What is the management approach for residual PEG (Percutaneous Endoscopic Gastrostomy) tube feeding volumes exceeding 100 cc?

Management of Residual PEG Tube Feeding Volumes Exceeding 100 cc

When residual PEG tube feeding volume exceeds 100 cc, the feeding should be held temporarily, reassessed in 1-2 hours, and if residual volume decreases, feeding can be resumed; if residual volume remains high, further clinical evaluation is needed.

Understanding Gastric Residual Volumes (GRV)

• There is significant variation in nursing practice regarding what constitutes a "high" gastric residual volume, with thresholds ranging from 100 mL to 200 mL at which point feedings are typically withheld 1
• Checking gastric residual volumes is a common practice intended to reduce the risk of aspiration pneumonia, though there is limited scientific evidence supporting specific thresholds 1
• High gastric residual volumes may indicate delayed gastric emptying, which could increase the risk of regurgitation and aspiration 2

Management Algorithm for High Residual Volumes

Initial Assessment

• When residual volume exceeds 100 cc:
  • Temporarily hold the feeding 1, 2
  • Document the residual volume 1
  • Check for signs of intolerance (abdominal distention, nausea, vomiting) 2

Handling the Residual Volume

• Options for managing the withdrawn residual:
  • Return the residual to the stomach to prevent electrolyte imbalances, particularly potassium 3
  • If returning the residual, be aware of potential complications including tube clogging and contamination of the feeding system 3
  • If discarding the residual, monitor for potential electrolyte imbalances 3

Reassessment Protocol

• Recheck residual volume in 1-2 hours 2
• If residual volume has decreased below threshold:
  • Resume feeding at a slower rate (50-75% of previous rate) 2
  • Gradually increase to target rate as tolerated 2
• If residual volume remains high:
  • Consider prokinetic agents to improve gastric emptying 2
  • Evaluate for potential causes of delayed gastric emptying 2

Preventive Measures

• Flush feeding tubes with approximately 40 ml of water after feed or medication administration to prevent tube occlusion 4
• Position the patient with head elevated at least 30 degrees during feeding and for 30-60 minutes after feeding to reduce risk of aspiration 2
• Consider using a controller pump to administer continuous feedings at a constant rate, which may improve tolerance compared to bolus feedings 2
• Flush feeding tubes with water every 4 hours during continuous feedings, after giving intermittent feedings, after giving medications, and after checking for gastric residuals 2

Special Considerations

• Early initiation of PEG feedings (within 3-4 hours after placement) appears to be safe and well-tolerated, though higher rates of gastric retention (25% vs 9%) have been observed compared to delayed feeding (24 hours after placement) 5, 6
• A meta-analysis found no significant differences between early (≤3 hours) and delayed feeding in terms of complications, mortality, or significant gastric residual volumes during day 1 6
• For patients with persistent high gastric residual volumes, consider:
  • Switching to a more easily digested formula 2
  • Changing from bolus to continuous feeding 2
  • Consulting with a dietitian to adjust the feeding regimen 2

Common Pitfalls to Avoid

• Avoid unnecessary checks of gastric residual volumes, which can increase healthcare costs and potentially impact patient outcomes 1
• Do not automatically discard residual volumes without considering the potential impact on electrolyte balance 3
• Avoid using food coloring in tube feedings to detect aspiration, as this practice is no longer recommended 2
• Do not replace tubes with larger-diameter tubes if feeding intolerance occurs, as this can result in an enlarged stoma tract with more leakage 4