Murray Susan M, Pindoria Sima
National Collaborating Centre for Acute Care, Royal College of Surgeons of England, London, UK, WC2A 3PE.
Cochrane Database Syst Rev. 2009 Jan 21(1):CD002920. doi: 10.1002/14651858.CD002920.pub3.
This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates.
To determine efficacy of EN or PN support for patients receiving bone marrow transplant.
Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006.
RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients.
Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival.
In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN.
AUTHORS' CONCLUSIONS: In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.
这是对2002年第2期发表的原始Cochrane系统评价的更新。骨髓移植涉及给予毒性化疗和输注骨髓细胞。治疗后，患者可能出现食欲减退、粘膜炎和胃肠功能衰竭，导致营养不良。为预防这种情况，肠外营养（PN）支持通常是首选，但与感染风险增加相关。肠内营养（EN）是一种替代方法，添加底物也是如此。
确定EN或PN支持对接受骨髓移植患者的疗效。
2000年11月检索了Cochrane图书馆、MEDLINE、EMBASE和CINAHL，随后在2006年6月进行了检索。
比较一种营养支持形式与另一种营养支持形式或对照，用于骨髓移植患者的随机对照试验（RCT）。
确定了29项研究。收集了关于参与者特征、不良反应、中性粒细胞减少、体重变化百分比、移植物抗宿主病和生存率的数据。
在两项研究（82名参与者）中，与安慰剂相比，谷氨酰胺漱口水减少了患者中性粒细胞减少的天数（6.82天，95%CI（1.67至11.98），P = 0.009）。三项研究报告（103名参与者），与接受标准PN的患者相比，接受添加谷氨酰胺PN的患者住院时间缩短，为6.6天（95%CI 3.47至9.77，P = 0.00004）。然而，在更新中增加了另一项研究（147名参与者），这改变了汇总结果：接受添加谷氨酰胺PN的患者住院时间可能增加 - 0.22天（95%CI（1.29至1.72）。另外两项研究报告（73名参与者），与接受标准PN的患者相比，接受PN加谷氨酰胺的患者血培养阳性发生率降低（OR 0.23，95%CI 0.08至0.65，P = 0.006）。然而，更新中的一项研究（总共113名参与者）表明，血培养阳性的几率增加，但与标准PN相比，如果患者接受添加谷氨酰胺的PN，仍不太可能发生（OR 0.46，95%CI 0.20至1.04）。当将PN与静脉补液进行比较时（25名参与者），与接受标准静脉输液的患者相比，接受PN的患者发生导管相关感染的发生率更高（OR 21.23，95%CI 4.15至108.73，P = 0.0002）。更新中确定了一项研究，该研究认识到（55名参与者）接受静脉输液的患者住院时间可能较短，为3.30天（95%CI -0.38至6.98，P = 0.08），尽管这一结果不显著。如原始评价中所报告，仍然没有可评估的数据来正确比较PN与EN。
在本次更新中，一项比较PN加谷氨酰胺与标准PN的额外研究表明，与标准PN相比，添加谷氨酰胺的肠外营养在缩短住院时间方面的某些益处不再确定。当将添加谷氨酰胺的PN与标准PN进行比较时，患者可能不会更早出院，但与接受标准PN的患者相比，血培养阳性的发生率确实降低。在可能的情况下，应优先考虑使用静脉输液和口服饮食，而不是肠外营养，然而，如果患者即使在尝试肠内喂养后仍患有严重胃肠功能衰竭，则可以考虑添加谷氨酰胺的PN。
