Management of Gastric Residual Volumes:
Evidence Based Practice
By: Lauren Doty, BSN, RN, Alexandria Pipa, BSN, RN, & Nicole Viglietta, BSN, RN
Medical Intensive Care Unit
Introduction
Current Policy at HMC
Early enteral feeding for mechanically
“Aspiration Precautions”
ventilated patients is associated with positive policy number: A-5
A 5 CPMN:
effects on gut mucosa integrity, immune
*If receiving enteral nutrition:
function, infection rates, glycemic control and
aspirate stomach contents before
overall survival. Not unlike other therapies,
enteral nutrition has its risks. The most feared
feedings or as ordered. For
and talked about complication of enteral
continuous tube feedings, if
feeding is aspiration. Current practice utilizes
gastric
g
residual exceeds 250 ml,,
gastric residual volumes (GRVs) as the main
hold feeding and notify physician.
marker for risk of aspiration. This practice is
neither standardized nor is it universal, with
Literature
cutoffs ranging from 150ml to 500ml volumes.
Because of the positive effects of enteral
feeding support, and unsure relationship of
GRVs to aspiration, stopping enteral
feedings when the GRVs reach an
arbitrarily low set cutoff could be harming
patients rather than benefiting them. The
purpose of this literature review and
critique of available studies is to determine
the optimal GRV cutoff volume.
STUDY
Level IC
Level IIA
PICO Question
“For mechanically ventilated adult
ICU patients receiving continuous
enteral feedings (p), does holding the
t b ffeeds
tube
d ffor GRVs
GRV greater
t than
th
250ml (I), reduce the incidence of
aspiration (o) as compared to not
holding the tube feeds until residual
volumes are greater than 500 ml (c)?”
Don’t stop feedings for
RV <400-500.
Abrupt cessation only with
overt regurgitation
--Specific statistical findings
from the studies reviewed
were discussed
--No discussion of
methods for article
selection or leveling
criteria
A limiti of 500 ml is not
associated with adverse
effects and can be
recommended as a
normal limit for GRV
--Sample includes 329
patients from 28 ICUs
--Blind statistical analysis
with significance defined as
P <0.05
--No standardization of
tube feeding rates or
methods for measuring
GRV
No apparent relationship
between residual volume
and aspiration was found
--Well defined methods
--Extensive literature review
comparing findings to that
of other studies.
--Small sample size of
only 40 patients.
McClave, Snider (2002)
REGANE study
Pneumonia
Chest xx-ray
ray
--Grade
G d B
recommendation: only
one level I study
referenced
A id holding
Avoid
h ldi ffeedings
di
ffor
RV <500 without signs
and symptoms of
intolerance.
North American Summit on
Aspiration
McClave et al. (2005)
Level IIB
A non-restricted search of Cinahl, Pro
Q
Quest,
t Ovid,
O id Pub
P b Med,
M d and
dC
Cochrane
h
databases was conducted using
combinations of the following terms:
*gastric residual volumes
Implications
*enteral nutrition
*tube feed residual
Practice
*aspiration
Implementation of an evidence based
protocol designed to accept GRVs up
Review
to 500 ml, with attention being added
STRENGTHS
WEAKNESSES
to the importance of assessing for
g of intolerance.
signs
--Extensive
E t
i lit.
lit review.
i
--Well defined methodology
with specific leveling
criteria
M Cl
McClave
ett al.l (2009)
SCCM and ASPEN.
Level IA
Montejo et al. (2010)
Normal
Chest xx-ray
ray
FINDINGS
Methods
Conclusions
According to the best evidence available, not withholding feeds until GRVs
are > 500 ml does not increase the risk of aspiration as compared to
holding tube feeds for residuals >250 ml
ml. Patients aspirate with all levels of
residual volumes. Attention must therefore shift away from GRV as an
important marker of aspiration, to the need for careful assessments for
other signs of gastric intolerance, and to the implementation of further
methods to reduce aspiration.
Research
Investigation into the following terms
to determine their usefulness in the
management of enteral feedings:
refractometry testing
*refractometry
*use of prokinetic agents
*use of narcotic antagonists
infused through the feeding
tube
References
McClave, S.A., Lukan, J.K., Stefater, J.A., Lowen, C.C., Looney, S.W.,
Matheson, P.J., . . . Spain, D.A. (2005). Poor validity of residual volumes as
a marker for risk of aspiration in critically ill patients. Critical Care Medicine,
33(2), 449-450. doi:10.1097/01.CCM.0000153413.46627.3A.
McClave, S. A., Martindale, R. G., Vanek, V.W., McCarthy, M., Roberts, P.,
Taylor, B., . . . Cresci, G. (2009). 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).
) Journal of Parenteral and
Enteral Nutrition, 33(3), 277-316. doi:10.1177/0148607109335234
\
McClave, S.A., Snider, H.L. (2002). Clinical use of gastric residual volumes
as a marker for patients on enteral tube feeding. Journal of Parenteral and
Enteral Nutrition, 26(6), S43-S50. doi:10.1177/014860710202600607
Montejo, J.C., Minambres, E., Bordeje, L.., Mesejo, A., Acosta, J., Heras, A.,
. . . Manzanedo, R. (2010). Gastric residual volume during enteral nutrition
in ICU patients: the REGANE study. Intensive care med, 36(8), 1386-1393.
doi:10.1007/s00134-010-1856-y.