What is the evidence for the use of parenteral nutrition (PN) in critically ill surgical patients: a systematic review and meta-analysis

Background Malnutrition is associated with poor outcomes in surgical patients and corrective enteral feeding may not be possible. This is a particular problem in the acute setting where malnutrition is prevalent. The aim of this systematic review was to evaluate the use of parenteral nutrition (PN) in critically ill surgical patients. Methods This review was registered with PROSPERO (CRD42017079567). Searches of the CENTRAL, EMBASE, and MEDLINE databases were performed using a predefined strategy. Randomised trials published in English since 1995, reporting a comparison of PN vs any comparator in a critically ill surgical population were included. The primary outcome was mortality. Risk of bias was assessed using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation assessment. Meta-analysis was performed using a random effects model to assess variation in mortality and length of stay. Results Fourteen RCTs were identified; standard PN was compared vs other forms of PN in ten studies, to PN with variable dose amino acids in one, and to enteral nutrition (EN) in three. In trials comparing glutamine-supplemented PN (PN-GLN) to PN, a non-significant reduction in mortality was noted (risk difference − 0.08. 95% CI − 0.17, 0.01, p = 0.08). A trend for a reduction in length of stay was seen in PN-GLN to PN comparator (mean reduction − 2.4, 95% CI − 7.19 to 2.32 days, I² = 92%). Impact on other outcome measures varied in direction of effect. Conclusions PN may offer benefit in critically ill surgical patients. The size and quality of studies lead to uncertainty around the estimates of clinical effect, meaning a robust trial is required.