What are the guidelines for starting feeds in critically ill patients with residuals?

Guidelines for Starting Feeds with Residuals in Critically Ill Patients

Do not routinely monitor gastric residual volumes (GRVs) in critically ill patients receiving enteral nutrition, and continue feeding unless GRV exceeds 500 mL per 6 hours. 1

When to Measure Gastric Residuals

The Surviving Sepsis Campaign guidelines recommend against routine GRV monitoring in critically ill patients with sepsis or septic shock. 1 However, measure GRVs selectively in two specific situations:

• Patients with clinical signs of feeding intolerance: vomiting/regurgitation, abdominal distension, abdominal pain, or absence of bowel sounds 2, 3
• Patients at high risk for aspiration: impaired consciousness, neurological disorders affecting swallowing, or prone positioning 3

This approach is supported by research showing that allowing higher GRV thresholds with once-daily assessment enables successful enteral feeding without increased complications. 4

Starting and Continuing Enteral Feeds

Initial Feeding Strategy

• Begin enteral nutrition within the first 48 hours of diagnosis in critically ill patients who can be fed enterally 1
• Start with trophic/hypocaloric feeding (up to 500 calories per day) rather than full caloric feeding in the first week 1
• Advance feeds according to patient tolerance rather than mandatory full feeding 1

GRV Threshold for Continuing Feeds

Continue enteral feeding unless GRV exceeds 500 mL per 6 hours. 2, 3, 5 This threshold is critical—do not stop feeds for lower residual volumes. Research demonstrates that allowing GRVs up to 500 mL with once-daily assessment results in high calorie intake without significant complications. 4

Management Algorithm When GRV Exceeds 500 mL/6 Hours

Step 1: Immediate Actions

• Temporarily hold feeds and perform abdominal examination to rule out acute abdominal complications (bowel obstruction, ileus, ischemia) 2, 3
• Initiate prokinetic therapy immediately 2

Step 2: Pharmacologic Intervention

• Administer intravenous erythromycin (200 mg) or metoclopramide as first-line prokinetic agents 1, 2, 6
• Erythromycin has been shown in randomized controlled trials to significantly improve gastric emptying in critically ill patients, with 58% of patients tolerating feeds at 48 hours versus 44% with placebo 7
• A single dose of IV erythromycin (200 mg) allows successful continuation of nasogastric feeding in 90% of patients with large gastric aspirates 8

Step 3: Resume Trophic Feeds

• Resume trophic/hypocaloric feeding once acute issues are excluded 2
• Do not keep patients NPO—continue some enteral nutrition even with intolerance 2

Step 4: Feeding Route Modification

• Place a post-pyloric (jejunal) feeding tube if intolerance persists despite prokinetic therapy 1, 2
• This bypasses the stomach and reduces aspiration risk in patients who cannot tolerate gastric feeding 2
• Research shows that 36% of critically ill medical patients require post-pyloric feeding due to high gastric residuals 9

Critical Pitfalls to Avoid

Do NOT:

• Stop enteral nutrition completely—instead use trophic feeds and advance as tolerated 1, 2
• Routinely check GRVs every 4-6 hours in all patients—this is not recommended and leads to unnecessary feed interruptions 1, 2
• Use parenteral nutrition in the first 7 days if enteral feeding is feasible, even with some intolerance 1
• Add immune-modulating supplements (omega-3 fatty acids, glutamine, arginine, selenium)—these are not recommended 1, 2
• Use a GRV threshold lower than 500 mL/6 hours as a reason to stop feeds 2, 3

Common Pitfall:

Many clinicians stop feeds at GRV thresholds of 150-200 mL based on older practices. 6 The current evidence-based threshold is 500 mL per 6 hours, and feeds should continue below this level. 2, 3

Special Considerations

• Feeding intolerance is associated with higher mortality (73.3% vs. 26.1% in patients who achieve feeding targets), making aggressive management essential 9
• Position patients at 30° or more during feeding and for 30 minutes after to minimize aspiration risk 5
• The goal is to achieve target feeding volume by day 4 of ICU admission when possible 9