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Heyland DK, Novak F, Drover JW, Jain M, Su X, Suchner U. Should Immunonutrition Become Routine in Critically Ill Patients? A Systematic Review of the Evidence. JAMA. 2001;286(8):944–953. doi:10.1001/jama.286.8.944
Author Affiliations: Departments of Medicine (Drs Heyland and Novak) and Surgery (Drs Drover and Jain), Queen's University, Kingston General Hospital, Kingston, Ontario; and Department of Anesthesiology, Grosshadern University Hospital, Ludwig Maximilian's University, Munich, Germany (Dr Suchner). Dr Su works in Munich, Germany. Dr Suchner is now employed by Fresenius-Kabi, Munich, Germany.
Caring for the Critically Ill Patient Section Editor: Deborah J. Cook, MD, Consulting Editor, JAMA
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 lists of articles identified by database
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.
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