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Heyland DK, MacDonald S, Keefe L, Drover JW. Total Parenteral Nutrition in the Critically Ill Patient: A Meta-analysis. JAMA. 1998;280(23):2013–2019. doi:10.1001/jama.280.23.2013
From the Departments of Medicine (Drs Heyland and MacDonald) and Surgery (Dr Drover), Queen's University and Nutritional Services, Kingston General Hospital (Ms Keefe), Kingston, Ontario.
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
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
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
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.
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