Fentanyl iontophoretic transdermal system versus morphine intravenous patient-controlled analgesia for pain management following gynecological surgery: a meta-analysis of randomized, controlled trials.

AIM: To compare the efficacy and safety of patient-controlled fentanyl iontophoretic transdermal system (ITS) with morphine intravenous (i.v.) patient-controlled analgesia (PCA) for pain management following gynecological surgery. METHODS: Two-open-label, multicenter, randomized, active-controlled, parallel-group studies (n = 1142) were conducted that compared fentanyl ITS with morphine iv. PCA for postoperative pain. The subgroup of gynecological surgery patients from each trial was utilized for this meta-analysis (n = 604). Of these patients, 295 received fentanyl ITS (40 µg/dose) and 309 received morphine i.v. PCA (1 mg/dose) for up to 72 h. Efficacy measures included the patient global assessment (PGA) and the investigator global assessment (IGA) of the method of pain control. RESULTS: Gynecological surgery patients (n = 604) included in this meta-analysis had a mean age of 45 years, were predominantly Caucasian (65%) and had a mean body mass index of 29 mg/kg2. There were statistically significantly more patients treated with fentanyl ITS and more investigators who rated their pain control method as 'excellent' on the PGA at 24 h (49.3 vs 37.4%, respectively; p = 0.0029) and IGA at the last assessment (59.5 vs. 38.0%, respectively; p < 0.0001), respectively, compared with morphine iv. PCA at the last assessment. CONCLUSION: Following gynecological surgery, patients and investigators were more satisfied (had a higher percent of an 'excellent' rating on the PGA and IGA, respectively) with fentanyl ITS than morphine iv. PCA as a method of pain control.

An effective pressure pack for severe pelvic hemorrhage.

OBJECTIVE: To evaluate our experience with the "pelvic pressure pack," a surgical technique for controlling posthysterectomy bleeding. METHODS: This is an observational descriptive report of cases collected by the authors during the years 1968-2006. Packs were constructed of various materials (eg, pillow cases, gauze sheets, plastic X-ray cassette drapes, or orthopedic stockings) filled with gauze rolls introduced abdominally and exiting the vagina. RESULTS: We report 11 new cases (10 obstetric and one gynecologic). Massive red blood cell transfusion and coagulopathy occurred in all cases. The pelvic pressure pack successfully controlled bleeding in 82% (9 of 11) of cases. Postoperative febrile morbidity occurred in most cases. There were no maternal deaths. CONCLUSION: In the contemporary management of posthysterectomy bleeding, the pelvic pressure pack appears to be a valuable surgical option, affording correction of coagulopathy and further stabilization. Given near-universal postoperative febrile morbidity in our series, prophylactic broad-spectrum antibiotic therapy should be strongly considered. We believe all obstetrician-gynecologists should be familiar with this simple, potentially life-saving technique. LEVEL OF EVIDENCE: III.