Warttig Sheryl, Alderson Phil, Lewis Sharon R, Smith Andrew F
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, UK, M1 4BD.
Cochrane Database Syst Rev. 2016 Nov 22;11(11):CD009906. doi: 10.1002/14651858.CD009906.pub2.
BACKGROUND: Inadvertent perioperative hypothermia (a drop in core temperature to below 36°C) occurs because normal temperature regulation is disrupted during surgery, mainly because of the effects of anaesthetic drugs and exposure of the skin for prolonged periods. Many different ways of maintaining body temperature have been proposed, one of which involves administration of intravenous nutrients during the perioperative period that may reduce heat loss by increasing metabolism, thereby increasing heat production. OBJECTIVES: To assess the effectiveness of preoperative or intraoperative intravenous nutrients in preventing perioperative hypothermia and its complications during surgery in adults. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; November 2015) in the Cochrane Library; MEDLINE, Ovid SP (1956 to November 2015); Embase, Ovid SP (1982 to November 2015); the Institute for Scientific Information (ISI) Web of Science (1950 to November 2015); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO host; 1980 to November 2015), as well as the reference lists of identified articles. We also searched the Current Controlled Trials website and ClincalTrials.gov. SELECTION CRITERIA: Randomized controlled trials (RCTs) of intravenous nutrients compared with control or other interventions given to maintain normothermia in adults undergoing surgery. DATA COLLECTION AND ANALYSIS: Two review authors extracted data and assessed risk of bias for each included trial, and a third review author checked details if necessary. We contacted some study authors to request additional information. MAIN RESULTS: We included 14 trials (n = 565), 13 (n = 525) of which compared intravenous administration of amino acids to a control (usually saline solution or Ringer's lactate). The remaining trial (n = 40) compared intravenous administration of fructose versus a control. We noted much variation in these trials, which used different types of surgery, variable durations of surgery, and different types of participants. Most trials were at high or unclear risk of bias owing to inappropriate or unclear randomization methods, and to unclear participant and assessor blinding. This may have influenced results, but it is unclear how results might have been influenced.No trials reported any of our prespecified primary outcomes, which were risk of hypothermia and major cardiovascular events. Therefore, we decided to analyse data related to core body temperature instead as a primary outcome. It was not possible to conduct meta-analysis of data related to amino acid infusion for the 60-minute and 120-minute time points, as we observed significant statistical heterogeneity in the results. Some trials showed that higher temperatures were associated with amino acids, but not all trials reported statistically significant results, and some trials reported the opposite result, where the amino acid group had a lower core temperature than the control group. It was possible to conduct meta-analysis for six studies (n = 249) that provided data relating to the end of surgery. Amino acids led to a statistically significant increase in core temperature in comparison to those receiving control (MD = 0.46°C 95% CI 0.33 to 0.59; I 0.0%; random-effects; moderate quality evidence).Three trials (n = 155) reported shivering as an outcome. Meta-analysis did not show a clear effect, and so it is uncertain whether amino acids reduce the risk of shivering (RR 0.36, 95% CI 0.13 to 1.00; I = 93%; random-effects model; very low-quality evidence). AUTHORS' CONCLUSIONS: Intravenous amino acids may keep participants up to a half-degree C warmer than the control. This difference was statistically significant at the end of surgery, but not at other time points. However, the clinical importance of this finding remains unclear. It is also unclear whether amino acids have any effect on the risk of shivering and if intravenous nutrients confer any other benefits or harms, as high-quality data about these outcomes are lacking.
背景:围手术期意外低温(核心体温降至36°C以下)的发生是因为手术期间正常体温调节被打乱,主要是由于麻醉药物的作用以及皮肤长时间暴露。已经提出了许多维持体温的不同方法,其中一种方法是在围手术期给予静脉营养,这可能通过增加新陈代谢来减少热量散失,从而增加产热。 目的:评估术前或术中静脉营养在预防成人手术期间围手术期低温及其并发症方面的有效性。 检索方法:我们检索了Cochrane图书馆中的Cochrane对照试验中央注册库(CENTRAL;2015年11月);MEDLINE,Ovid SP(1956年至2015年11月);Embase,Ovid SP(1982年至2015年11月);科学信息研究所(ISI)科学网(1950年至2015年11月);以及护理及相关健康文献累积索引(CINAHL,EBSCO主机;1980年至2015年11月),以及已识别文章的参考文献列表。我们还检索了当前对照试验网站和ClinicalTrials.gov。 选择标准:将静脉营养与对照或其他干预措施进行比较的随机对照试验(RCT),这些干预措施用于在接受手术的成人中维持正常体温。 数据收集与分析:两位综述作者提取数据并评估每个纳入试验的偏倚风险,如有必要,第三位综述作者会检查细节。我们联系了一些研究作者以索取更多信息。 主要结果:我们纳入了14项试验(n = 565),其中13项试验(n = 525)将氨基酸静脉输注与对照(通常是生理盐水溶液或乳酸林格氏液)进行了比较。其余一项试验(n = 40)将果糖静脉输注与对照进行了比较。我们注意到这些试验存在很大差异,它们使用了不同类型的手术、不同的手术持续时间以及不同类型的参与者。由于随机化方法不当或不明确,以及参与者和评估者的盲法不明确,大多数试验存在高偏倚风险或偏倚风险不明确。这可能影响了结果,但尚不清楚结果可能受到了怎样的影响。没有试验报告我们预先设定的任何主要结局,即低温风险和主要心血管事件。因此,我们决定将与核心体温相关的数据作为主要结局进行分析。对于60分钟和120分钟时间点与氨基酸输注相关的数据,无法进行荟萃分析,因为我们观察到结果存在显著的统计学异质性。一些试验表明较高的体温与氨基酸有关,但并非所有试验都报告了具有统计学意义的结果,一些试验报告了相反的结果,即氨基酸组的核心体温低于对照组。对于提供了与手术结束相关数据的六项研究(n = 249),可以进行荟萃分析。与接受对照的患者相比,氨基酸导致核心体温有统计学意义的升高(MD = 0.46°C,95% CI 0.33至0.59;I² = 0.0%;随机效应;中等质量证据)。三项试验(n = 155)将寒战作为结局进行了报告。荟萃分析未显示出明确的效果,因此尚不确定氨基酸是否能降低寒战风险(RR = 0.36,95% CI 0.13至1.00;I² = 93%;随机效应模型;极低质量证据)。 作者结论:静脉输注氨基酸可能使参与者的体温比对照组高近0.5摄氏度。这种差异在手术结束时具有统计学意义,但在其他时间点则不然。然而,这一发现的临床重要性仍不明确。同样不清楚氨基酸是否对寒战风险有任何影响,以及静脉营养是否带来任何其他益处或危害,因为缺乏关于这些结局的高质量数据。
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