What are the treatment options for high residual volumes in tube feeding (Total Parenteral Nutrition - TPN)?

From the Guidelines

To manage high residual volumes in tube feeding, the most effective approach is to implement prokinetic medications, such as metoclopramide or erythromycin, and consider post-pyloric tube placement, as these interventions have been shown to improve gastric emptying and reduce residual volumes 1.

Key Considerations

• Assess the patient's clinical status and consider temporarily reducing the feeding rate or holding feeds if residual volumes exceed 250-500 mL.
• Resume feeding at a lower rate once residuals decrease, and gradually advance as tolerated.
• Implement prokinetic medications, such as metoclopramide 10 mg IV/PO every 6 hours or erythromycin 250 mg IV/PO every 6 hours, to improve gastric emptying, as recommended by the ESPEN guidelines 1.
• Position the patient with the head of bed elevated to at least 30 degrees to reduce aspiration risk.
• Consider switching to a post-pyloric feeding tube placement if gastric residuals remain persistently high despite interventions, as suggested by the Surviving Sepsis Campaign guidelines 1.

Additional Strategies

• Continuous feeding rather than bolus feeding may also help reduce residual volumes.
• Ensure proper medication management by avoiding medications that slow gastric motility when possible.
• Monitor for signs of feeding intolerance, such as abdominal distension, vomiting, or constipation, and treat underlying causes.
• Addressing factors that contribute to delayed gastric emptying, such as critical illness, medications, electrolyte abnormalities, or underlying gastrointestinal disorders, is essential for patient recovery.

Guideline Recommendations

• The ASPEN/SCCM guidelines recommend against using gastric residual volumes as part of routine care to monitor ICU patients on enteral nutrition, but suggest using metoclopramide or erythromycin where indicated 1.
• The ESPEN guidelines recommend using IV erythromycin as a first-line therapy or using IV metoclopramide or combination therapy for enteral nutrition intolerance 1.
• The Surviving Sepsis Campaign guidelines suggest against routinely monitoring gastric residual volumes, but recommend measuring gastric residuals in patients with feeding intolerance or who are considered to be at high risk of aspiration 1.

From the FDA Drug Label

For the Relief of Symptoms Associated with Diabetic Gastroparesis (Diabetic Gastric Stasis) If only the earliest manifestations of diabetic gastric stasis are present, oral administration of metoclopramide may be initiated. However, if severe symptoms are present, therapy should begin with Metoclopramide Injection (intramuscular or intravenous)

The treatment option for high residual volumes in tube feeding (Total Parenteral Nutrition - TPN) that can be considered is metoclopramide.

• Key points:
  • Metoclopramide can be administered intravenously to help relieve symptoms associated with diabetic gastroparesis.
  • The dose of metoclopramide for this purpose is 10 mg, administered slowly over a 1 to 2 minute period.
  • Administration of metoclopramide may be required for up to 10 days before symptoms subside. 2

From the Research

Treatment Options for High Residual Volumes in Tube Feeding

• The use of prokinetic agents such as erythromycin and metoclopramide has been studied as a treatment option for high residual volumes in tube feeding 3, 4, 5.
• Erythromycin has been shown to be more effective than metoclopramide in reducing gastric residual volumes and improving feeding tolerance in critically ill patients 3, 5.
• Combination therapy with erythromycin and metoclopramide has also been found to be effective in treating feed intolerance in critical illness, and may be considered as a first-line treatment 4.
• However, the effectiveness of these treatments can decline over time, and rescue combination therapy may be necessary for patients who fail monotherapy 5.
• The use of metoclopramide to aid in post-pyloric placement of naso-enteral feeding tubes has been found to be ineffective 6.
• National guidelines suggest that gastric residual volumes of less than 500 mL should not result in termination of enteral feeding, and that allowing larger residual volumes may allow patients to receive more calories without a deleterious clinical impact 7.

Prokinetic Agents

• Erythromycin and metoclopramide are two prokinetic agents that have been studied as treatment options for high residual volumes in tube feeding.
• Erythromycin has been found to be more effective than metoclopramide in reducing gastric residual volumes and improving feeding tolerance 3, 5.
• Combination therapy with erythromycin and metoclopramide may be more effective than monotherapy with either agent alone 4.

Clinical Implications

• The treatment of high residual volumes in tube feeding should be individualized based on the patient's specific needs and circumstances.
• Prokinetic agents such as erythromycin and metoclopramide may be useful in reducing gastric residual volumes and improving feeding tolerance, but their effectiveness can decline over time 4, 5.
• National guidelines and clinical judgment should be used to determine the optimal approach to managing gastric residual volumes in critically ill patients 7.