间接测热法指导营养支持治疗危重症患者的预后影响：随机对照试验的Meta分析

doi:10.3877/cma.j.issn.2095-9133.2022.06.004

目的

系统评价间接测热法(IC)指导危重症患者营养支持治疗对预后的影响。

方法

检索中国知网(CNKI)、万方、维普(VIP)等中文数据库和PubMed、Embase、Springer、Ovid、CINAHL和Cochrane图书馆等英文数据库，检索IC和预测方程(PE)用于指导危重症患者营养支持治疗的所有临床随机对照试验(RCT)，检索时限为2002年1月至2022年8月。文献检索由2名研究者采用标准化方法独立进行；采用RevMan5.4软件进行数据分析。试验组使用IC指导能量输送，对照组使用PE指导能量输送。使用Cochrane偏倚风险工具来评估纳入研究的质量。主要观察指标为入住重症监护室(ICU)危重症患者的90 d病死率、180 d病死率、机械通气时间、ICU住院时间、总住院时间、感染发生率等；次要观察指标为平均能量输送量水和蛋白质输送水平。

结果

共纳入7篇文献、931例患者，IC组和PE组分别为468例、463例。与PE组相比，IC组患者的90 d病死率(RR＝0.77，95%CI＝0.60~0.98，P＝0.03)显著降低，180 d病死率无明显变化(RR＝0.95，95%CI＝0.71~1.27，P＝0.73)，未缩短机械通气时间(MD＝0.87，95%CI＝－0.81~2.56，P＝0.31)、ICU住院时间(MD＝－0.46，95%CI＝－2.84~1.92，P＝0.70)和总住院时间(MD＝0.23，95%CI＝－3.27~3.72，P＝0.90)，感染发生率未下降(MD＝1.18，95%CI＝0.73~1.91，P＝0.51)。IC组平均每日能量输送量显著高于PE组(MD＝619.91，95%CI＝407.81~832.02，P<0.00001)；蛋白质的输送水平也显著高于PE组(MD＝14.13，95%CI＝2.45~25.61，P＝0.02)。

结论

IC指导的能量输送降低了危重症患者的90 d病死率，增加了平均每日能量的摄入量和蛋白质摄入量；未延长机械通气时间、ICU住院时间和总住院时间；对感染发生率和180 d病死率无显著影响。

关键词: 间接测热法, 预测方程, 静息能量消耗, 营养支持治疗, Meta分析

Objective

To systematically evaluate the clinical effect of indirect calorimetry (IC)-guided nutritional support therapy in critically ill patients.

Methods

Electronic databases CNKI, Wanfang data, VIP, PubMed, Embase, Springer, Ovid, CINAHL and the Cochrane Library were searched using the following key words: indirect calorimetry, resting energy measurement, metabolic car, resting energy expenditure, predictive equations, prediction formula, energy delivery, nutritional support therapy, and Harris-Benedict. All databases were published from January 2002 to August 2022. The experimental group was guided by the IC method, and the control group was guided by the PE method. We used the Cochrane risk-of-bias tool to assess the quality of the included studies. The main outcome indicators were the 90-day mortality, 180-day mortality, mechanical ventilation time, intensive care unit(ICU)stays, total length of hospital stays, and infection incidence of critically ill patients admitted to the ICU. The secondary outcome indicators were average energy delivery levels and protein delivery levels. The literature search was conducted independently by 2 researchers using standardized methods. Meta-analysis was performed using RevMan 5.4.

Results

A total of 931 patients were enrolled in 7 RCTs, including 468 patients in the IC group and 463 patients in the PE group. The summary results showed that compared with the PE group, the 90-day mortality rate (RR=0.77, 95%CI=0.60 to 0.98, P=0.03)of the IC group patients was significantly lower, and the 180-day mortality rate had no significant change(RR=0.95, 95%CI=0.71 to 1.27, P=0.73), which did not shorten the mechanical ventilation time (MD=0.87, 95%CI=-0.81 to 2.56, P=0.31), and ICU hospital stays(MD=-0.46, 95%CI=-2.84 to 1.92, P=0.70) and total length of hospital stays(MD=0.23, 95%CI=-3.27 to 3.72, P=0.90), and the incidence of infection did not decrease(MD=1.18, 95%CI=0.73 to 1.91, P=0.51). The average energy delivery in the IC group was significantly higher than that in the PE group (MD=619.91, 95%CI=407.81 to 832.02, P<0.01) and the protein delivery level was also significantly higher than that in the PE group(MD=14.13, 95%CI=2.45 to 25.61, P=0.02).

Conclusions

This meta-analysis indicates that IC-guided energy delivery reduces 90-day mortality and increases mean daily energy intake and protein intake in critically ill patients; mechanical ventilation time, ICU stays, and total length of stays are not prolonged; it has no significant effect on infection incidence and 180-day mortality. This finding encourages the use of IC-guided energy delivery during critical nutrition support. But more high-quality studies are still needed to confirm these findings.

Key words: Indirect calorimetry, Predictive equations, Resting energy expenditure, Nutritional support therapy, Meta-analysis

图1 文献筛选流程图

表1 纳入Meta分析文献的基本特征

作者+年份	研究类型	研究时限	组别	例数	年龄	BMI	营养方式	干预措施	APHACHEⅡ评分
1.Singer2011^[16]	单中心	2周	IC组	65	59	28	肠内+肠外	2周/次	22
			PE组	65	62	27		25 kcal·kg^－1·d^－1	22
2.杨小娟2016^[17]	单中心	2周	IC组	30	56	NR	肠内+肠外	0、3、7、14 d测量	NR
			PE组	30	58	NR		HB预测方程	NR
3.Landes2016^[18]	单中心	2周	IC组	15	72	25	肠内	1次/周，连续3周	35
			PE组	12	74	26		HB预测方程1	39
4.Allingstrup2017^[19]	单中心	转出ICU/3个月	IC组	100	63	22	肠内+肠外	每天测量	NR
		转出ICU/3个月	PE组	99	68	22		25 kcal·kg^－1·d^－1	NR
5.Gonzalez2018^[20]	单中心	直至转出	IC组	20	57	28	优先肠内	每周测量	29
		ICU	PE组	20	56	25		25 kcal·kg^－1·d^－1	29
6.赵士兵2019^[21]	单中心	1周	IC组	29	44	NR	优先肠内	每天测量	19
			PE组	29	45	NR		HB预测方程	18
7.Singer2020^[22]	多中心	2周	IC组	209	59	28	优先肠内	每天测量	22
			PE组	208	61	28		25 kcal·kg^－1·d^－1	22

表1 纳入Meta分析文献的基本特征

作者+年份	研究类型	研究时限	组别	例数	年龄	BMI	营养方式	干预措施	APHACHEⅡ评分
1.Singer2011^[16]	单中心	2周	IC组	65	59	28	肠内+肠外	2周/次	22
			PE组	65	62	27		25 kcal·kg^－1·d^－1	22
2.杨小娟2016^[17]	单中心	2周	IC组	30	56	NR	肠内+肠外	0、3、7、14 d测量	NR
			PE组	30	58	NR		HB预测方程	NR
3.Landes2016^[18]	单中心	2周	IC组	15	72	25	肠内	1次/周，连续3周	35
			PE组	12	74	26		HB预测方程1	39
4.Allingstrup2017^[19]	单中心	转出ICU/3个月	IC组	100	63	22	肠内+肠外	每天测量	NR
		转出ICU/3个月	PE组	99	68	22		25 kcal·kg^－1·d^－1	NR
5.Gonzalez2018^[20]	单中心	直至转出	IC组	20	57	28	优先肠内	每周测量	29
		ICU	PE组	20	56	25		25 kcal·kg^－1·d^－1	29
6.赵士兵2019^[21]	单中心	1周	IC组	29	44	NR	优先肠内	每天测量	19
			PE组	29	45	NR		HB预测方程	18
7.Singer2020^[22]	多中心	2周	IC组	209	59	28	优先肠内	每天测量	22
			PE组	208	61	28		25 kcal·kg^－1·d^－1	22

表2 纳入Meta分析文献的营养特征及能量输送情况

作者+年份	IC设备型号	组别	REE(kcal/d)	平均能量输送(kcal/d)	能量平衡量(kcal)	平均蛋白质输送量(g/d)	测量值的输送能量百分比(%)
1.Singer2011^[16]	DeltatracⅡ	IC组	1 976	2 086±460	186±206	76±16	106
		PE组	1 838	1 480±356	－312±481	53±16	81
2.杨小娟2016^[17]	Engestrom	IC组	1 900	NR	NR	NR	NR
	Careatation	PE组	1 481	NR	NR	NR	NR
3.Landes2016^[18]	Colorado Med Tech	IC组	1 976	NR	NR	NR	87
	Metascope	PE组	2 067	NR	NR	NR	77
4.Allingstrup2017^[19]	COSMED Quark	IC组	2 069	1 877±509	－66±112	NR	91
	RMR	PE组	1 887	1 061±537	－787±659.3	NR	56
5.Gonzalez2018^[20]	COSMED Quark	IC组	NR	NR	NR	78±18	98
	RMR	PE组	NR	NR	NR	76±16	79
6.赵士兵2019^[21]	Medgraphics	IC组	1 443	NR	NR	NR	NR
	CCM	PE组	1 615	NR	NR	NR	NR
7.Singer2020^[22]	Deltatrac II	IC组	1 953	1 746±755	－282±896	77±53	89
	COVX and Quark	PE组	1 942	1 301±535	－885±535	62±34	67

表2 纳入Meta分析文献的营养特征及能量输送情况

作者+年份	IC设备型号	组别	REE(kcal/d)	平均能量输送(kcal/d)	能量平衡量(kcal)	平均蛋白质输送量(g/d)	测量值的输送能量百分比(%)
1.Singer2011^[16]	DeltatracⅡ	IC组	1 976	2 086±460	186±206	76±16	106
		PE组	1 838	1 480±356	－312±481	53±16	81
2.杨小娟2016^[17]	Engestrom	IC组	1 900	NR	NR	NR	NR
	Careatation	PE组	1 481	NR	NR	NR	NR
3.Landes2016^[18]	Colorado Med Tech	IC组	1 976	NR	NR	NR	87
	Metascope	PE组	2 067	NR	NR	NR	77
4.Allingstrup2017^[19]	COSMED Quark	IC组	2 069	1 877±509	－66±112	NR	91
	RMR	PE组	1 887	1 061±537	－787±659.3	NR	56
5.Gonzalez2018^[20]	COSMED Quark	IC组	NR	NR	NR	78±18	98
	RMR	PE组	NR	NR	NR	76±16	79
6.赵士兵2019^[21]	Medgraphics	IC组	1 443	NR	NR	NR	NR
	CCM	PE组	1 615	NR	NR	NR	NR
7.Singer2020^[22]	Deltatrac II	IC组	1 953	1 746±755	－282±896	77±53	89
	COVX and Quark	PE组	1 942	1 301±535	－885±535	62±34	67

图2 纳入Meta分析文献的质量评价图

图3 IC法和PE法指导危重症患者营养支持治疗的90 d病死率Meta分析森林图

图4 IC法和PE法指导危重症患者营养支持治疗的180 d病死率Meta分析森林图

图5 IC法和PE法指导危重症患者营养支持治疗的机械通气时间Meta分析森林图

图6 IC法和PE法指导危重症患者营养支持治疗的住ICU时间Meta分析森林图

图7 IC法和PE法指导危重症患者营养支持治疗的总住院时间Meta分析森林图

图8 IC法和PE法指导危重症患者营养支持治疗的感染发生率Meta分析森林图

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Prognostic impact of nutritional support therapy in critically ill patients guided by indirect calorimetry: a meta-analysis of randomized controlled trials

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Prognostic impact of nutritional support therapy in critically ill patients guided by indirect calorimetry: a meta-analysis of randomized controlled trials