Should feeding be held in a patient with a Gastrostomy (G)-tube residual of 200cc?

Management of G-Tube Feeding with 200cc Gastric Residual

When gastric residual volume reaches 200 mL in a patient with doubtful gastrointestinal motility, feeding should be paused and the feeding strategy reviewed, though this threshold alone should not automatically mandate complete cessation of nutrition. 1, 2

Evidence-Based Threshold and Clinical Action

The 200 mL threshold represents a clinical decision point rather than an absolute contraindication to feeding:

• Guidelines specifically state that when gastric aspirates exceed 200 mL (checked every 4 hours in patients with questionable GI motility), the feeding policy should be reviewed 1, 2
• This recommendation applies particularly to patients with doubtful gastrointestinal motility, making assessment of the underlying clinical context essential 1, 2
• More recent evidence suggests that in non-surgical critically ill patients without feeding intolerance symptoms, routine GRV monitoring may not even be necessary 2

Stepwise Management Algorithm

When encountering a 200 mL gastric residual:

1. Assess for other signs of feeding intolerance:

• Check for abdominal distension, vomiting, or reflux of feeds into the oral cavity 2
• Evaluate for nausea or abdominal discomfort 3
• Monitor respiratory status for signs of aspiration 4

2. Modify feeding approach rather than stopping completely:

• Reduce the feeding rate temporarily 2
• Transition from continuous to intermittent feeding if currently on continuous infusion 1, 2
• Consider prokinetic agents (metoclopramide or erythromycin) to improve gastric emptying 2

3. Optimize aspiration risk reduction:

• Ensure patient is positioned at 30° or greater during feeding and for 30 minutes afterward 1, 4, 2
• Avoid continuous overnight feeding in patients at aspiration risk 1, 4, 2
• Switch to intermittent daytime feeding when possible 4

4. Consider post-pyloric feeding for persistent high residuals:

• If GRVs remain elevated despite interventions, placement of a jejunal feeding tube should be considered 2
• Post-pyloric feeding bypasses gastric emptying issues entirely 1

Important Context: The 200 mL Threshold is Conservative

Critical nuance: While the 200 mL threshold triggers review, research evidence suggests this may be overly conservative:

• U.S. guidelines actually state that GRVs less than 500 mL should not result in termination of enteral feeding 5
• Studies show little correlation between large GRVs and development of aspiration pneumonia 5, 6
• The practice of checking GRVs may actually impede adequate nutritional delivery by promoting inappropriate cessation 6

However, the guideline-based 200 mL threshold remains the standard for patients with questionable motility 1, 2, representing a more cautious approach prioritizing safety.

Common Pitfalls to Avoid

• Do not automatically discard all residual volume - this can lead to electrolyte imbalances and fluid losses 7
• Do not rely solely on GRV without assessing clinical signs - GRVs do not reliably predict aspiration risk 5, 6
• Do not continue continuous overnight feeding in high-risk patients - this significantly increases aspiration risk during sleep when protective reflexes are reduced 1, 4
• Do not use bolus feeding into the jejunum - this causes dumping syndrome 1, 4

Practical Clinical Approach

For a patient with 200 mL residual:

1. Hold the current feeding temporarily 1, 2
2. Recheck residual in 1-2 hours
3. If residual decreases, resume at reduced rate (e.g., 50% of previous rate) 2
4. If residual remains elevated or increases, initiate prokinetic therapy and consider jejunal feeding 2
5. Maintain elevation and aspiration precautions throughout 1, 4, 2