Immunonutrition as an adjuvant therapy for burns

Hannah B Tan; Stefan Danilla; Alexandra Murray; Ramón Serra; Regina El Dib; Tom OW Henderson; Jason Wasiak

doi:10.1002/14651858.CD007174.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 All‐cause mortality, Outcome 1 Glutamine vs control.

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Analysis 1.2

Comparison 1 All‐cause mortality, Outcome 2 Ornithine α‐ketoglutarate vs control.

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Analysis 1.3

Comparison 1 All‐cause mortality, Outcome 3 Branched‐chain amino acids vs control.

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Analysis 1.4

Comparison 1 All‐cause mortality, Outcome 4 Fish oil vs control.

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Analysis 1.5

Comparison 1 All‐cause mortality, Outcome 5 Combined immunonutrients vs control.

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Analysis 2.1

Comparison 2 Length of hospital stay, Outcome 1 Glutamine vs control.

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Analysis 2.2

Comparison 2 Length of hospital stay, Outcome 2 Ornithine α‐ketoglutarate vs control.

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Analysis 2.3

Comparison 2 Length of hospital stay, Outcome 3 Branched‐chain amino acids.

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Analysis 2.4

Comparison 2 Length of hospital stay, Outcome 4 Fish oil vs control.

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Analysis 2.5

Comparison 2 Length of hospital stay, Outcome 5 Combined immunonutrients vs control.

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Analysis 3.1

Comparison 3 Rate of burn wound infection, Outcome 1 Glutamine vs control.

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Analysis 3.2

Comparison 3 Rate of burn wound infection, Outcome 2 Ornithine α‐ketoglutarate vs control.

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Analysis 3.3

Comparison 3 Rate of burn wound infection, Outcome 3 Combined immunonutrients vs control.

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Analysis 4.1

Comparison 4 Rate of non‐wound infection, Outcome 1 Glutamine vs control.

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Analysis 4.2

Comparison 4 Rate of non‐wound infection, Outcome 2 Fish oil vs control.

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Analysis 4.3

Comparison 4 Rate of non‐wound infection, Outcome 3 Combined immunonutrients vs control.

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Comparison 1. All‐cause mortality

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Glutamine vs control Show forest plot	3	111	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.08, 0.78]

1.1 Enteral	2	85	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.06, 0.93]
1.2 Parenteral	1	26	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.04, 2.27]
2 Ornithine α‐ketoglutarate vs control Show forest plot	3	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.37, 2.36]

2.1 Enteral	3	155	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.37, 2.36]
3 Branched‐chain amino acids vs control Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 Parenteral	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Fish oil vs control Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 Enteral	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Combined immunonutrients vs control Show forest plot	4	163	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.47, 2.60]

5.1 Enteral	4	163	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.47, 2.60]

Comparison 1. All‐cause mortality

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Comparison 2. Length of hospital stay

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Glutamine vs control Show forest plot	7	255	Mean Difference (IV, Fixed, 95% CI)	‐5.65 [‐8.09, ‐3.22]

1.1 Enteral	5	199	Mean Difference (IV, Fixed, 95% CI)	‐6.29 [‐9.12, ‐3.46]
1.2 Parenteral	2	56	Mean Difference (IV, Fixed, 95% CI)	‐3.84 [‐8.63, 0.95]
2 Ornithine α‐ketoglutarate vs control Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Enteral	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Branched‐chain amino acids Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Parenteral	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Fish oil vs control Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Enteral	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Combined immunonutrients vs control Show forest plot	3	113	Mean Difference (IV, Fixed, 95% CI)	1.93 [‐4.41, 8.28]

5.1 Enteral	3	113	Mean Difference (IV, Fixed, 95% CI)	1.93 [‐4.41, 8.28]

Comparison 2. Length of hospital stay

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Comparison 3. Rate of burn wound infection

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Glutamine vs control Show forest plot	2	81	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.16, 1.06]

1.1 Enteral	2	81	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.16, 1.06]
2 Ornithine α‐ketoglutarate vs control Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Enteral	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Combined immunonutrients vs control Show forest plot	3	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.51, 1.20]

3.1 Enteral	3	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.51, 1.20]

Comparison 3. Rate of burn wound infection

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Comparison 4. Rate of non‐wound infection

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Glutamine vs control Show forest plot	2	67	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.27, 1.95]

1.1 Bacteraemia	2	67	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.27, 1.95]
2 Fish oil vs control Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Pneumonia	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Combined immunonutrients vs control Show forest plot	3	266	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.86, 1.57]

3.1 Pneumonia	3	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.59, 1.15]
3.2 Urinary tract infection	2	72	Risk Ratio (M‐H, Fixed, 95% CI)	2.46 [0.98, 6.20]
3.3 Bacteraemia	2	72	Risk Ratio (M‐H, Fixed, 95% CI)	1.77 [0.81, 3.88]

Comparison 4. Rate of non‐wound infection

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