Severe Acute Pancreatitis: Step-Up versus Step-Down Approach for Pain Control in Initial 72 hours

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S. . Batool, “Severe Acute Pancreatitis: Step-Up versus Step-Down Approach for Pain Control in Initial 72 hours”, ijmhs, vol. 10, no. 09, pp. 1247–1252, Sep. 2020.
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Abstract

Background Attenuating pain in severe acute pancreatitis (SAP) remains a challenge for clinicians specially in first 48-72 hours. Randomized trials are difficult to plan and execute as the pain is very severe and management is frustrating. Moreover, most of the have on comparison of two drugs rather than comparing the pain regimens as multi-modality treatment. Objectives The objective of the study was to compare step-up versus step-down approach of pain management in SAP patients admitted in surgical critical care unit. Methods Retrospective analysis of data related to control of pain in SAP was carried out. Patients of acute pancreatitis classified as severe or critical as per Atlanta or determinant based classification were included in the study. Chronic pancreatitis, Etiology other than or alcoholic pancreatitis (BP and AP) and incomplete data entry were the major exclusions. Patients’ files were reviewed, and they were re-classified as SAP. VAS and analgesia requirement were tabulated and . Patients of and alcoholic pancreatitis were divided into two subgroups viz step-up ( started later) and step-down ( started from the beginning).   Data of 84 patients was calculated and . Mean age of BP patients was significantly less than AP. Males were the major sufferers in AP and females in BP. The mean VAS on arrival was not significantly different between BP and AP. The difference in mean VAS remains insignificant for up to 8 hours of admission, after which, patients with AP started having relief at a faster rate compared to patients with BP. From 4th hour , the fall in VAS was more and significant in step down approach. The time when the difference in mean VAS between the step-up and step-down groups of patients with AP was found significant was 10th hour from admission. The difference persisted till 72 hours of observation. Patients of AP responded more to routine analgesics or when the were added later compared to patients of BP. The difference in mean VAS between step down sub-groups of BP and AP did not show significance. An overall comparison of step-up and step-down sub-groups of both BP and AP patients revealed a significant difference in mean VAS from 4th hour . Conclusion Patients who followed step-down approach of pain management significantly better compared to those who followed step-up approach.

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