50-100µg), to treat spinal hypotension. The primary outcome was umbilical arterial base excess. Secondary outcomes were umbilical arterial and venous pH and lactate concentration, venous base excess, and Apgar scores. RESULTS: Among 133 women, 64 who required vasopressor treatment were randomised into groups of 32 with similar patient characteristics. Pre-delivery blood pressure changes were similar. There was no difference in mean [standard deviation] umbilical artery base excess (-4.9 [3.7] vs -6.0 [4.6] mmol/L for ephedrine and phenylephrine respectively; P=0.29). Mean umbilical arterial and venous pH and lactate concentrations did not significantly differ between groups (7.25 [0.08] vs 7.22 [0.10], 7.28 [0.07] vs 7.27 [0.10], and 3.41 [2.18] vs 3.28 [2.44] mmol/L respectively). Umbilical venous oxygen tension was higher in the ephedrine group (2.8 [0.7] vs 2.4 [0.62]) kPa, P=0.02). There was no difference in 1- or 5-min Apgar scores, numbers of neonates with 1-min Apgar scores <7 or with a pH <7.2. CONCLUSIONS: In patients with severe preeclampsia and fetal compromise, fetal acid-base status is independent of the use of bolus ephedrine versus phenylephrine to treat spinal hypotension.

Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe pre-eclampsia: a randomised, controlled trial.

We examined the haemodynamic effects of colloid preload, and phenylephrine and ephedrine administered for spinal hypotension, during caesarean section in 42 women with severe early onset pre-eclampsia. Twenty patients with pre-delivery spinal hypotension were randomly allocated to receive an initial dose of either 50 µg phenylephrine or 7.5 mg ephedrine; the primary outcome was percentage change in cardiac index. After a 300-ml colloid preload, mean (SD) cardiac index increased from 4.9 (1.1) to 5.6 (1.2) l.min-1 .m-2 (p < 0.01), resulting from an increase in both heart rate, from 81.3 (17.2) to 86.3 (16.5) beats.min-1 (p = 0.2), and stroke volume, from 111.8 (19.0) to 119.8 (17.9) ml (p = 0.049). Fourteen (33%) and 23 (54.8%) patients exhibited a stroke volume response > 10% and > 5%, respectively; a significant negative correlation was found between heart rate and stroke volume changes. Spinal hypotension in 20 patients was associated with an increase from baseline in cardiac index of 0.6 l.min-1 .m-2 (mean difference 11.5%; p < 0.0001). After a median [range] dose of 50 [50-150] µg phenylephrine or 15 [7.5-37.5] mg ephedrine, the percentage change in cardiac index during the measurement period of 150 s was greater, and negative, in patients receiving phenylephrine vs. ephedrine, at -12.0 (7.3)% vs. 2.6 (6.0)%, respectively (p = 0.0001). The percentage change in heart rate after vasopressor was higher in patients receiving phenylephrine, at -9.1 (3.4)% vs. 5.3 (12.6)% (p = 0.0027), as was the change in systemic vascular resistance, at 22.3 (7.5) vs. -1.9 (10.5)% (p < 0.0001). Phenylephrine effectively reverses spinal anaesthesia-induced haemodynamic changes in severe pre-eclampsia, if left ventricular systolic function is preserved.

High-Technology Based Gait Assessment in Frail People: Associations between Spatio-Temporal and Three-Dimensional Gait Characteristics with Frailty Status across Four Different Frailty Measures.

OBJECTIVE: We analyzed associations between a battery of gait characteristics and frailty status across four different frailty instruments in old patients. DESIGN: Cross-sectional study. SETTING: Geriatric wards of a general hospital. PARTICIPANTS: 123 hospitalized patients aged ≥65 years. MEASUREMENTS: Spatio-temporal and three-dimensional gait characteristics were assessed by an electronic walkway and a shoe-mounted, inertial sensor-based mobile gait analysis system. Frailty status was assessed by the frailty phenotype (FP), Clinical Frailty Scale (CFS), frailty index (FI), and frailty index based on a comprehensive geriatric assessment (FI-CGA). RESULTS: A reduction in walking speed (FP, FI, FI-CGA), stride length (FP, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FI-CGA) and greater stride length variability (FP, CFS, FI, FI-CGA), stride time variability (FP, FI), double support time (FP, FI), and stride width (CFA, FI-CGA) were associated with frailty status across the four frailty instruments (all P < 0.05, respectively). Walking speed (FP, CFS, FI, FI-CGA), stride length (FP, CFS, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FP, FI), stride length variability (CFS, FI, FI-CGA), stride time variability (FI), double support time (FP), and stride width (FP, CFS, FI) were related with frailty severity across the four frailty instruments independent of age and sex (all P adjusted < 0.05, respectively). CONCLUSIONS: Gait changes in frail patients include more than solely a reduction in walking speed.

[German translation of the performance-oriented mobility assessment according to Tinetti]. / Deutsche Übersetzung des "Performance-Oriented Mobility Assessment" nach Tinetti.

BACKGROUND: In clinical research as well as good clinical practice increasing importance is placed on standardized and evaluated procedures. They provide information which is important for the prognosis, determination of the need for interventions, determination of treatment goals and evaluation of treatment approaches and outcomes. Furthermore, they serve as justification of the reimbursement for presentation to official bodies. Until now no officially authorized German version of the performance-oriented mobility assessment (POMA) according to Tinetti was available. OBJECTIVES: This article presents a methodically translated German version of the POMA that also includes so far partially unpublished instructions for the examiner and the examined person. MATERIAL AND METHODS: The internationally recognized recommendations for the cross-cultural adaptation of health status measures served as the foundation of the translation process. By means of three translations from the original language into the target language a preliminary consensus version was developed, which was then translated back into the original language by two native speakers. RESULTS AND CONCLUSION: With this new and for the first time authorized German translation of the POMA a version of this assessment is available that achieves unification and standardization in German speaking countries and guarantees an improved comparability with international studies.

[Comparison of the performance-oriented mobility assessment and the Berg balance scale. Assessment tools in geriatrics and geriatric rehabilitation]. / Performance-Oriented Mobility Assessment und Berg Balance Scale im Vergleich. Assessmentinstrumente in der Geriatrie und geriatrischen Rehabilitation.

BACKGROUND: In order to develop and coordinate an integrated plan for treatment of hospitalized elderly patients in danger of future falls it is of utmost importance to ensure using the assessment that best targets people who are at risk for falling. For this purpose the performance-oriented mobility assessment (POMA) and the Berg balance scale (BBS) can be used. The purpose of this study was to collate the results of articles published on these assessment tools in order to appraise whether one of them could be favored under the viewpoint of practicability and expressiveness. METHOD: A literature search was conducted for studies examining the two assessment tools published since 1986 through December 2011 in English and German language. Reference sections were also inspected for additional citations. RESULT: Overall 19 studies were retrieved in order to answer the posed question. Of the total number of 1,455 patients in the identified articles, 712 with an average age of 74.1 years were included in the BBS trials and the POMA was assessed using 743 patients with an average age of 75.7 years. The BBS was good at identifying elderly people who are at risk for falling (sensitivity 84-95.5 %) and those who are not at-risk for falling (specificity 76.5-95.5 %. The demonstrated results for the POMA ranged from relatively poor to good (sensitivity 64-95.5 %) and from poor to very high (specificity 60-100 %). The BBS demonstrated its strengths in the more precise survey for monitoring balance and predicting risk for falling. Weaknesses of the BBS were the higher average time of processing and the inability to detect changes in gait. The advantages of the POMA was the short processing time, the possibility for separate identification of balance and gait and the high accuracy in recognition of gait changes. CONCLUSION: The results suggest that the POMA can be used as a fast screening tool to evaluate risk for falling or changes in gait ability. Geriatric patients who screen positive for risks of falls using the POMA should be selected for further assessment using the BBS. The BBS is a concise assessment tool for monitoring balance and to predict a person's current risk for falling.