Total parenteral nutrition in the critically ill patient
Total parenteral nutrition in the critically ill patient
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DOI：
10.1001/jama.280.23.2013
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发表时间：
1998-12-16
影响因子：
120.7
通讯作者：
Drover, JW
中科院分区：
文献类型：
--
作者：
Heyland, DK;MacDonald, S;Drover, JW
背景.-营养支持已成为住院患者的护理标准，但全肠外营养 (TPN) 是否影响发病率和死亡率尚不清楚。目的.-检查危重患者 TPN 与并发症和死亡率之间的关系。数据来源.-计算机检索 1980 年至 1998 年 MEDLINE 上发表的研究、个人档案以及相关参考文献列表的回顾。研究选择。-我们回顾了 210标题、摘要和论文。如果是对危重病或手术患者进行随机临床试验，评估 TPN（与标准治疗相比）对并发症和死亡率的影响，则纳入初步研究。我们排除了比较 TPN 与肠内营养的研究。数据提取。-根据初步研究的方法和结果提取了相关数据。数据独立地一式两份提取。数据综合。-有 26 项随机试验，涉及 2211 名患者，将 TPN 的使用与标准护理（常规口服饮食加静脉注射葡萄糖）在手术和危重患者中进行比较。将这些试验的结果汇总后，TPN 对死亡率没有影响（风险比 [RR]，1.03；95% 置信区间 [CI]，0.81-1.31）。接受TPN的患者并发症发生率往往较低，但这一结果并不具有统计学意义（RR，0.84；95% CI，0.64-1.09），我们检查了几个先验假设，发现仅包括营养不良患者的研究与较低的并发症发生率相关，但与非营养不良患者的研究相比，死亡率没有差异，1989年以来发表的研究和方法评分较高的研究显示没有治疗效果，而研究发表于 1988 年或之前，方法得分较低的研究显示了显着的治疗效果。不使用脂质的研究中并发症发生率较低；然而，不使用脂质的研究和使用脂质的研究之间的死亡率没有差异。仅限于危重患者的研究表明，与手术患者的研究相比，并发症和死亡率显着增加。结论：全肠外营养不影响手术或危重患者的总体死亡率。它可能会降低并发症发生率，尤其是营养不良的患者，但研究结果受到患者群体、脂质使用、方法学质量和发表年份的影响。
Context.-Nutritional support has become a standard of care for hospitalized patients, but whether total parenteral nutrition (TPN) affects morbidity and mortality is unclear.Objective.-To examine the relationship between TPN and complication and mortality rates in critically ill patients.Data Sources.-Computerized search of published research on MEDLINE from 1980 to 1998, personal files, and review of relevant reference lists.Study Selection.-We reviewed 210 titles, abstracts, and papers. Primary studies were included if they were randomized clinical trials of critically ill or surgical patients that evaluated the effect of TPN (compared with standard care) on complication and mortality rates. We excluded studies comparing TPN with enteral nutrition.Data Extraction.-Relevant data were abstracted on the methodology and outcomes of primary studies. Data were abstracted in duplicate, independently.Data Synthesis.-There were 26 randomized trials of 2211 patients comparing the use of TPN with standard care (usual oral diet plus intravenous dextrose) in surgical and critically ill patients. When the results of these trials were aggregated, TPN had no effect on mortality (risk ratio [RR], 1.03; 95% confidence interval [CI], 0.81-1.31). Patients who received TPN tended to have a lower complication rate, but this result was not statistically significant (RR, 0.84; 95% CI, 0.64-1.09), We examined several a priori hypotheses and found that studies including only malnourished patients were associated with lower complication rates but no difference in mortality when compared with studies of nonmalnourished patients, Studies published since 1989 and studies with a higher methods score showed no treatment effect, while studies published in 1988 or before and studies with a lower methods score demonstrated a significant treatment effect. Complication rates were lower in studies that did not use lipids; however, there was no difference in mortality rates between studies that did not use lipids and those studies that did, Studies limited to critically ill patients demonstrated a significant increase in complication and mortality rates compared with studies of surgical patients.Conclusions.-Total parenteral nutrition does not influence the overall mortality rate of surgical or critically ill patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by patient population, use of lipids, methodological quality, and year of publication.