Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

• Published in: World journal of surgery 2022-04, Vol.46 (4), p.878-890
• Main Authors: Thavanesan, Navamayooran, White, Sophie, Lee, Shiela, Ratnayake, Bathiya, Oppong, Kofi W., Nayar, Manu K., Sharp, Linda, Drewes, Asbjørn Mohr, Capurso, Gabriele, De-Madaria, Enrique, Siriwardena, Ajith K., Windsor, John A., Pandanaboyana, Sanjay
• Format: Article
• Language: English
• Subjects: Abdominal Surgery; Analgesia; Analgesics; Analgesics - therapeutic use; Analgesics, Opioid - therapeutic use; Anesthetics; Anesthetics, Local - therapeutic use; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use; Cardiac Surgery; Clinical trials; Epidural; Equivalence; General Surgery; Heterogeneity; Humans; Medicine; Medicine & Public Health; Meta-analysis; Narcotics; Nonsteroidal anti-inflammatory drugs; Opiate Alkaloids - therapeutic use; Opioids; Pain; Pain - drug therapy; Pain Management; Pain perception; Pancreatitis; Pancreatitis - complications; Pancreatitis - drug therapy; Paracetamol; Placebos; Randomized Controlled Trials as Topic; Scientific Review; Statistical analysis; Surgery; Systematic review; Thoracic Surgery; Vascular Surgery
• ISSN: 0364-2313; 1432-2323
• DOI: 10.1007/s00268-021-06420-w

Background The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. Objective The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP. Methods A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. Conclusions There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.