do not use gastric residual for enteral feeding

Fewer than half of patients who are critically ill meet their goal caloric intake during their ICU stay. Factors include ordering nutrition that does not fully meet nutritional goals and delivery that is inadequate due to cessation of enteral feeding. Enteral feeding cessation occurs in >85% of patients, and up to 33% of cessation time is due to patient intolerance.

Many factors, including gastric dysmotility, ileus, and medications, contribute to enteral feeding intolerance in patients who are critically ill. Holding enteral feeding because of gastric intolerance and planned procedures is common in the ICU and can lead to a potentially detrimental calorie deficit. Using gastric residual volume (GRV) as a means to evaluate enteral feeding tolerance is a common tool in nutrition protocols in the ICU. In a survey study, Metheny and colleagues reported that >97% of ICU nurses assessed feeding intolerance by measuring GRV alone. Common thresholds for interrupting enteral feeding were 200 to 250 mL GRV.

However, the current (2016) ASPEN guidelines do not recommend routine GRV monitoring. If GRV monitoring is part of the protocol for nutrition care in the ICU, other signs of GI intolerance (abdominal distension, vomiting, regurgitation, diarrhea, reduced passage of flatus or stool, abnormal abdominal radiographic findings) should be assessed before deciding to withhold feeding. Clinical risk factors for aspiration should be evaluated, and a proactive approach to reducing aspiration risk should be pursued.

The GRV threshold does not correlate with the incidence of pneumonia, regurgitation, or aspiration, and a lower GRV threshold does not prevent these pulmonary and GI complications in patients.

The NUTRIREA-2 trial (Reignier and colleagues) was a randomized controlled trial in patients receiving medical critical care in which the investigators compared a strategy of holding enteral nutrition when GRV was >250 mL vs a strategy of not measuring GRV at all. There was no difference in outcomes. The question remains whether GRV should be measured in patients who are critically ill and have undergone abdominal surgery or have other intraabdominal abnormalities.

It is recommended that supplemental parenteral nutrition be considered for patients receiving enteral nutrition meeting less than 60% of their protein and energy needs by day 7 to 10. Supplemental parenteral nutrition earlier in the clinical course for patients who are critically ill does not improve, and may worsen, outcomes.

Volume-based feeding protocols that have a 24-h or daily volume target instead of an hourly rate target have been shown to increase the proportion of prescribed protein and energy delivered by enteral nutrition.123456

Footnotes

  1. SEEK Questionnaires ↩

  2. Heyland DK, Murch L, Cahill N, et al. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013;41(12):2743-2753. PubMed ↩

  3. McClave SA, Taylor BE, Martindale RG, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211. PubMed ↩

  4. Metheny NA, Stewart BJ, Mills AC. Blind insertion of feeding tubes in intensive care units: a national survey. Am J Crit Care. 2012;21(5):352-360. PubMed ↩

  5. Montejo JC, Miñambres E, Bordejé L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386-1393. PubMed ↩

  6. Reignier J, Mercier E, Le Gouge A, et al; Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256. PubMed ↩