title: Immunonutrition in the intensive care unit. A systematic review and consensus statement.
abstract: OBJECTIVE
  To systematically review the effects of enteral nutrition with pharmaconutrients-enriched diets in critically ill patients and to establish recommendations for their use.
  
  
  METHODS
  Computerized bibliographic search of published research and citation review of relevant articles.
  
  
  METHODS
  Randomized clinical trials of critically ill patients treated with enteral nutrition comparing diets enriched with pharmaconutrients vs not enriched diets were included. Infectious complications and outcome variables (days on mechanical ventilation, ICU and hospital length of stay and mortality) were evaluated. Studies were classified in four subgroups according to the patient's primary diagnosis: surgical, trauma, burned or medical.
  
  
  METHODS
  A group of experts in methodology performed data extraction and statistical processes. A global analysis of the studies was done and also a separate study for each subgroup. Results of the meta-analysis were discussed within a 'clinical group' of clinicians with experience in the nutritional support of ICU patients, in order to find agreement about recommendations for the use of pharmaconutrients-enriched diets in critically ill patients.
  
  
  RESULTS
  Independent review of 267 articles identified 26 relevant primary studies. Global results indicate that there was a reduction in infection rate in the pharmaconutrition group, considering the appreciated lower incidence in abdominal abscesses (OR: 0.26, CI: 0.12-0.55) (P=0.005), nosocomial pneumonia (OR: 0.54, CI: 0.35-0.84) (P=0.007) and bacteremia (OR: 0.45, CI: 0.35-0.84) (P=0.0002). Also, patients treated with pharmaconutrition diets have a reduction in time on mechanical ventilation (mean 2.25 days, CI: 0.5-3.9) (P=0.009), ICU length of stay (mean reduction of 1.6 days, CI: 1.9-1.2) (P<0.0001) and hospital length of stay (mean reduction of 3.4 days, CI: 4.0-2.7) (P<0.0001). No effects were appreciated on mortality (OR: 1.10, CI: 0.85-1.42) (P=0.5). Nevertheless, the separate analysis for each subgroup showed that the reported beneficial effects were not the same for each patient population. Also, the clinician panel of experts identifies several problems in the published data about enteral pharmaconutrition in critically ill patients. In spite of the subgroup differences and of the problems detected, the clinician group considered that the appreciated results could support a Grade B recommendation for the use of these formulas in ICU patients.
  
  
  CONCLUSIONS
  Considering the beneficial effects and the absence of detrimental ones, the use of diets enriched with pharmaconutrients could be recommended in ICU patients requiring enteral feeding. Nevertheless, more investigation is needed in this field in order to find the more appropriate population of patients that can benefit from this nutritional therapy.
authors.affiliation: Intensive Care Unit Hospital Universitario 12 de Octubre, Madrid, Spain.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Montejo
authors.forename: Antonio
authors.initials: A
authors.lastname: Zarazaga
authors.forename: Jorge
authors.initials: J
authors.lastname: López-Martínez
authors.forename: Gerard
authors.initials: G
authors.lastname: Urrútia
authors.forename: Marta
authors.initials: M
authors.lastname: Roqué
authors.forename: Antonio L
authors.initials: AL
authors.lastname: Blesa
authors.forename: Sebastián
authors.initials: S
authors.lastname: Celaya
authors.forename: Ramón
authors.initials: R
authors.lastname: Conejero
authors.forename: Cristóbal
authors.initials: C
authors.lastname: Galbán
authors.forename: Abelardo
authors.initials: A
authors.lastname: García de Lorenzo
authors.forename: Teodoro
authors.initials: T
authors.lastname: Grau
authors.forename: Alfonso
authors.initials: A
authors.lastname: Mesejo
authors.forename: Carlos
authors.initials: C
authors.lastname: Ortiz-Leyba
authors.forename: Mercé
authors.initials: M
authors.lastname: Planas
authors.forename: Javier
authors.initials: J
authors.lastname: Ordóñez
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Jiménez
mesh_terms: D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000628:therapy*; D004750:Enteral Nutrition; D017052:Hospital Mortality; D006801:Humans; D007107:Immune System / Q000502:physiology; D007362:Intensive Care Units; D009747:Nutritional Physiological Phenomena; D017063:Outcome Assessment, Health Care; D016032:Randomized Controlled Trials as Topic