Intravenous fish oil lipid emulsions in critically ill patients: an updated systematic review and meta-analysis

William Manzanares, Pascal L Langlois, Rupinder Dhaliwal, Margot Lemieux, Daren K Heyland, William Manzanares, Pascal L Langlois, Rupinder Dhaliwal, Margot Lemieux, Daren K Heyland

Abstract

Introduction: Intravenous fish oil (FO) lipid emulsions (LEs) are rich in ω-3 polyunsaturated fatty acids, which exhibit anti-inflammatory and immunomodulatory effects. We previously demonstrated that FO-containing LEs may be able to decrease mortality and ventilation days in patients who are critically ill. Since 2014, several additional randomized controlled trials (RCTs) of FO-containing LEs have been published. Therefore, the purpose of this systematic review was to update our previous systematic review with the aim of elucidating the efficacy of FO-containing LEs on clinical outcomes of patients who are critically ill.

Methods: We searched electronic databases from 1980 to 2014. We included four new RCTs conducted in critically ill adult patients in which researchers evaluated FO-containing LEs in parenterally or enterally fed patients.

Results: A total of 10 RCTs (n = 733) met inclusion criteria. The mean methodological score was 8 (range, 3 to 12). No effect on overall mortality was found. When we aggregated the results of five RCTs in which infections were reported, we found that FO-containing LEs significantly reduced infections (risk ratio (RR) = 0.64; 95% confidence interval (CI), 0.44 to 0.92; P = 0.02; heterogeneity I (2) = 0%). Subgroup analysis demonstrated that predominantly enteral nutrition-based trials showed a tendency toward a reduction in mortality (RR = 0.69; 95% CI, 0.40 to 1.18; P =0.18; heterogeneity I (2) =35%). High-quality trials showed a significant reduction in hospital length of stay (LOS) (weighted mean difference = -7.42; 95% CI, -11.89 to -2.94; P = 0.001), whereas low-quality trials had no effect (P = 0.45). The results of the test for subgroup differences in hospital LOS was significant (P = 0.001).

Conclusion: FO-containing LEs may be associated with a reduction in infections and also could be associated with a reduction in duration of ventilation and hospital LOS. Further large-scale RCTs are warranted and should be aimed at consolidating potential positive treatment effects.

Figures

Figure 1
Figure 1
Flow diagram of the literature search according to the Quality of Reporting of Meta-analyses statement [72].
Figure 2
Figure 2
Effects on mortality of fish oil lipid emulsion strategies (n =9). CI, Confidence interval; EN, Enteral nutrition; LCT, Long-chain triglycerides; MCT, Medium-chain triglycerides; M-H, Mantel-Haenszel test; PN, Parenteral nutrition.
Figure 3
Figure 3
Effects on infections of parenteral fish oil containing emulsions (n =5). CI, Confidence interval; EN, Enteral nutrition; LCT, Long-chain triglycerides; MCT, Medium-chain triglycerides; M-H, Mantel-Haenszel test; PN, Parenteral nutrition.
Figure 4
Figure 4
Effects on mechanical ventilation days of parenteral fish oil containing emulsions (n =6). CI, Confidence interval; EN, Enteral nutrition; IV, Inverse Variance; M-H, Mantel-Haenszel test; PN, Parenteral nutrition; SD, Standard deviation.
Figure 5
Figure 5
Effects on hospital length of stay of parenteral fish oil containing emulsions (n =7). CI, Confidence interval; EN, Enteral nutrition; IV, Inverse Variance; M-H, Mantel-Haenszel test; PN, Parenteral nutrition; SD, Standard deviation.
Figure 6
Figure 6
Effects on ICU length of stay of parenteral fish oil containing emulsions (n =7). CI, Confidence interval; EN, Enteral nutrition; IV, Inverse Variance; M-H, Mantel-Haenszel test; PN, Parenteral nutrition; SD, Standard deviation.

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