From the Guidelines
Yes, pause the tube feeding due to the high residual volume of 240 mL and restart at half the previous rate in one hour. After restarting, check residuals every 4 hours. If residuals remain below 200 mL, you can gradually increase the rate by 10-20 mL/hour every 8-12 hours until reaching the goal rate. This approach is supported by the ESPEN guideline on clinical nutrition in the intensive care unit 1, which suggests that enteral feeding should be delayed when gastric residual volume (GRV) is >500 mL/6 h, but also considers the use of prokinetics like erythromycin to improve gastric emptying in cases of feeding intolerance.
Key Considerations
- High residual volumes in a patient with pneumonia indicate delayed gastric emptying, which increases aspiration risk 1.
- Pausing feeds temporarily and restarting at a lower rate helps prevent aspiration while maintaining nutritional support.
- The use of prokinetic medications like metoclopramide or erythromycin may be considered if high residuals persist, as they have been shown to promote gastric motility and improve feeding tolerance 1.
- Document all residual checks, rate changes, and the patient's tolerance to the feeding.
Monitoring and Adjustments
- Continue to monitor the patient's residual volumes and adjust the feeding rate as needed to prevent aspiration and maintain nutritional support.
- Consider the use of post-pyloric feeding if high residuals persist, as it may help reduce the risk of aspiration 1.
From the Research
Gastric Residual Volumes and Tube Feeding
- The patient has a high residual volume of 240mls, which may indicate gastroparesis or other gastrointestinal motility issues 2.
- Gastroparesis is a common motility disorder characterized by delayed gastric emptying, and it can be difficult to treat 3.
- The use of gastric residual volumes (GRVs) as a marker of feeding tolerance is of questionable utility, and allowing larger GRVs may enable patients to receive more calories without a deleterious clinical impact 2.
Management of High Residual Volumes
- Reducing tube-feeding rates may improve symptoms, as seen in a case report where metoclopramide and reduced tube-feeding rates improved symptoms in a patient with gastroparesis 3.
- Prokinetic agents, such as metoclopramide, may have an inconsistent effect on GRV size, and their efficacy can vary depending on the patient population 4.
- In patients with delayed gastric emptying refractory to metoclopramide, nasointestinal feeding may be a viable option to increase the amount of feed tolerated 5.
- Neostigmine may be more effective than metoclopramide in reducing GRV and improving gastric emptying in mechanically ventilated ICU patients 6.