Abstract
BackgroundParenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in pro-inflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients.MethodsA systematic search of MEDLINE, EMBASE, CINAHL and CENTRAL was conducted to identify all randomized controlled trials in critically ill patients published from inception to June 2021, which investigated clinical omega-6 sparing effects. Two independent reviewers extracted bias risk, treatment details, patient characteristics and clinical outcomes. Random effect meta-analysis was performed.Results1054 studies were identified in our electronic search, 136 trials were assessed for eligibility and 26 trials with 1733 critically ill patients were included. The median methodologic score was 9 out of 14 points (95% confidence interval [CI] 7, 10). Omega-6 FA sparing PN in comparison with traditional lipid emulsions did not decrease overall mortality (20 studies; risk ratio [RR] 0.91; 95% CI 0.76, 1.10; p = 0.34) but hospital length of stay was substantially reduced (6 studies; weighted mean difference [WMD] − 6.88; 95% CI − 11.27, − 2.49; p = 0.002). Among the different lipid emulsions, fish oil (FO) containing PN reduced the length of intensive care (8 studies; WMD − 3.53; 95% CI − 6.16, − 0.90; p = 0.009) and rate of infectious complications (4 studies; RR 0.65; 95% CI 0.44, 0.95; p = 0.03). When FO was administered as a stand-alone medication outside PN, potential mortality benefits were observed compared to standard care.ConclusionOverall, these findings highlight distinctive omega-6 sparing effects attributed to PN. Among the different lipid emulsions, FO in combination with PN or as a stand-alone treatment may have the greatest clinical impact.Trial registration PROSPERO international prospective database of systematic reviews (CRD42021259238).Graphical abstract
Highlights
Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in proinflammatory omega-6 fatty acids (FAs)
Information sources We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews (CENTRAL) for all relevant Randomized controlled trial (RCT) published between January 1980 and June 2021 with the following keywords: “fat emulsion”, “lipid emulsion”, “lipid injectable emulsion”, “lipids”, “triglycerides”, “medium chain triglycerides”, “long chain triglycerides”, “polyunsaturated fatty acids”, “omega-3 fatty acids”, “omega-6 fatty acids”, “fish oil”, “olive oil”, “soybean oil”, “linoleic acid”, “linolenic acid”, “eicosapentaenoic acid”, “EPA”, “docosahexaenoic acid” and “DHA”
Included trials From the 1054 studies that were identified through our systematic searching, a total of 136 potential studies were sought for retrieval (Fig. 1). 40 trials covered nonICU, elective surgery and cancer patients and 31 trials did not report on our clinical outcomes. 23 studies were not RCTs, including systematic reviews, meta- or subanalyses
Summary
Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in proinflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients. Parenteral lipid emulsions are derived from plant—and especially soybean oil (SO) to provide the patient with essential long-chain triglycerides (LCTs). After aggregating 10 randomized controlled trials (RCTs) in 2015, Manzanares et al found that lipid emulsions with a FO component may reduce infectious complications, duration of mechanical ventilation (MV) and hospital length of stay (LOS) in critically ill patients [13]. In the most recent meta-analysis by Pradelli et al, FO containing parenteral nutrition (PN) again reduced the rate of infections and hospital as well as ICU LOS [14]. This systematic review and meta-analysis aims to give a broad and comprehensive update on the emerging topic
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