围手术期标准化喂养方案对危重症先天性心脏病婴儿体格发育和临床结局的系统评价/Meta分析

A standardized perioperative feeding protocol on physical development and clinical outcomes in infants with critical congenital heart disease:A systematic review and meta-analysis

背景近20年来,围手术期喂养方案应用于危重症先天性心脏病(CCHD)婴儿对促进其体格发育和临床结局改善起到一定的作用,但仍存在临床适用人群和阶段不统一、喂养方案多样化等问题。目的 评价围手术期标准化喂养方案对改善CCHD婴儿临床结局和体格发育指标的效果。设计系统评价/Meta分析。方法 检索英文数据库(PubMed、Embase、The Cochrane Library、Web of Science)和中文数据库(中国生物医学文献服务系统SinoMed、中国知网,万方数据库),纳入围手术期或术前或术后对CCHD婴儿实施符合本文定义的标准化喂养方案,结局指标包括NEC发生率、体格发育指标、住院时间(LOS)、ICU LOS、机械通气持续时间其中之一的RCT、非随机对照试验、队列研究、干预前后对照试验、病例系列报告和系统评价/Meta分析。检索时限均为建库至2022年12月11日。由3名研究人员按照文献筛选标准筛选文献、提取资料,采用ROBINS-Ⅰ评价文献质量偏倚风险,并采用RevMan 5.4和R version 4.2.2软件进行Meta分析。主要结局指标NEC发生率。结果 共纳入11篇相关研究,病例均来自美国2000至2020年的研究,非随机对照试验1篇,不同病例前后对照试验9篇,自身前后对照试验1篇。实施喂养方案阶段为术前3篇,术后4篇,围手术期5篇;干预组和对照组胎龄均为35~41周。8篇文献报道了NEC发生率,干预组较对照组,围手术期(2篇文献Meta分析)、术前(3篇文献Meta分析)、术后(3篇文献Meta分析)喂养方案亚组NEC发生率差异均无统计学意义,OR分别为0.57(95%CI:0.19~1.76)、0.95(95%CI:0.48~1.88)和0.69(95%CI:0.35~1.34)。4篇文献报告了CCHD婴儿出院时年龄别体重z评分的变化,汇总3篇文献行Meta分析显示,干预组较对照组出院时年龄别体重z评分差异无统计学意义,WMD=-0.10(95%CI:-0.37~0.17)。10篇文献报告了LOS,仅干预组较对照组术前(3篇文献Meta分析)喂养方案亚组LOS差异有统计学意义,WMD=-6.83(95%CI:-12.13~-1.53);干预组较对照组,ICU LOS(2篇文献Meta分析)、机械通气持续时间(3篇文献Meta分析显示)差异无统计学意义。中等风险4篇、高风险6篇,极高风险1篇。结论 CCHD婴儿不论术前、术后、围手术期,是否给予标准化喂养方案,均不降低NEC的风险;标准化喂养方案不改善出院时年龄别体重z评分、不缩短LOS、ICU LOS和机械通气持续时间。

Background Over the past two decades,implementing perioperative feeding protocols in infants with critical congenital heart disease(CCHD)has a certain effect on fostering their physical development and enhancing their clinical outcomes.Nevertheless,the existence of diverse feeding protocols and their appropriate application to different infant populations and feeding stages remains a pending issue.Objective To evaluate the effect of standardized perioperative feeding protocols on the physical development and clinical outcomes of critically ill infants with CCHD.Design Systematic review and meta-analysis.Methods Systematic retrieval was conducted across foreign language databases,including PubMed,Embase,The Cochrane Library,and Web of Science,as well as Chinese databases,such as SinoMed,China National Knowledge Infrastructure,and Wanfang Database.CCHD infants adhering to a standardized feeding protocol during the perioperative period were included.The outcomes evaluated included the incidence of necrotizing enterocolitis(NEC),physical development indicators,hospital length of stay(LOS),ICU LOS and mechanical ventilation duration.The study type consisted of randomized controlled trial(RCT),non-randomized trial,cohort study,case series report,and systematic review/meta-analysis.The literature was searched from the inception of the database up to December 11,2022.Three individuals conducted literature screening and data extraction based on the predefined criteria.The risk of bias assessment for non-randomized studies and randomized clinical trials was performed using ROBINS-I and ROB 2,respectively.Meta-analysis was carried out using RevMan 5.4 and R version 4.2.2.Main outcome measures The incidence of NEC.Results A total of 11 studies conducted in the US from 2000 to 2020 were included.One article employed a non-randomized control trial,9 used case before-after study design,and 1 used self-before-after study design.The standardized feeding protocol was implemented in 3 studies during the pre-operation period,4 during the post-operation period,and 5 during the perioperative period.The gestational age of participants ranged from 35 to 41 weeks.Among the included articles,8 reported the incidence of NEC as the primary outcome.Separate meta-analyses were conducted by different stages of intervention implementation.In a meta-analysis of two articles that implemented standardized protocols during the peri-operation period,the result revealed that there was no statistically significant difference in the incidence of NEC between the two groups[odds ratio(OR)=0.57(95%CI:0.19-1.76)].The results of the other 2 meta-analyses were as follows:one for 3 articles implementing intervention during the pre-operation period showed no statistically significant difference[OR=0.95(95%CI:0.48-1.88)],and the other for 3 articles during the post-operation also showed no statistically significant difference[OR=0.69(95%CI:0.35-1.34)].Among the 4 articles that reported the weight-for-age z-score at discharge,a meta-analysis of 3 of them found no statistically significant difference between the two groups,WMD=-0.10(95%CI:-0.37-0.17).Ten articles reported LOS.A meta-analysis of LOS for intervention during the pre-operation period revealed that LOS was significantly shorter in the study group,WMD=-6.83(95%CI:-12.13--1.53).However,other meta-analyses of ICU LOS(2 articles)and mechanical ventilation duration(3 articles)all revealed no statistically significant differences between the two groups.The critical appraisal of the included articles indicated that 4 of them were at moderate risk of bias,6 were at high risk,and 1 was at critical risk.Conclusions A standardized perioperative feeding protocol implemented in surgical infants with CCHD can not reduce the incidence of NEC,improve the weight-for-age z-score at discharge,and cut down the LOS,ICU LOS,and mechanical ventilation duration.