Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting

Epiploic foramen entrapment in a dog

OBJECTIVE

To report small intestinal herniation through the epiploic foramen in a dog.

ANIMALS

Nine-year-old male castrated Shih Tzu.

STUDY DESIGN

Case report.

METHODS

The dog presented with an 8-year history of vomiting and regurgitation and acute onset of melena, lethargy, anorexia, anemia, and suspected gastrointestinal mass or obstruction on prereferral imaging. Abnormalities on abdominal radiographs included a large, midcaudal soft tissue structure and cranial displacement and segmental dilation of the small intestine. On abdominal ultrasound, severe gastric dilation, jejunal tortuosity and stacking, and peritoneal effusion were observed. Epiploic herniation of the small intestine and segmental jejunal devitalization was diagnosed on exploratory laparotomy, and the dog underwent hernia reduction, jejunal resection and anastomosis, and nasogastric tube placement.

RESULTS

Severe gastric distention and atony persisted 24 h after surgery, despite medical management. The dog was taken to surgery for decompressive gastrotomy and placement of gastrostomy and nasojejunostomy tubes for postoperative decompression and feeding, respectively. Three days after the original surgery, the dog developed a septic abdomen from anastomotic dehiscence and underwent jejunal resection and anastomosis and peritoneal drain placement. Gastric dysmotility gradually resolved with the administration of motility stimulants, removal of gastric residual volume, and nutritional support via nasojejunostomy tube feedings. Three months after discharge, the dog was clinically normal.

CONCLUSION

Epiploic foramen entrapment should be considered a type of herniation in dogs. Clinical suspicion should be raised in dogs with unresolving regurgitation and vomiting, visceral displacement, and stacking and distension of small intestine.

Effects of ultrasound monitoring of gastric residual volume on feeding complications, caloric intake and prognosis of patients with severe mechanical ventilation

BACKGROUND

Monitoring of gastric residual is an important approach for assessing gastric emptying in patients with mechanical ventilation. By monitoring gastric contents, the enteral nutrition scheme can be adjusted in time to ensure feeding safety.

AIM

To investigate the effects of ultrasound monitoring on the incidence of feeding complications, daily caloric intake and prognosis of patients with severe mechanical ventilation. To analyze the clinical significance of ultrasound monitoring of gastric residual volume (GRV) up to 250 mL to provide a theoretical basis for clinical practice.

METHODS

Patients admitted to the department of emergency medicine of the Affiliated Hospital of Nantong University from January 2018 to June 2022 who received invasive mechanical ventilation and continuous enteral nutrition support within 24-48 h after admission were enrolled in this study. Medical records for patients within 7 d of hospitalization were retrospectively analyzed to compare the incidence of feeding complications, daily caloric intake and clinical prognosis between patients with gastric residual ≥ 250 mL and < 250 mL, as monitored by ultrasound on the third day.

RESULTS

A total of 513 patients were enrolled in this study. Incidences of abdominal distension, diarrhea, and vomiting in the < 250 mL and ≥ 250 mL groups were: 18.4% vs 21.0%, 23.9% vs 32.3% and 4.0% vs 6.5%, respectively; mortality rates were 20.8% vs 22.65%; mechanical ventilation durations were 18.30 d vs 17.56 d while lengths of stay in the intensive care units (ICU) were 19.87 d vs 19.19 ± 5.19 d. Differences in the above factors between groups were not significant. Gastric residual ≥ 250 mL was not an independent risk factor for death and prolonged ICU stay. However, target feeding time of patients in the ≥ 250 mL group was longer than that of patients in the ≥ 250 mL group, and caloric intake (22.0, 23.6, 24.8, 25.3 kcal/kg/d) for patients in the ≥ 250 mL group from the 4^th day to the 7^th day of hospitalization was lower than that of patients in the ≥ 250 mL group (23.2, 24.8, 25.7, 25.8 kcal/kg/d). On the 4^th day (Z = 4.324, P = 0.013), on the 5^th day (Z = 3.376, P = 0.033), while on the 6^th day (Z = 3.098, P = 0.04), the differences were statistically significant.

CONCLUSION

The use of ultrasound to monitor GRV and undertaking clinical interventions when the monitoring value is ≥ 250 mL has no significant effects on incidences of feeding complications and clinical prognostic outcomes, however, it significantly prolongs the time to reach target feeding, reduces the daily intake of calories during ICU hospitalization, and increases the risk of insufficient nutrition of patients. The accuracy and necessity of monitoring gastric remnants and monitoring frequencies should be investigated further.

Using Nurse-Driven Protocols to Eliminate Routine Gastric Residual Volume Measurements: A Retrospective Study

BACKGROUND

Multiple critical care guidelines support the elimination of routine gastric residual volume monitoring in patients receiving enteral nutrition. However, transitioning nursing practice away from routine gastric residual volume assessments has proved challenging.

OBJECTIVE

To evaluate outcomes after the elimination of routine gastric residual volume monitoring in a 14-bed adult intensive care unit at a large teaching hospital in the southeastern United States.

METHODS

Practice change was accomplished through in-service training and implementation of a validated protocol. Data were collected for 30 days before and 30 days after protocol implementation to determine effects on the total volume of enteral nutrition received as well as the rate of adverse events after elimination of routine gastric residual volume assessments (n = 22) as compared with previous standard practice (n = 25).

RESULTS

When gastric residual volume was not measured, the mean (SD) percentage of enteral nutrition delivery was 81% (12%) of the ordered volume, compared with 60% (18%) in the historic control group (P = .002). Eliminating gastric residual volume monitoring was not associated with an increased rate of adverse events (emesis, aspiration pneumonia) or a change in length of stay. Nursing staff demonstrated a high degree of compliance with this protocol change.

CONCLUSION

The findings of this study indicate that the elimination of routine gastric residual volume assessment does not increase the rate of adverse events and results in increased nutrition provision. Use of a protocol for practice change as well as mandatory in-service training may effect changes in nursing practice.

Sonographic Evaluation of Gastric Residual Volume during Enteral Nutrition in Critically Ill Patients Using a Miniaturized Ultrasound Device

Background: To assess the risk of aspiration, nutrient tolerance, and gastric emptying of patients in ICUs, gastric ultrasound can provide information about the gastric contents. Using established formulas, the gastric residual volume (GRV) can be calculated in a standardized way by measuring the gastric antrum. The purpose of this study was to determine the GRV in a cohort of enterally fed patients using a miniaturized ultrasound device to achieve knowledge about feasibility and the GRV over time during the ICU stay. The findings could contribute to the optimization of enteral nutrition (EN) therapy. Methods: A total of 217 ultrasound examinations with 3 measurements each (651 measurements in total) were performed twice daily (morning and evening) in a longitudinal observational study on 18 patients with EN in the interdisciplinary surgical ICU of Saarland University Medical Center. The measured values of the GRV were analyzed in relation to the clinical course, the nutrition, and other parameters. Results: Measurements could be performed without interrupting the flow of clinical care and without pausing EN. The GRV was significantly larger with sparsely auscultated bowel sounds than with normal and excited bowel sounds (p < 0.01). Furthermore, a significantly larger GRV was present when using a high-caloric/low-protein nutritional product compared to an isocaloric product (p = 0.02). The GRV at the morning and evening measurements showed no circadian rhythm. When comparing the first and last ultrasound examination of each patient, there was a tendency towards an increased GRV (p = 0.07). Conclusion: The GRV measured by miniaturized ultrasound devices can provide important information about ICU patients without restricting treatment procedures in the ICU. Measurements are possible while EN therapy is ongoing. Further studies are needed to establish gastric ultrasound as a management tool in nutrition therapy.

Implementation Science and Nutrition: From Research to Practice

Implementation science (IS) is a young field that seeks to minimize the gap between what we know and what we practice, otherwise known as the "know-do gap." Recently, IS has focused on research that expedites the dissemination of evidence-based knowledge, accelerates the translation of interventions to improve knowledge gaps, shrinks healthcare disparities, enhances care of complex medical conditions, and narrows variation in clinical practice and policy. This article seeks to review theoretical frameworks of IS and demonstrate how IS can be utilized to improve nutrition care. Specific examples in this article include implementation of initiatives to improve documentation of malnutrition, increase provision of oral nutrition supplements, increase use of Enhanced Recovery After Surgery protocols, and increase energy and protein delivery. Clinical nutrition is a growing field with more and more research findings pointing to new therapies. In implementing these new therapies, practitioners should recognize the complex system present in healthcare and lean on IS findings to speed implementation and more rapidly improve clinical outcomes.