Omega-3 Fish Oil Reduces Mortality Due to Severe Sepsis with Acute Gastrointestinal Injury Grade III

The efficacy and acceptability of anti-inflammatory omega-3 polyunsaturated fatty acid supplements in sepsis management: a network meta-analysis of randomized controlled trials

Sepsis is a critical medical condition associated with high mortality for patients. Current pharmacological strategies for sepsis management or prevention had not achieved satisfactory results. The omega-3 fatty acids, with anti-inflammatory benefits, are considered to be promising agents for sepsis management/prevention. The aim of this network meta-analysis (NMA) is to compare the efficacy of various dosages and formulations of fish oil supplements for sepsis management and sepsis prevention. The current NMA consisted of two parts: (1) sepsis management and (2) sepsis prevention. The PubMed, ClinicalKey, Embase, ProQuest, Cochrane CENTRAL, ScienceDirect, Web of Science, and ClinicalTrials.gov databases were systematically searched to date of February 22nd, 2024 for relevant randomized controlled trials (RCTs). RCTs were eligible for inclusion if they enrolled participants with a diagnosis of sepsis or who with high risk for sepsis. All NMA procedures were conducted under the frequentist model. The primary outcomes assessed are (1) mortality rate in sepsis treatment or (2) incidence of sepsis in sepsis prevention. Our NMA, based on 28 RCTs and 1718 participants (mean age=51.6 years, mean female proportion=35.6 %), showed that (1) high dose parenteral fish oil supplement yield the lowest mortality rate in sepsis management in adult patients, and (2) high dose enteral fish oil supplement yield the lowest incidence of sepsis in pediatric patients. This study provides compelling evidence that high-dose fish oil supplements provide beneficial effects for both sepsis management and sepsis prevention. Our findings provide a preliminary rationale for future large-scale RCTs to investigate the role of fish oil supplementation in sepsis management or prevention.

Omega-3 fatty acids in parenteral nutrition - A systematic review with network meta-analysis on clinical outcomes

BACKGROUND & AIMS

Accumulating scientific evidence supports the benefits of parenteral nutrition (PN) with fish oil (FO) containing intravenous lipid emulsions (ILEs) on clinical outcomes. Yet, the question of the most effective ILE remains controversial. We conducted a network meta-analysis (NMA) to compare and rank different types of ILEs in terms of their effects on infections, sepsis, ICU and hospital length of stay, and in-hospital mortality in adult patients.

METHODS

MEDLINE, EMBASE, and Web of Science databases were searched for randomized controlled trials (RCTs) published up to May 2022, investigating ILEs as a part of part of PN covering at least 70% of total energy provision. Lipid emulsions were classified in four categories: FO-ILEs, olive oil (OO)-ILEs, medium-chain triglyceride (MCT)/soybean oil (SO)-ILEs, and pure SO-ILEs. Data were statistically combined through Bayesian NMA and the Surface Under the Cumulative RAnking (SUCRA) was calculated for all outcomes.

RESULTS

1651 publications were retrieved in the original search, 47 RCTs were included in the NMA. For FO-ILEs, very highly credible reductions in infection risk versus SO-ILEs [odds ratio (OR) = 0.43 90% credibility interval (CrI) (0.29-0.63)], MCT/soybean oil-ILEs [0.59 (0.43-0.82)], and OO-ILEs [0.56 (0.33-0.91)], and in sepsis risk versus SO-ILEs [0.22 (0.08-0.59)], as well as substantial reductions in hospital length of stay versus SO-ILEs [mean difference (MD) = -2.31 (-3.14 to -1.59) days] and MCT/SO-ILEs (-2.01 (-2.82 to -1.22 days) were shown. According to SUCRA score, FO-ILEs were ranked first for all five outcomes.

CONCLUSIONS

In hospitalized patients, FO-ILEs provide significant clinical benefits over all other types of ILEs, ranking first for all outcomes investigated.

REGISTRATION NO

PROSPERO 2022 CRD42022328660.

[Parenteral supplementation with EPA/DHA omega-3 fatty acids improves recovery prognosis in critically ill patients]

Introduction

Introduction: the decision to supplement total parenteral nutrition (TPN) with emulsions of omega-3 (Ω3) eicosapentaenoic (EPA) and docosahexaenoic (DHA) fatty acids (FA) of marine origin is based on the clinical benefits obtained in different medical situations and surgical procedures, among which reductions in hospital stay, days of mechanical ventilation, incidence of infections and mortality stand out. However, the evidence in critically ill patients remains contradictory. Objective: the objective of this clinical trial was to analyze the effect of supplementation with EPA/DHA Ω3 FAs on clinical prognostic markers - medical, nutritional and biochemical - in critically ill patients, relating to outcome. Method: a clinical, controlled, randomized, single-center trial in 64 critically ill adult patients, of which 47 patients were randomized to receive TPN supplemented with EPA/DHA Ω3 FAs in doses of 0.1 g/kg/day (n = 23) and 0.2 g/kg/day (n = 24), compared with a historical control group with TPN without supplementation (n = 17). Clinical prognosis markers were determined at baseline and at the end of nutritional support (medical, nutritional and biochemical). Results: the two groups with supplementation showed a statistically significant reduction in mortality (p < 0.005); the clinical prognostic markers SOFA, APACHE II, SAPS 3, NUTRIC, RTL and CRS were consistent in showing a significant improvement (p < 0.005), of prognosis with doses of 0.1 and 0.2 g/kg/day of EPA/DHA Ω3 FAs, respectively. Conclusion: supplementation of parenteral nutrition with EPA/DHA Ω3 fatty acids at doses of 0.1 g and 0.2 g/kg/day improves recovery prognosis and the probability of survival in critically ill patients.

Effects of fish oil-containing nutrition supplementation in adult sepsis patients: a systematic review and meta-analysis

BACKGROUND

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Although fish oil has been used as an immunonutritional preparations for the treatment of sepsis patients, there is still controversy as to whether it is beneficial to them. We systematically reviewed published clinical trial data to evaluate the effectiveness of fish oil-containing nutrition supplementation in sepsis patients.

METHODS

A systematic search was undertaken in PubMed, Embase, Chinese Biomedicine Database, the Cochrane Library and the China Knowledge Resource Integrated Database to obtain clinical controlled trails. RCTs on nutrition therapy containing fish oil among adult sepsis patients were selected for analysis in comparison with routine therapy.

RESULTS

Twenty-five published trials were included in the meta-analysis. Fish oil-containing nutrition supplementation reduced the mortality compared with the control group (relative risk (RR) 0.74, I ² = 0%). Fish oil also shortened the ICU stay (MD -3.57 days; 95% CI -4.54, -2.59; p<0.00001; I ² = 76%), hospital stay (MD -9.92 days; 95% CI -15.37, -4.46; p = 0.0004; I ² = 91%) and the duration of mechanical ventilation support (MD -2.26; 95% CI -4.27, -0.26; p = 0.03; I ² = 83%). A subgroup analysis based on the route of administration revealed that parenteral administration of fish oil could reduce mortality in septic patients (RR =0.68, I ² = 0%), but no significant difference in mortality was observed in the fish oil group administered by enteral route (RR = 0.80, I ² = 0%). No statistically significant publication biases were detected for the above clinical endpoints (p>0.05).

CONCLUSIONS

Parenteral nutrition containing fish oil could significantly decrease mortality in sepsis patients while enteral administration could not. Fish oil-containing nutrition supplementation.

Omega-3 fatty acids impair miR-1-3p-dependent Notch3 down-regulation and alleviate sepsis-induced intestinal injury

Background

Sepsis is a troublesome syndrome that can cause intestinal injury and even high mortality rates. Omega-3 fatty acids (FAs) are known to protect against intestinal damage. Accordingly, the current study set out to explore if omega-3 FAs could affect sepsis-induced intestinal injury with the involvement of the microRNA (miR)-1-3p/Notch3-Smad axis.

Methods

First, cecal ligation and perforation (CLP) was performed to establish septic mouse models in C57BL/6J mice, and mouse intestinal epithelial MODE-K cells were induced by lipopolysaccharide (LPS) to establish sepsis cell models. The CLP-induced septic mice or LPS-exposed cells were subjected to treatment with Omega-3 FAs and activin (Smad signaling activator), miR-1-3p inhibitor and over-expressed/short hairpin RNA (oe-/sh)-Notch3 to explore their roles in inflammation, intestinal oxidative stress and cell apoptosis. A dual-luciferase reporter gene assay was further performed to verify the regulatory relationship between miR-1-3p and Notch3.

Results

Omega-3 FAs inhibited CLP-induced intestinal injury and ameliorated LPS-induced intestinal epithelial cell injury by down-regulating miR-1-3p, as evidenced by decreased levels of tumor necrosis factor-α, interleukin-1β (IL-1β) and IL-6, in addition to diminished levels of reactive oxygen species, malondialdehyde levels and superoxide dismutase activity. Furthermore, miR-1-3p could down-regulate Notch3, which inactivated the Smad pathway.

Conclusion

Collectively, our findings indicated that omega-3 FAs elevate the expression of Notch3 by down-regulating miR-1-3p, and then blocking the Smad pathway to alleviate intestinal epithelial inflammation and oxidative stress injury caused by sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10020-021-00425-w.

Omega-6 sparing effects of parenteral lipid emulsions-an updated systematic review and meta-analysis on clinical outcomes in critically ill patients

BACKGROUND

Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in pro-inflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL and CENTRAL was conducted to identify all randomized controlled trials in critically ill patients published from inception to June 2021, which investigated clinical omega-6 sparing effects. Two independent reviewers extracted bias risk, treatment details, patient characteristics and clinical outcomes. Random effect meta-analysis was performed.

RESULTS

1054 studies were identified in our electronic search, 136 trials were assessed for eligibility and 26 trials with 1733 critically ill patients were included. The median methodologic score was 9 out of 14 points (95% confidence interval [CI] 7, 10). Omega-6 FA sparing PN in comparison with traditional lipid emulsions did not decrease overall mortality (20 studies; risk ratio [RR] 0.91; 95% CI 0.76, 1.10; p = 0.34) but hospital length of stay was substantially reduced (6 studies; weighted mean difference [WMD] - 6.88; 95% CI - 11.27, - 2.49; p = 0.002). Among the different lipid emulsions, fish oil (FO) containing PN reduced the length of intensive care (8 studies; WMD - 3.53; 95% CI - 6.16, - 0.90; p = 0.009) and rate of infectious complications (4 studies; RR 0.65; 95% CI 0.44, 0.95; p = 0.03). When FO was administered as a stand-alone medication outside PN, potential mortality benefits were observed compared to standard care.

CONCLUSION

Overall, these findings highlight distinctive omega-6 sparing effects attributed to PN. Among the different lipid emulsions, FO in combination with PN or as a stand-alone treatment may have the greatest clinical impact. Trial registration PROSPERO international prospective database of systematic reviews (CRD42021259238).

Guidelines for the provision of nutrition support therapy in the adult critically Ill patient: American society for parenteral and enteral nutrition

BACKGROUND

New randomized controlled trials have been conducted since publication of the 2016 ASPEN/SCCM critical care nutrition guideline. This guideline updates recommendations for foundational questions central to critical care nutrition support.

METHODS

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose (2) higher vs lower protein dose (3) exclusive isocaloric PN vs EN (4) supplemental PN (SPN) plus EN vs EN alone (5a) mixed oil lipid injectable emulsions (ILE) vs soybean oil, and (5b) Fish oil (FO) containing ILE vs non-FO ILE. To assess safety, weight based energy intake was plotted against hospital mortality when study heterogeneity precluded meaningful Forest plot inferences.

RESULTS

Between 1/1/2001 and 07/15/2020, 2,320 citations were identified and data were abstracted from 39 trials, including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Due to lack in certainty regarding harm, the energy prescription recommendation was decreased to 12-25kcal/kg/day.

CONCLUSION

No differences in clinical outcomes were identified among numerous nutritional interventions, including higher energy or protein intake, isocaloric PN or EN, supplemental PN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors.  This article is protected by copyright. All rights reserved.

Omega-3 fatty acid supplementation is associated with favorable outcomes in patients with sepsis: an updated meta-analysis

Objectives

The efficacy of omega-3 fatty acids in the treatment of sepsis is controversial. We conducted an updated meta-analysis to clarify the efficacy of omega-3 fatty acids in patients with sepsis.

Methods

PubMed, EMBASE, and the Cochrane Library were searched for randomized clinical trials (RCTs) on omega-3 fatty acid supplementation in adults with sepsis.

Results

Twenty eligible RCTs involving 1514 patients were included in the meta-analysis. Omega-3 fatty acid supplementation was linked to reductions of mortality (I² = 0, relative risk [RR] = 0.82, 95% confidence interval [CI] = 0.69–0.97), the duration of mechanical ventilation (DMV; I² = 74%, weighted mean difference [WMD] = −2.20, 95% CI = −4.00 to −0.40), and intensive care unit (ICU) length of stay (LOS; I² = 91%, WMD = −3.86, 95% CI = −5.72 to −2.01). Subgroup analysis illustrated that mortality was significantly reduced in patients with sepsis and gastrointestinal dysfunction (RR = 0.5, 95% CI = 0.29–0.86, I² = 0).

Conclusion

Omega-3 fatty acid supplementation might be associated with reduced mortality in patients with sepsis, especially those with gastrointestinal dysfunction. Furthermore, omega-3 fatty acid administration could shorten DMV and ICU LOS.

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis

Background

Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.

Methods

We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses.

Results

In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (− 3.05 days; 95% CI − 5.03, − 1.07; p = 0.003) and ICU length of stay (LOS) (− 1.89 days; 95% CI − 3.33, − 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (− 3.98 days; 95% CI − 6.90, − 1.06; p = 0.008) and ICU LOS (− 2.14 days; 95% CI − 3.89, − 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US.

Conclusion

These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.

Study registration

PROSPERO CRD42019129311.

Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US

Background

ω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US.

Methods

This pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses.

Results

Overall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively).

Conclusion

This cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.

Composition and Functionality of Lipid Emulsions in Parenteral Nutrition: Examining Evidence in Clinical Applications

Lipid emulsions (LEs), an integral component in parenteral nutrition (PN) feeding, have shifted from the primary aim of delivering non-protein calories and essential fatty acids to defined therapeutic outcomes such as reducing inflammation, and improving metabolic and clinical outcomes. Use of LEs in PN for surgical and critically ill patients is particularly well established, and there is enough literature assigning therapeutic and adverse effects to specific LEs. This narrative review contrarily puts into perspective the fatty acid compositional (FAC) nature of LE formulations, and discusses clinical applications and outcomes according to the biological function and structural functionality of fatty acids and co-factors such as phytosterols, α-tocopherol, emulsifiers and vitamin K. In addition to soybean oil-based LEs, this review covers clinical studies using the alternate LEs that incorporates physical mixtures combining medium- and long-chain triglycerides or structured triglycerides or the unusual olive oil or fish oil. The Jaded score was applied to assess the quality of these studies, and we report outcomes categorized as per immuno-inflammatory, nutritional, clinical, and cellular level FAC changes. It appears that the FAC nature of LEs is the primary determinant of desired clinical outcomes, and we conclude that one type of LE alone cannot be uniformly applied to patient care.

Antioxidant and Cardioprotective Effects of EPA on Early Low-Severity Sepsis through UCP3 and SIRT3 Upholding of the Mitochondrial Redox Potential

Sepsis still causes death, often through cardiac failure and mitochondrial dysfunction. Dietary ω3 polyunsaturated fatty acids are known to protect against cardiac dysfunction and sepsis lethality. This study set out to determine whether early low-severity sepsis alters the cardiac mitochondrial function in animals fed a Western-type diet and whether dietary eicosapentaenoic acid (EPA) administration protects the myocardium against the deleterious effects of sepsis and if so to seek possible mechanisms for its effects. Rats were divided into two groups fed either an ω3 PUFA-deficient diet (“Western diet,” DEF group) or an EPA-enriched diet (EPA group) for 5 weeks. Each group was subdivided into two subgroups: sham-operated rats and rats subjected to cecal ligation and puncture (CLP). In vivo cardiac mechanical function was examined, and mitochondria were harvested to determine their functional activity. Oxidative stress was evaluated together with several factors involved in the regulation of reactive oxygen species metabolism. Sepsis had little effect on cardiac mechanical function but strongly depressed mitochondrial function in the DEF group. Conversely, dietary EPA greatly protected the mitochondria through a decreased oxidative stress of the mitochondrial matrix. The latter was probably due to an increased uncoupling protein-3 expression, already seen in the sham-operated animals. CLP rats in the EPA group also displayed increased mitochondrial sirtuin-3 protein expression that could reinforce the upholding of oxidative phosphorylation. Dietary EPA preconditioned the heart against septic damage through several modifications that protect mitochondrial integrity. This preconditioning can explain the cardioprotective effect of dietary EPA during sepsis.

ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis

This systematic review and meta-analysis investigated ω-3 fatty-acid enriched parenteral nutrition (PN) vs standard (non-ω-3 fatty-acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω-3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω-3 fatty-acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49-0.72; P < 0.00001). Patients given ω-3 fatty-acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42-3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36-2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω-3 fatty-acid enriched PN (RR 0.44, 95% CI 0.28-0.70; P = 0.0004). Mortality rate (co-primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65-1.07; P = 0.15) for the ω-3 fatty-acid enriched group. In summary, ω-3 fatty-acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω-3-enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN.

The fragility of statistically significant results from clinical nutrition randomized controlled trials

BACKGROUND & AIMS

Recently, a parameter called "Fragility index" (FI) has been proposed, which measures how many events the statistical significance relies on. The lower the FI the more "fragile" the results, and thus more care should be taken when interpreting the results. Our aim in this study was to check FI of nutritional trials.

METHODS

We conducted a systematic review of human clinical nutrition RCTs that report statistically significant dichotomous primary outcomes. We searched the EMBASE, MEDLINE, and Scopus databases. The FI of primary outcomes using the Fisher exact test was calculated and checked the correlations of FI with the number of randomised trials, the p-value of primary outcomes, the publication date, the journal impact factor and the number of patients lost to follow-up.

RESULTS

The initial database search revealed 5790 articles, 37 of which were included in qualitative synthesis. The median (IQR) FI for all studies was 1 (1-3). 28 studies (75.7%) had an FI lower or equal to 2, and in 12 (32.43%) articles, the FI was lower than the number of patients lost to follow-up. No correlations were found between FI and the study characteristics (number of randomized patients, p value of primary outcome, event ratio in experimental group, event ratio in control group, publication date, journal impact factor, lost to follow-up).

CONCLUSION

The results of RCTs in nutritional research often rely on a small number of events or patients. The number of patients lost to follow-up is frequently higher than the FI calculation. Formulating recommendations based on RCTs should be done with caution and FI may be used as auxiliary parameter when assessing the robustness of their findings.

Intravenous n-3 fatty acids in the critically ill

PURPOSE OF REVIEW

Lipid emulsions are an integral part of parenteral nutrition. Enteral nutrition is the preferred route to feed critically ill patients and parenteral nutrition is used in case of contraindications or when enteral nutrition does not reach the nutritional goals. n-3 Lipids are included into some newer lipid emulsions including fish oil or may be added by a fish oil-based lipid emulsion to lipid emulsion without fish oil. This review focuses on recent clinical trials, metaanalyses, and guidelines of parenteral nutrition with n-3 lipids in critically ill patients.

RECENT FINDINGS

Two single-center studies report a mortality benefit of adding fish oil-based lipid emulsions to the parenteral nutrition. Metaanalyses performed without these two studies had demonstrated beneficial effects of n-3 lipids regarding infections, length of stay, and time of mechanical ventilation but not on mortality. However, all metaanalyses judged the database derived from the underlying studies as not sufficient for a firm recommendation. Consecutively, guidelines and expert groups issue very cautious recommendations for the use of n-3 lipids in parenteral nutrition.

SUMMARY

Beneficial effects of n-3 lipids in trials and metaanalyses became available; however, high-quality multicenter randomized controlled trials are needed before more endorsing recommendation will be available.

Impact of Intravenous Lipid Emulsions Containing Fish Oil on Clinical Outcomes in Critically Ill Surgical Patients: A Literature Review

A fish oil (FO)-containing intravenous lipid emulsion (ILE; FO ILE) has been approved for use in the United States; however, similar formulations have been used throughout Europe and China in intensive care units since the 1990s. This literature review evaluates the evidence regarding the effectiveness of FO ILE on clinical outcomes in the critically ill surgical patient population. The review of available evidence demonstrates that ILEs containing FO lower triglyceride concentrations, inflammatory markers, and liver function enzymes, and improve morbidity and mortality outcomes in critically ill surgical patients.

Current evidence on ω-3 fatty acids in enteral nutrition in the critically ill: A systematic review and meta-analysis

Fish oil exerts anti-inflammatory and immunomodulatory properties that may be beneficial for critically ill patients, thus multiple randomized controlled trials and meta-analyses have been performed. However, controversy remains as to whether fish oil-enriched enteral nutrition can improve clinical outcomes in adult critically ill patients in intensive care units (ICUs). The aim of this study was to provide an up-to-date systematic review and meta-analysis of all randomized controlled trials of fish oil-containing enteral nutrition addressing relevant clinical outcomes in critically ill patients. A systematic literature search was conducted. The primary outcome was 28-d mortality. Secondary outcomes were ICU and hospital mortality, ICU and hospital length of stay (LOS), ventilation duration, and infectious complications. Predefined subgroup and sensitivity analyses were performed. Twenty-four trials, enrolling 3574 patients, met the inclusion criteria. The assessment of risk for bias showed that most of included studies were of moderate quality. The overall results revealed no significant effects of enteral fish oil supplementation on 28-d, ICU or hospital mortality. However, ICU LOS and ventilation duration were significantly reduced in patients receiving fish oil supplementation. Furthermore, subgroup analysis revealed a significant reduction in 28-d mortality, ICU LOS, and ventilation duration in patients with acute respiratory distress syndrome but not in other subgroups. When comparing high- and low-quality trials, significant reductions in 28-d mortality and ventilation duration in low-quality trials only were observed. Regarding ICU LOS a significant reduction was observed in high-quality trials; whereas only a trend was observed in low-quality trials. No significant effects on hospital LOS or infectious complications were observed in overall or subgroup analyses. Enteral fish oil supplementation cannot be recommended for critically ill patients, as strong scientific evidence for improved clinical benefits was not found. There is a signal of mortality benefit in patients with acute respiratory distress syndrome; however, results are based on low-quality studies. Further research should focus on the relation between the individual critically ill patients' immune response, the administration of fish oil, and clinical outcomes.

Correlation analysis of omega-3 fatty acids and mortality of sepsis and sepsis-induced ARDS in adults: data from previous randomized controlled trials

Objective

This study aimed to investigate the possible effect of omega-3 fatty acids on reducing the mortality of sepsis and sepsis-induced acute respiratory distress syndrome (ARDS) in adults.

Methods

Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) database, WangFang database, and Chinese BioMedical Literature Database from their inception to March 6, 2017, were searched using systematic review researching methods. Five factors were analyzed to investigate the correlation between omega-3 fatty acids (either parenteral or enteral supplementation) and mortality rate.

Results

Forty randomized controlled trials (RCTs) were initially included, but only 25 of them assessed mortality. Of these RCTs, nine used enteral nutrition (EN) and 16 used parenteral nutrition (PN). The total mortality rate in the omega-3 fatty acid group was lower than that in the control group. However, the odds ratio (OR) value was not significantly different in the EN or PN subgroup. Eighteen RCTs including 1790 patients with similar severity of sepsis and ARDS were also analyzed. The OR value was not significantly different in the EN or PN subgroup. Omega-3 fatty acids did not show positive effect on improving mortality of sepsis-induced ARDS (p = 0.39). But in EN subgroup, omega-3 fatty acids treatment seemed to have some benefits in reducing mortality rate (p = 0.04). In the RCTs including similar baseline patients, partial correlation analysis found that the concentration ratio of n-6 to n-3 fatty acids had positive correlation with reduction of mortality (RM) (γ = 0.60, P = 0.02), whereas the total number of each RCT had negative correlation with RM (γ = − 0.54, P = 0.05).

Conclusions

This review found that omega-3 fatty acid supplementation could reduce the mortality rate of sepsis and sepsis-induced ARDS. However, further investigation based on suitable concentrations and indications is needed to support the findings.