Tan HB, Danilla S, Murray A, Serra R, El Dib R, Henderson TO, Wasiak J, et al.
The Cochrane database of systematic reviews. Date of publication 2014 Jan 1;volume (12):CD007174.
1. Cochrane Database Syst Rev. 2014;(12):CD007174. doi:
10.1002/14651858.CD007174.pub2. Epub 2014 Dec 23.
Immunonutrition as an adjuvant therapy for burns.
Tan HB(1), Danilla S, Murray A, Serra R, El Dib R, Henderson TO, Wasiak J.
Author information:
(1)Victorian Adult Burns Service, The Alfred Hospital, Commercial Road, Prahran,
Victoria, (2) Monash University, Melbourne, Australia.
BACKGROUND: With burn injuries involving a large total body surface area (TBSA),
the body can enter a state of breakdown, resulting in a condition similar to that
seen with severe lack of proper nutrition. In addition, destruction of the
effective skin barrier leads to loss of normal body temperature regulation and
increased risk of infection and fluid loss. Nutritional support is common in the
management of severe burn injury, and the approach of altering immune system
activity with specific nutrients is termed immunonutrition. Three potential
targets have been identified for immunonutrition: mucosal barrier function,
cellular defence and local or systemic inflammation. The nutrients most often
used for immunonutrition are glutamine, arginine, branched-chain amino acids
(BCAAs), omega-3 (n-3) fatty acids and nucleotides.
OBJECTIVES: To assess the effects of a diet with added immunonutrients
(glutamine, arginine, BCAAs, n-3 fatty acids (fish oil), combined immunonutrients
or precursors to known immunonutrients) versus an isonitrogenous diet (a diet
wherein the overall protein content is held constant, but individual constituents
may be changed) on clinical outcomes in patients with severe burn injury.
SEARCH METHODS: The search was run on 12 August 2012. We searched the Cochrane
Injuries Group's Specialised Register, The Cochrane Library, MEDLINE (OvidSP),
Embase (OvidSP), ISI WOS SCI-EXPANDED & CPCI-S and four other databases. We
handsearched relevant journals and conference proceedings, screened reference
lists and contacted pharmaceutical companies. We updated this search in October
2014, but the results of this updated search have not yet been incorporated.
SELECTION CRITERIA: Randomised controlled trials comparing the addition of
immunonutrients to a standard nutritional regimen versus an isonitrogenated diet
or another immunonutrient agent.
DATA COLLECTION AND ANALYSIS: Two review authors were responsible for
handsearching, reviewing electronic search results and identifying potentially
eligible studies. Three review authors retrieved and reviewed independently full
reports of these studies for inclusion. They resolved differences by discussion.
Two review authors independently extracted and entered data from the included
studies. A third review author checked these data. Two review authors
independently assessed the risk of bias of each included study and resolved
disagreements through discussion or consultation with the third and fourth review
authors. Outcome measures of interest were mortality, hospital length of stay,
rate of burn wound infection and rate of non-wound infection (bacteraemia,
pneumonia and urinary tract infection).
MAIN RESULTS: We identified 16 trials involving 678 people that met the inclusion
criteria. A total of 16 trials contributed data to the analysis. Of note, most
studies failed to report on randomisation methods and intention-to-treat
principles; therefore study results should be interpreted with caution. Glutamine
was the most common immunonutrient and was given in seven of the 16 included
studies. Use of glutamine compared with an isonitrogenous control led to a
reduction in length of hospital stay (mean stay -5.65 days, 95% confidence
interval (CI) -8.09 to -3.22) and reduced mortality (pooled risk ratio (RR) 0.25,
95% CI 0.08 to 0.78). However, because of the small sample size, it is likely
that these results reflect a false-positive effect. No study findings suggest
that glutamine has an effect on burn wound infection or on non-wound infection.
All other agents investigated showed no evidence of an effect on mortality,
length of stay or burn wound infection or non-wound infection rates.
AUTHORS' CONCLUSIONS: Although we found evidence of an effect of glutamine on
mortality reduction, this finding should be taken with care. The number of study
participants analysed in this systematic review was not sufficient to permit
conclusions that recommend or refute the use of glutamine. Glutamine may be
effective in reducing mortality, but larger studies are needed to determine the
overall effects of glutamine and other immunonutrition agents.
DOI: 10.1002/14651858.CD007174.pub2
PMID: 25536183 [Indexed for MEDLINE]
