What to do with high NGT aspiration volume in a patient on Glucerna?

Management of High NGT Aspiration Volume in a Patient on Glucerna

For a patient with high NGT aspiration volume (300ml), the aspirate should be discarded rather than refed, and feeding should be temporarily held to reduce aspiration risk while implementing strategies to improve gastric emptying.

Assessment of the Situation

When faced with high nasogastric tube (NGT) aspiration volume (300ml) in a patient receiving Glucerna 200ml with 50ml water flush six times daily, several factors need consideration:

Risk Assessment

• High gastric residual volume (GRV) of 300ml indicates potential feeding intolerance
• This is the first occurrence of high aspiration, suggesting an acute change
• Current regimen delivers approximately 1200ml of formula plus 300ml of water daily

Management Algorithm

Immediate Actions

1. Discard the aspirate rather than refeeding it 1

   • Refeeding aspirate is not recommended in current guidelines
   • Discarding helps reduce bacterial contamination risk

2. Hold enteral feeding temporarily 1

   • Guidelines suggest holding feeds when there is evidence of feeding intolerance
   • This reduces risk of aspiration pneumonia, which increases mortality and hospital costs

Next Steps (After Holding Feeding)

1. Elevate head of bed to at least 30-45 degrees 1, 2

   • Reduces risk of regurgitation and aspiration

2. Consider prokinetic medication 1

   • Guidelines suggest prokinetic agents for patients with feeding intolerance
   • Examples include metoclopramide or erythromycin

3. Reassess in 2-4 hours with repeat aspiration check 1, 3

   • Monitor for improvement in gastric emptying
   • Guidelines recommend checking GRV every 4 hours when adjusting feeding rates

Resumption of Feeding

1. If repeat GRV is <250ml, restart feeding at 50% of previous rate 1, 3

   • Gradually increase as tolerated
   • Continue monitoring GRV every 4-6 hours

2. If GRV remains high after 8-12 hours despite prokinetics 1:

   • Consider post-pyloric feeding tube placement
   • This bypasses the stomach and may reduce aspiration risk

Additional Considerations

• Continuous vs. intermittent feeding: Consider switching to continuous feeding over 20 hours if currently on intermittent bolus feeding 3

• Formula concentration: The current Glucerna formula (energy-dense at >1.25 kcal/ml) is appropriate per guidelines 1

• Medication review: Assess if patient is on medications that delay gastric emptying (opioids, anticholinergics)

• Underlying causes: Evaluate for ileus, gastroparesis, or other causes of delayed gastric emptying

Caution Points

• Avoid routine use of blue food coloring to detect aspiration as it's insensitive and unreliable 2

• Do not automatically place post-pyloric tubes without first attempting management strategies for gastric feeding intolerance 1

• Recognize that GRV monitoring itself has limitations as a predictor of aspiration risk, but is still recommended by most guidelines for high-risk patients 1, 2

• Avoid prolonged feeding holds as this may compromise nutritional status; aim to restart feeding as soon as safely possible 1