When should gastric residual volume be checked in ICU patients receiving Ryle's Tube (RT) feed?

Gastric Residual Volume Monitoring in ICU Patients Receiving RT Feeding

Routine monitoring of gastric residual volume (GRV) is not recommended for ICU patients receiving Ryle's tube (RT) feeding, except in patients with feeding intolerance or those at high risk of aspiration. 1

When to Check GRV

• GRV should not be routinely monitored in critically ill patients receiving enteral nutrition via RT 1
• GRV measurement should be performed in specific situations:
  • When patients demonstrate signs of feeding intolerance 1
  • In patients considered at high risk for aspiration 1

Signs of Feeding Intolerance Requiring GRV Measurement

• Vomiting or regurgitation 1, 2
• Abdominal distension 1, 2
• Abdominal pain or discomfort 1
• Absence of bowel sounds 1
• Clinical deterioration potentially related to enteral feeding 1

High-Risk Patients Who May Benefit from GRV Monitoring

• Surgical patients, particularly in the immediate postoperative period 3
• Patients with impaired consciousness 1
• Patients with neurological disorders affecting swallowing 1
• Patients with known gastroparesis or gastrointestinal motility disorders 2
• Patients in prone position 1

GRV Threshold and Management

• If GRV monitoring is performed, enteral feeding should be continued unless GRV exceeds 500 mL/6 hours 1
• For patients with GRV >500 mL/6 hours:
  • Temporarily hold enteral feeding 1
  • Perform abdominal examination to rule out acute abdominal complications 1
  • Consider prokinetic agents (erythromycin as first-line therapy) 1
  • If large GRV persists despite prokinetics, consider post-pyloric feeding rather than withholding enteral nutrition 1

Alternative Approaches When GRV is Elevated

• Use of prokinetic agents:

  • Intravenous erythromycin (100-250 mg 3 times daily) as first-line therapy 1
  • Intravenous metoclopramide (10 mg 2-3 times daily) or combination of metoclopramide and erythromycin as alternatives 1
  • Limit prokinetic use to 48-72 hours as effectiveness decreases after this period 1

• Consider post-pyloric feeding tube placement for patients with persistent feeding intolerance despite prokinetic use 1

Common Pitfalls and Caveats

• Overreliance on GRV can lead to unnecessary interruptions in enteral feeding and subsequent underfeeding 2, 4
• GRV measurement techniques are not standardized, leading to inconsistent results 3, 2
• There is poor correlation between GRV and risk of aspiration pneumonia in most critically ill patients 2, 4
• Ultrasound assessment of gastric antrum may provide a more accurate assessment of gastric volume than traditional aspiration methods 5
• Returning aspirated gastric contents after measurement helps maintain electrolyte balance and nutritional status 4

Special Considerations

• For pediatric ICU patients, routine GRV measurement is also not recommended 1
• In non-surgical critically ill patients with sepsis or septic shock, GRV monitoring should be avoided unless feeding intolerance is present 1
• Early enteral nutrition (within 24-48 hours of ICU admission) is recommended for most critically ill patients, with gradual advancement as tolerated 1