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中华卫生应急电子杂志 ›› 2022, Vol. 08 ›› Issue (06) : 335 -343. doi: 10.3877/cma.j.issn.2095-9133.2022.06.004

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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
丁琼莉1, 迪丽热巴·吐尔逊2, 于湘友1,†()   
  1. 1. 830054　新疆乌鲁木齐，新疆医科大学第一附属医院重症医学中心；830000　新疆乌鲁木齐，新疆医科大学
    2. 830000　新疆乌鲁木齐，新疆医科大学
  • 收稿日期:2022-10-11 出版日期:2022-12-18
  • 通信作者: 于湘友
  • 基金资助:
    国家自然科学基金(82160360)

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

Qiongli Ding1, Tuerxun Dilireba·2, Xiangyou Yu1,†()   

  1. 1. Critical Medicine Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China; Xinjiang Medical University, Urumqi 830000, China
    2. Xinjiang Medical University, Urumqi 830000, China
  • Received:2022-10-11 Published:2022-12-18
  • Corresponding author: Xiangyou Yu
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引用本文：

丁琼莉, 迪丽热巴·吐尔逊, 于湘友. 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[J]. 中华卫生应急电子杂志, 2022, 08(06): 335-343.

Qiongli Ding, Tuerxun Dilireba·, Xiangyou Yu. Prognostic impact of nutritional support therapy in critically ill patients guided by indirect calorimetry: a meta-analysis of randomized controlled trials[J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2022, 08(06): 335-343.

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
    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
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
1
Hoffmann M, Schwarz CM, Fürst S，et al.Risks in management of enteral nutrition in intensive care units：a ；iterature review and narrative synthesis[J]．Nutrients，2020,13(1):82.
2
Reintam Blaser A, Starkopf J, Alhazzani W，et al.Early enteral nutrition in critically ill patients：ESICM clinical practice guidelines[J]．Intensive Care Med，2017,43(3):380-398.
3
Taylor BE, McClave SA, Martindale RG，et al.Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient：society of critical care medicine (SCCM) and american society for parenteral and enteral nutrition(A.S.P.E.N.)[J]．Crit Care Med，2016,44(2):390-438.
4
Compher C, Bingham AL, McCall M，et al.Guidelines for the provision of nutrition support therapy in the adult critically ill patient：the american society for parenteral and enteral nutrition[J]．JPEN J Parenter Enteral Nutr，2022,46(1):12-41.
5
Singer P, Blaser AR, Berger MM，et al.ESPEN guideline on clinical nutrition in the intensive care unit[J]．Clin Nutr，2019,38(1):48-79.
6
Tatucu－Babet OA, Ridley EJ, Tierney AC.Prevalence of underprescription or overprescription of energy needs in critically ill mechanically ventilated adults as determined by indirect calorimetry：a systematic literature review[J]．JPEN J Parenter Enteral Nutr，2016,40(2):212-225.
7
Moonen HPFX, Beckers KJH, van Zanten ARH.Energy expenditure and indirect calorimetry in critical illness and convalescence：current evidence and practical considerations[J]．J Intensive Care，2021,9(1):8.
8
Walker RN, Heuberger RA.Predictive equations for energy needs for the critically ill[J]．Respir Care，2009,54(4):509-521.
9
张会云，李锐，王勇强，等．代谢车指导多器官功能障碍综合征患者的营养支持治疗[J]．中华危重病急救医学，2016,28(8):741-743.
10
王丽娟，赵兰菊，杨小娟，等．间接测热法与HB公式法测定多发伤机械通气患者能量消耗的一致性研究[J]．中华危重病急救医学，2018,30(10):946-949.
11
Zusman O, Theilla M, Cohen J，et al.Resting energy expenditure，calorie and protein consumption in critically ill patients：a retrospective cohort study[J]．Crit Care，2016,20(1):367.
12
Barazzoni R, Bischoff S C, Breda J，et al.ESPEN expert statements and practical guidance for nutritional management of individuals with SARS－CoV－2 infection[J]．Clin Nutr，2020,39(6):1631-1638.
13
De Waele E, Honoré PM, Malbrain MLNG.Does the use of indirect calorimetry change outcome in the ICU? yes it does[J]．Curr Opin Clin Nutr Metab Care，2018,21(2):126-129.
14
Lambell KJ, Tatucu－Babet OA, Chapple LA，et al.Nutrition therapy in critical illness：a review of the literature for clinicians[J]．Crit Care，2020,24(1):35.
15
Casy T, Grasseau A, Charras A，et al.Assessing the robustness of clinical trials by estimating jadad’s score using artificial intelligence approaches[J]．Comput Biol Med，2022(148):105851.
16
Singer P, Anbar R, Cohen J，et al.The tight calorie control study(TICACOS)：a prospective，randomized，controlled pilot study of nutritional support in critically ill patients[J]．Intensive Care Med，2011,37(4):601-609.
17
杨小娟，张珺，王丽娟，等．呼吸间接测热法和HB系数法指导脓毒症患者目标能量的对比研究[J]．中华临床营养杂志，2019,27(4):238-243.
18
Landes S, McClave SA, Frazier TH，et al.Indirect calorimetry：is it required to maximize patient outcome from nutrition therapy？[J]．Curr Nutr Rep，2016(5):233-239.
19
Allingstrup MJ, Kondrup J, Wiis J，et al.Early goal－directed nutrition versus standard of care in adult intensive care patients：the single－centre，randomised，outcome assessor－blinded EAT－ICU trial[J]．Intensive Care Med，2017,43(11):1637-1647.
20
Gonzalez－Granda A, Schollenberger A, Haap M，et al.Optimization of nutrition therapy with the use of calorimetry to determine and control energy needs in mechanically ventilated critically ill patients：the ONCA study，a randomized，prospective pilot study[J]．JPEN J Parenter Enteral Nutr，2019,43(4):481-489.
21
赵士兵，段立彬，余刚，等．应用代谢车监测ICU患者REE变化规律并指导营养支持的前瞻性研究[J]．中华危重病急救医学，2019,31(12):1512-1513.
22
Singer P, De Waele E, Sanchez C，et al.TICACOS international：a multi－center, randomized，prospective controlled study comparing tight calorie control versus liberal calorie administration study[J]．Clin Nutr，2021,40(2):380-387.
23
Sharma K, Mogensen KM, Robinson MK.Pathophysiology of critical illness and role of nutrition[J]．Nutr Clin Pract，2019,34(1):12-22.
24
Al－Dorzi HM, Arabi YM.Nutrition support for critically ill patients[J]．JPEN J Parenter Enteral Nutr，2021,45(S2):47-59.
25
Tatucu－Babet OA, Ridley EJ.Clinimetrics：indirect calorimetry[J]．J Physiother，2019,65(4):240.
26
Zusman O, Kagan I, Bendavid I，et al.Predictive equations versus measured energy expenditure by indirect calorimetry：a retrospective validation[J]．Clin Nutr, 2019,38(3):1206-1210.
27
Oshima T, Berger MM, De Waele E，et al.Indirect calorimetry in nutritional therapy.a position paper by the ICALIC study group[J]．Clin Nutr，2017,36(3):651-662.
28
Tatucu－Babet OA, Fetterplace K, Lambell K，et al.Is energy delivery guided by indirect calorimetry associated with improved clinical outcomes in critically ill patients？a systematic review and meta－analysis[J]. Nutr Metab Insights，2020(13):1010633087.
29
Weijs PJ, Looijaard WG, Beishuizen A，et al.Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non－septic mechanically ventilated critically ill patients[J]．Crit Care，2014,18(6):701.
30
Nicolo M, Heyland DK, Chittams J，et al.Clinical outcomes related to protein delivery in a critically ill population：a multicenter，multinational observation study[J]．JPEN J Parenter Enteral Nutr，2016,40(1):45-51.
31
Villet S, Chiolero RL, Bollmann MD，et al.Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients[J]．Clin Nutr，2005,24(4):502-509.
32
Frankenfield DC, Ashcraft CM, Galvan DA.Longitudinal prediction of metabolic rate in critically ill patients[J]. JPEN J Parenter Enteral Nutr，2012,36(6):700-712.
33
Chapple LS, Fetterplace K, Asrani V，et al.Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID－19) in australia and new zealand[J]. Nutr Diet，2020,77(4):426-436.
34
Kaukonen KM, Bailey M, Suzuki S，et al.Mortality related to severe sepsis and septic shock among critically ill patients in australia and new zealand，2000－2012[J]．JAMA，2014,311(13):1308-1316.
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