Should immunonutrition become routine in critically ill patients? A systematic review of the evidence
Should immunonutrition become routine in critically ill patients? A systematic review of the evidence
复制标题
DOI：
10.1001/jama.286.8.944
复制
发表时间：
2001-08-22
影响因子：
120.7
通讯作者：
Suchner, U
中科院分区：
文献类型：
--
作者：
Heyland, DK;Novak, F;Suchner, U
研究背景几种营养素已被证明影响人体的免疫和炎症反应。这些影响是否转化为改善临床结果在危重病patients.Objective研究肠内营养补充免疫增强营养素和感染并发症和死亡率之间的关系在危重病patients.Data Sources的MEDLINE，EMBASE，Biosis和CINAHL数据库中检索1990年至2000年发表的文章。其他数据来源包括1990年至2000年的科克伦对照试验注册，个人档案，摘要会议记录，并通过数据库审查确定的文章的相关参考文件。如果这些研究是针对危重患者或手术患者的随机试验，评价了补充精氨酸、谷氨酰胺、核苷酸和omega-3脂肪酸的肠内营养与标准肠内营养相比对感染并发症和死亡率的影响，并包括临床重要结局，例如死亡率。数据提取对单项研究的方法质量进行评分，并独立地一式两份提取必要的数据。数据综合二十-两项随机试验共纳入2419例患者，比较了免疫营养素与标准肠内营养在外科和危重患者中的应用。关于死亡率，免疫组化与1.10的合并风险比（RR）相关（95%置信区间[CI]，0.93-1.31）。免疫治疗与较低的感染并发症相关（RR，0.66; 95%CI，0.54-0.80）。由于研究之间存在显著异质性，我们检查了几个先验亚组分析。我们发现，与其他免疫增强饮食相比，使用高精氨酸含量的商业配方的研究与感染并发症的显着减少和死亡率降低的趋势有关。与重症患者的研究相比，手术患者的研究与感染并发症发生率的显著降低相关。在危重患者的研究中，研究与高质量的评分与死亡率增加和感染性并发症的发生率显着降低相比，研究与低质量score.Conclusion免疫纽卡素可能会降低感染性并发症的发生率，但它是不相关的整体死亡率优势。然而，治疗效果取决于干预措施、患者人群和研究的方法学质量。
Context Several nutrients have been shown to influence immunologic and inflammatory responses in humans. Whether these effects translate into an improvement in clinical outcomes in critically ill patients remains unclear.Objective To examine the relationship between enteral nutrition supplemented with immune-enhancing nutrients and infectious complications and mortality rates in critically ill patients.Data Sources The databases of MEDLINE, EMBASE, Biosis, and CINAHL were searched for articles published from 1990 to 2000. Additional data sources included the Cochrane Controlled Trials Register from 1990 to 2000, personal files, abstract proceedings, and relevant reference fists of articles identified by database review.Study Selection A total of 326 titles, abstracts, and articles were reviewed. Primary studies were included If they were randomized trials of critically ill or surgical patients that evaluated the effect of enteral nutrition supplemented with some combination of arginine, glutamine, nucleotides, and omega-3 fatty acids on infectious complication and mortality rates compared with standard enteral nutrition, and included clinically important outcomes, such as mortality.Data Extraction Methodological quality of individual studies was scored and necessary data were abstracted in duplicate and independently.Data Synthesis Twenty-two randomized trials with a total of 2419 patients compared the use of immunonutrition with standard enteral nutrition in surgical and critically Ill patients. With respect to mortality, immunonutrition was associated with a pooled risk ratio (RR) of 1.10 (95% confidence interval [CI], 0.93-1.31). Immunonutrition was associated with lower infectious complications (RR, 0.66; 95% CI, 0.54-0.80). Since there was significant heterogeneity across studies, we examined several a priori subgroup analyses. We found that studies using commercial formulas with high arginine content were associated with a significant reduction in infectious complications and a trend toward a lower mortality rate compared with other immune-enhancing diets. Studies of surgical patients were associated with a significant reduction in infectious complication rates compared with studies of critically Ill patients. In studies of critically ill patients, studies with a high-quality score were associated with increased mortality and a significant reduction in infectious complication rates compared with studies with a low-quality score.Conclusion Immunonutrition may decrease infectious complication rates but it is not associated with an overall mortality advantage. However, the treatment effect varies depending on the intervention, the patient population, and the methodological quality of the study.