Should tube feeding residuals be checked?

From the Guidelines

Checking tube feed residuals is generally not recommended as a routine practice for most patients receiving enteral nutrition. Instead, focus on monitoring for signs of feeding intolerance such as abdominal distension, vomiting, or increased abdominal pain. If a patient shows these symptoms, then checking residual volumes may be appropriate as part of a comprehensive assessment. When residuals are checked, volumes less than 500 mL should not prompt interruption of feeding in most adult patients. For critically ill patients, some institutions may use a threshold of 200-250 mL, though this varies by facility protocol. If high residuals are found along with other signs of intolerance, consider temporarily reducing the feeding rate rather than stopping entirely, and reassess after a few hours. The practice of routine residual checks has fallen out of favor because studies have shown that discontinuing feeds based solely on residual volumes can lead to inadequate nutrition delivery without improving patient outcomes or reducing aspiration risk 1. Proper patient positioning (head of bed elevated 30-45 degrees), use of prokinetic agents when needed, and post-pyloric feeding placement for high-risk patients are more effective strategies for reducing aspiration risk than relying on residual volume checks.

Some key points to consider:

• The Surviving Sepsis Campaign guidelines suggest against routinely monitoring gastric residual volumes in critically ill patients with sepsis or septic shock, except in cases of feeding intolerance or high risk of aspiration 1.
• The use of prokinetic agents and post-pyloric feeding tubes may be beneficial in patients with feeding intolerance or at high risk of aspiration 1.
• Early initiation of enteral feeding is recommended in critically ill patients with sepsis or septic shock who can be fed enterally 1.
• The American Heart Association/American Stroke Association guidelines recommend early dysphagia screening and management to reduce the risk of pneumonia and other adverse health consequences in patients with stroke 1.

Overall, the approach to tube feeding residuals should prioritize patient-centered care, focusing on signs of feeding intolerance and using residual checks judiciously, rather than as a routine practice.

From the Research

Tube Feeding Residuals

• The practice of checking gastric residual volumes (GRV) in tube-fed patients is a common one, aimed at reducing the risk of aspiration pneumonia 2.
• However, there is limited scientific evidence to support this practice, which can consume significant healthcare resources 2, 3.
• The utility of GRVs for preventing aspiration events with tube feeding has been questioned, with some studies suggesting that large GRVs do not correlate with the development of aspiration pneumonia 3.
• US guidelines state that GRVs of less than 500 ml should not result in termination of enteral feeding, and allowing larger GRVs may enable patients to receive more calories without adverse clinical impact 3.

Gastric Residual Volume Measurement

• There are various methods for measuring GRVs, but most have not been standardized 3.
• The significance of a large GRV can be influenced by factors such as gastroparesis, concomitant drug therapy, and formula-related factors 4, 3.
• Some studies suggest that elevating the head of the bed by 30 to 45 degrees can reduce the frequency and severity of aspiration, although this does not prevent it entirely 5.

Potential Complications

• Aspirating gastric residuals can cause occlusion of small-bore feeding tubes, with one study finding a statistically significant difference in occlusive episodes between patients who had gastric residuals checked and those who did not 6.
• Other potential complications of tube feeding include gastrointestinal disturbances, mechanical and metabolic complications, and bacterial contamination 4.

Monitoring and Management

• Nurses can prevent many problems associated with enteral feeding through careful monitoring, including checking for correct tube placement, preventing tube obstruction, and handling and selecting formulas 4.
• Ongoing nutritional assessments are necessary to provide information about the overall adequacy of enteral feeding in restoring or maintaining nutrition 4.