How often should residual be checked in patients with tube feeding (Total Parenteral Nutrition - TPN)?

Gastric Residual Volume Monitoring in Tube Feeding

Gastric residual volumes (GRV) should be checked every 4 hours initially in patients receiving tube feeding, and if aspirates exceed 200 ml, the feeding policy should be reviewed. 1

Recommendations for GRV Monitoring

• Routine monitoring of GRV is not necessary for all ICU patients receiving tube feeding, but should be performed in patients with feeding intolerance or those at high risk of aspiration 2
• For patients requiring GRV monitoring, enteral feeding should be continued unless GRV exceeds 500 mL/6 hours 2
• Fine-bore tubes (8 French) should be used in patients at risk of aspiration, such as stroke patients 3
• Patients should be positioned at 30° or more during feeding and for 30 minutes after to minimize aspiration risk 1

When to Check GRV

GRV monitoring is indicated in the following situations:

• During initial stabilization of tube feeding regimen (every 4 hours) 1
• When patients demonstrate signs of feeding intolerance such as:
  • Vomiting or regurgitation 2
  • Abdominal distension and pain 2
  • Absence of bowel sounds 2
• In high-risk patients:
  • Those with impaired consciousness 2
  • Patients with neurological disorders affecting swallowing 2
  • Patients in prone position 2

GRV Thresholds and Management

• If GRV exceeds 200 ml, the feeding policy should be reviewed 1
• For GRV >500 mL/6 hours:
  • Temporarily hold enteral feeding 2
  • Perform an abdominal examination to rule out acute abdominal complications 2
  • Consider prokinetic agents such as erythromycin 2

Practical Considerations

• Flush feeding tubes with water every 4 hours during continuous feedings, after giving intermittent feedings, after giving medications, and after checking for gastric residuals 4
• Use a controller pump to administer continuous feedings at a constant rate or to administer formulas that are viscous 4
• Continuous feeding is preferred initially for patients with limited intestinal tolerance and absorption capacity 1

Complications and Prevention

• Interruptions in enteral feedings to decrease presumed risk of aspiration occur frequently and can result in underfeeding 5
• Discarding versus returning gastric residual volumes does not significantly affect serum electrolyte levels, but returning residuals may increase the risk of tube clogging 6
• Nursing practices regarding GRV thresholds vary widely, with 89% of nurses in one study withholding feeds at volumes <300 mL, despite evidence supporting higher thresholds 7

Special Patient Populations

• For patients with severe gastroparesis, small bowel feeding (jejunal) may be more appropriate to bypass gastric emptying issues 1
• In patients with stroke, dysphagia therapy should start as early as possible, regardless of tube feeding status 3
• For malnourished patients, monitoring for refeeding syndrome is essential when initiating tube feeding 1

By following these evidence-based guidelines for GRV monitoring, healthcare providers can optimize nutritional support while minimizing the risk of complications such as aspiration pneumonia and underfeeding.