Evaluation of the effect on patient parameters of not monitoring gastric residual volume in intensive care patients on a mechanical ventilator receiving enteral feeding: A randomized clinical trial

Nurses' decision-making around gastric residual volume measurement in UK adult intensive care: A four-centre survey

BACKGROUND

Despite increasing evidence of the potential inaccuracy and unwarranted practice of regular GRV measurement in critically in adults, this practice persists within the United Kingdom.

AIM

To explore adult intensive care nurses' decision-making around the practice of GRV measurement to guide enteral feeding.

STUDY DESIGN

A cross-sectional 16 item electronic survey in four adult intensive care units (ICUs) in England and Wales.

RESULTS

Two hundred and seventy-three responses were obtained across four ICUs with acceptable response rates for most [Unit 1 74 /127 = 58.2%; Unit 2 87/129 = 67.4%; Unit 3 77/120 = 64.1%; Unit 4 35/168 = 20.8%]. Most (243/273 (89%) reported measuring GRV 4-6 hourly, with most (223/273 82%) reporting that the main reason was to assess feed tolerance or intolerance and 37/273 (13.5%) saying their unit protocol required it. In terms of factors affecting decision-making, volume obtained was the most important factor, followed by the condition of the patient, with aspirate colour and appearance less important. When asked how they would feel about not measuring GRV routinely, the majority (78.2%) of nurses felt worried (140/273 = 51.2%) or very worried (74/273 = 27%).

CONCLUSIONS

Factors affecting the nurses' decision-making around GRV were based largely on fear of risk (around vomiting and pulmonary aspiration) and compliance with unit protocols.

RELEVANCE TO CLINICAL PRACTICE

Despite increasing evidence suggesting it is unnecessary, nurses' beliefs around the value of this practice persist and it continues to be embedded into unit protocols around feeding.

Is monitoring of gastric residual volume for critically ill patients with enteral nutrition necessary? A meta-analysis and systematic review

BACKGROUND

There are many controversies over the necessity of monitoring gastric residual volume in the nursing care of enteral nutrition. We aimed to conduct an updated meta-analysis to evaluate the effects of monitoring or not monitoring gastric residual volume on patients' outcomes and complications.

METHODS

We searched the Cochrane Library database to 15 April 2021 for randomized controlled trials (RCTs) on the effects of gastric residual volume and no gastric residual volume monitoring. Review Manager software was used for data analysis.

RESULTS

A total of seven RCTs involving 1240 enteral nutrition patients were included. Gastric residual volume monitoring was associated with reduced incidence of vomiting (OR2.33, 95% CI:1.68-3.24), whereas no gastric residual volume monitoring was associated with reduced incidence of unnecessary interruptions of enteral nutrition (OR0.38,95% CI:0.26-0.55). There were no significant differences on the incidence of abdominal distention (OR1.87, 95% CI:0.82-4.28), diarrhoea (OR1.03,95% CI:0.74-1.43), VAP (OR0.83, 95%CI:0.37-1.89), duration of mechanical ventilation (MD -0.06,95% CI:-1.22-1.10), length of ICU stay (MD -1.33, 95% CI:-3.58-0.91) and mortality (OR0.90,95% CI:0.61-1.34).

CONCLUSIONS

Not monitoring gastric residual volume is associated with reduced unnecessary interruptions of enteral nutrition related to inadequate feeding and increased risk of vomiting.

The impact of high versus standard enteral protein provision on functional recovery following intensive care admission (PRECISE trial): study protocol for a randomized controlled, quadruple blinded, multicenter, parallel group trial in mechanically ventilated patients

BACKGROUND

Critically ill patients are subject to severe skeletal muscle wasting during intensive care unit (ICU) stay, resulting in impaired short- and long-term functional outcomes and health-related quality of life. Increased protein provision may improve functional outcomes in ICU patients by attenuating skeletal muscle breakdown. Supporting evidence is limited however and results in great variety in recommended protein targets.

METHODS

The PRECISe trial is an investigator-initiated, bi-national, multi-center, quadruple-blinded randomized controlled trial with a parallel group design. In 935 patients, we will compare provision of isocaloric enteral nutrition with either a standard or high protein content, providing 1.3 or 2.0 g of protein/kg/day, respectively, when fed on target. All unplanned ICU admissions with initiation of invasive mechanical ventilation within 24 h of admission and an expected stay on ventilator support of at least 3 days are eligible. The study is designed to assess the effect of the intervention on functional recovery at 1, 3, and 6 months following ICU admission, including health-related quality of life, measures of muscle strength, physical function, and mental health. The primary endpoint of the trial is health-related quality of life as measured by the Euro-QoL-5D-5-level questionnaire Health Utility Score. Overall between-group differences will be assessed over the three time points using linear mixed-effects models.

DISCUSSION

The PRECISe trial will evaluate the effect of protein on functional recovery including both patient-centered and muscle-related outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04633421 . Registered on November 18, 2020. First patient in (FPI) on November 19, 2020. Expected last patient last visit (LPLV) in October 2023.

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.

The intensivist's assessment of gastrointestinal function: A pilot study

Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.

Monitoring of gastric residual volume during enteral nutrition

BACKGROUND

The main goal of enteral nutrition (EN) is to manage malnutrition in order to improve clinical outcomes. However, EN may increase the risks of vomiting or aspiration pneumonia during gastrointestinal dysfunction. Consequently, monitoring of gastric residual volume (GRV), that is, to measure GRV periodically and modulate the speed of enteral feeding according to GRV, has been recommended as a management goal in many intensive care units. Yet, there is a lack of robust evidence that GRV monitoring reduces the level of complications during EN. The best protocol of GRV monitoring is currently unknown, and thus the precise efficacy and safety profiles of GRV monitoring remain to be ascertained.

OBJECTIVES

To investigate the efficacy and safety of GRV monitoring during EN.

SEARCH METHODS

We searched electronic databases including CENTRAL, MEDLINE, Embase, and CINAHL for relevant studies on 3 May 2021. We also checked reference lists of included studies for additional information and contacted experts in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), randomized cross-over trials, and cluster-RCTs investigating the effects of GRV monitoring during EN. We imposed no restrictions on the language of publication.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results for eligible studies and extracted trial-level information from each included study, including methodology and design, characteristics of study participants, interventions, and outcome measures. We assessed risk of bias for each study using Cochrane's risk of bias tool. We followed guidance from the GRADE framework to assess the overall certainty of evidence across outcomes. We used a random-effects analytical model to perform quantitative synthesis of the evidence. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous and mean difference (MD) with 95% CIs for continuous outcomes.

MAIN RESULTS

We included eight studies involving 1585 participants. All studies were RCTs conducted in ICU settings. Two studies (417 participants) compared less-frequent (less than eight hours) monitoring of GRV against a regimen of more-frequent (eight hours or greater) monitoring. The evidence is very uncertain about the effect of frequent monitoring of GRV on mortality rate (RR 0.91, 95% CI 0.60 to 1.37; I² = 8%; very low-certainty evidence), incidence of pneumonia (RR 1.08, 95% CI 0.64 to 1.83; heterogeneity not applicable; very low-certainty evidence), length of hospital stay (MD 2.00 days, 95% CI -2.15 to 6.15; heterogeneity not applicable; very low-certainty evidence), and incidence of vomiting (RR 0.14, 95% CI 0.02 to 1.09; heterogeneity not applicable; very low-certainty evidence). Two studies (500 participants) compared no GRV monitoring with frequent (12 hours or less) monitoring. Similarly, the evidence is very uncertain about the effect of no monitoring of GRV on mortality rate (RR 0.87, 95% CI 0.62 to 1.23; I² = 51%; very low-certainty evidence), incidence of pneumonia (RR 0.70, 95% CI 0.43 to 1.13; heterogeneity not applicable; very low-certainty evidence), length of hospital stay (MD -1.53 days, 95% CI -4.47 to 1.40; I² = 0%; very low-certainty evidence), and incidence of vomiting (RR 1.47, 95% CI 1.13 to 1.93; I² = 0%; very low-certainty evidence). One study (322 participants) assessed the impact of GRV threshold (500 mL per six hours) on clinical outcomes. The evidence is very uncertain about the effect of the threshold for GRV at time of aspiration on mortality rate (RR 1.01, 95% CI 0.74 to 1.38; heterogeneity not applicable; very low-certainty evidence), incidence of pneumonia (RR 1.03, 95% CI 0.72 to 1.46; heterogeneity not applicable; very low-certainty evidence), and length of hospital stay (MD -0.90 days, 95% CI -2.60 to 4.40; heterogeneity not applicable; very low-certainty evidence). Two studies (140 participants) explored the effects of returning or discarding the aspirated/drained GRV. The evidence is uncertain about the effect of discarding or returning the aspirated/drained GRV on the incidence of vomiting (RR 1.00, 95% CI 0.06 to 15.63; heterogeneity not applicable; very low-certainty evidence) and volume aspirated from the stomach (MD -7.30 mL, 95% CI -26.67 to 12.06, I² = 0%; very low-certainty evidence) We found no studies comparing the effects of protocol-based EN strategies that included GRV-related criteria against strategies that did not include such criteria.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of GRV on clinical outcomes including mortality, pneumonia, vomiting, and length of hospital stay.

Optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care: a mixed methods consensus process

BACKGROUND

Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design.

OBJECTIVE

To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care.

DESIGN

A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting.

PARTICIPANTS

Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting.

RESULTS

Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were categorised as 'consensus in', and no outcomes were voted 'consensus out'. 'No consensus' outcomes were discussed and voted on in a face-to-face meeting by 19 participants, where four were voted 'consensus in'. The final nine consensus outcomes were: mortality, necrotising enterocolitis, time to full enteral feeds, duration of parenteral nutrition, time feeds stopped per 24 hours, healthcare-associated infection; catheter-associated bloodstream infection, change in weight between birth and neonatal discharge and pneumonia due to milk aspiration.

CONCLUSIONS AND RELEVANCE

We have identified outcomes for a trial of no routine measurement of gastric residual volume to guide feeding in neonatal care. This outcome set will ensure outcomes are important to healthcare professionals and parents.

Evaluation of pneumonia due to mechanical ventilation and its association with the severity of disease in patients admitted to intensive care unit

Among the hospital-acquired infections, ventilator-associated pneumonia (VAP) has the highest mortality and morbidity rates. The aim of this study was to identify VAP in the intensive care unit (ICU) and its association with the severity of the disease. This descriptive-analytic study was conducted in Golestan University of Medical Sciences (Northern Iran). In the present study, 239 patients undergoing mechanical ventilation hospitalized in ICU were selected through non-random sampling. Data were recorded by using APACHE II criteria and diagnosis of VAP was made based on clinical criterion and physician confirmation. Data were analyzed by independent t-test, Chi-square test, Mann-Whitney test, and single-variable logistic test. The incidence of VAP was 19.2% and it was significantly related to mean arterial pressure (P = 0.035) and male sex (P = 0.122). There was a significant and direct correlation between the incidence of VAP and the increase in the value of gastric residual volume > 200 ml (P = 0.001). The findings of this study showed that male sex, increased arterial pressure, and gastric residual volume were the risk factors for the development of of VAP.

Routine gastric residual volume measurement to guide enteral feeding in mechanically ventilated infants and children: the GASTRIC feasibility study

BACKGROUND

The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it.

OBJECTIVE

To answer the question: is a trial of no gastric residual volume measurement feasible in UK paediatric intensive care units and neonatal units?

DESIGN

A mixed-methods study involving five linked work packages in two parallel arms: neonatal units and paediatric intensive care units. Work package 1: a survey of units to establish current UK practice. Work package 2: qualitative interviews with health-care professionals and caregivers of children admitted to either setting. Work package 3: a modified two-round e-Delphi survey to investigate health-care professionals' opinions on trial design issues and to obtain consensus on outcomes. Work package 4: examination of national databases to determine the potential eligible populations. Work package 5: two consensus meetings of health-care professionals and parents to review the data and agree consensus on outcomes that had not reached consensus in the e-Delphi study.

PARTICIPANTS AND SETTING

Parents of children with experience of ventilation and tube feeding in both neonatal units and paediatric intensive care units, and health-care professionals working in neonatal units and paediatric intensive care units.

RESULTS

Baseline surveys showed that the practice of gastric residual volume measurement was very common (96% in paediatric intensive care units and 65% in neonatal units). Ninety per cent of parents from both neonatal units and paediatric intensive care units supported a future trial, while highlighting concerns around possible delays in detecting complications. Health-care professionals also indicated that a trial was feasible, with 84% of staff willing to participate in a trial. Concerns expressed by junior nurses about the intervention arm of not measuring gastric residual volumes were addressed by developing a simple flow chart and education package. The trial design survey and e-Delphi study gained consensus on 12 paediatric intensive care unit and nine neonatal unit outcome measures, and identified acceptable inclusion and exclusion criteria. Given the differences in physiology, disease processes, environments, staffing and outcomes of interest, two different trials are required in the two settings. Database analyses subsequently showed that trials were feasible in both settings in terms of patient numbers. Of 16,222 children who met the inclusion criteria in paediatric intensive care units, 12,629 stayed for > 3 days. In neonatal units, 15,375 neonates < 32 weeks of age met the inclusion criteria. Finally, the two consensus meetings demonstrated 'buy-in' from the wider UK neonatal communities and paediatric intensive care units, and enabled us to discuss and vote on the outcomes that did not achieve consensus in the e-Delphi study.

CONCLUSIONS AND FUTURE WORK

Two separate UK trials (one in neonatal units and one in paediatric intensive care units) are feasible to conduct, but they cannot be combined as a result of differences in outcome measures and treatment protocols, reflecting the distinctness of the two specialties.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42110505.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 23. See the NIHR Journals Library website for further project information.

A Literature Review of Percutaneous Endoscopic Gastrostomy: Dealing With Complications

Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.

Determining Optimal Outcome Measures in a Trial Investigating No Routine Gastric Residual Volume Measurement in Critically Ill Children

BACKGROUND

Choosing trial outcome measures is important. When outcomes are not clinically relevant or important to parents/patients, trial evidence is less likely to be implemented into practice. This study aimed to determine optimal outcome measures for a trial of no routine gastric residual volume (GRV) measurement in critically ill children.

METHODS

A mixed-methods approach was used: a focused literature review, parent and clinician interviews, a modified 2-round Delphi, and a stakeholder consensus meeting.

RESULTS

The review generated 13 outcomes. Fourteen pediatric intensive care unit (PICU) parents proposed 3 additional outcomes; these 16 were then rated by 28 clinicians in Delphi round 1. Six further outcomes were proposed, and 22 outcomes were rated in the second round. No items were voted "consensus out." The 18 "no-consensus" items were voted in a face-to-face meeting by 30 participants. The final 12 outcome measures were time to reach energy targets, ventilator-associated pneumonia, vomiting, time enteral feeds withheld per 24 hours, necrotizing enterocolitis, length of invasive ventilation, PICU length of stay, mortality, change in weight and markers of feed intolerance (parenteral nutrition administered), feed formula altered, and change to postpyloric feeds all secondary to feed intolerance.

CONCLUSION

We have identified 12 outcomes for a trial of no GRV measurement through a multistage process, seeking views of parents and clinicians.

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Introduction

Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.

Aim

To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.

Methods

Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.

Results

Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.

Conclusions

There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Gastric Residual Volume Measurement in U.K. PICUs: A Survey of Practice

OBJECTIVES

Despite little evidence, the practice of routine measurement of gastric residual volume to guide both the initiation and delivery of enteral feeding in PICUs is widespread internationally. In light of increased scrutiny of the evidence surrounding this practice, and as part of a trial feasibility study, we aimed to determine enteral feeding and gastric residual volume measurement practices in U.K. PICUs.

DESIGN

An online survey to 27 U.K. PICUs.

SETTING

U.K. PICUs.

SUBJECTS

A clinical nurse, senior doctor, and dietician were invited to collaboratively complete one survey per PICU and send a copy of their unit guidelines on enteral feeding and gastric residual volume.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Twenty-four of 27 units (89%) approached completed the survey. Twenty-three units (95.8%; 23/24) had written feeding guidelines, and 19 units (19/23; 83%) sent their guidelines for review. More units fed continuously (15/24; 62%) than intermittently (9/24; 37%) via the gastric route as their primary feeding method. All but one PICU routinely measured gastric residual volume, regardless of the method of feeding. Eighteen units had an agreed definition of feed tolerance, and all these included gastric residual volume. Gastric residual volume thresholds for feed tolerance were either volume based (mL/kg body weight) (11/21; 52%) or a percentage of the volume of feed administered (6/21; 29%). Yet only a third of units provided guidance about the technique of gastric residual volume measurement.

CONCLUSIONS

Routine gastric residual volume measurement is part of standard practice in U.K. PICUs, with little guidance provided about the technique which may impact the accuracy of gastric residual volume. All PICUs that defined feed tolerance included gastric residual volume in the definition. This is important to know when proposing a standard practice arm of any future trial of no-routine gastric residual volume measurement in critically ill children.

Is discard better than return gastric residual aspirates: a systematic review and meta-analysis

BACKGROUND

The assessment of residual gastric volume is common practice in critical care units. However, the effects and safety of discarding or returning gastric aspirates remain uncertain. Therefore, we aimed to evaluate the role of discarding or returning gastric aspirates on the gastric residual volumes in critically ill patients.

METHODS

A comprehensive, systematic meta-analysis of randomized controlled trials (RCTs) on the efficacy and safety of discarding or returning gastric aspirates in critical ill patients was performed. Studies were identified by searching Pubmed and other databases (from inception to 31 Sept 2018). Summary odd ratios (ORs) or mean differences (MDs) with 95% confidence intervals were calculated using fixed- or random-effects model for outcome assessment.

RESULTS

Four RCTs, with a total number of 314 adult patients, were included in the analysis. No significant differences were found in the 48th hour residual volume (MD = 8.89, 95% CI: 11.97 to 29.74), the average potassium level (MD = 0.00, 95% CI: - 0.16 to 0.16), the episodes of gastric emptying delay (OR = 0.98, 95% CI: 0.35 to 2.80), the incidence of aspiration pneumonia (OR = 0.93, 95% CI: 0.14 to 6.17), the episodes of nausea or vomiting (OR = 0.53, 95% CI: 0.07 to 4.13) and diarrhea (OR = 0.99, 95% CI: 0.58 to 1.70).

CONCLUSIONS

No evidence confirms that returning residual gastric aspirates provides more benefits than discarding them without increasing potential complications. Rigorously designed, multi-center, large-sample randomized controlled trials must be further conducted to validate the role of discarding or returning residual gastric aspirates.

Effects of not monitoring gastric residual volume in intensive care patients: A meta-analysis

BACKGROUND

Monitoring gastric residual volume has been a common practice in intensive care patients receiving enteral feeding worldwide. Recent studies though, have challenged the reliability and necessity of this routine monitoring process. Several studies even reported improvements in the delivery of enteral feeding without monitoring gastric residual volume, while incurring no additional adverse events. However, the benefit of monitoring gastric residual volume remains controversial in intensive care patients.

OBJECTIVE

The aim of this review is to identify the effects of not monitoring gastric residual volume in intensive care patients through a meta-analysis of the data pooled from published studies that meet our inclusion criteria.

DESIGN

A systematic review DATA SOURCES: An electronic search of Embase, Pubmed, and the Cochrane Library was completed up to April 2018. The data included basic population characteristics, related complications, mortality, duration of mechanical ventilation and intensive care unit length of stay.

REVIEW METHODS

Eligibility and methodological quality of the studies were assessed by two researchers independently according to the Joanna Briggs Institute guidelines. The Review Manager Software was used to calculate the pooled risk ratio (RR), weighted mean difference, and the corresponding 95% confidential interval (95% CI). Sensitivity analyses were done by excluding each study. Publication bias analyses were conducted to avoid the exaggerated effect of the overall estimates.

RESULTS

Five studies involving 998 patients were included in this meta-analysis. Compared with monitoring gastric residual volume, not monitoring gastric residual volume decreased the rate of feeding intolerance in critically ill patients (RR = 0.61, 95%CI 0.51-0.72), and did not result in an increment in the rate of mortality (RR = 0.97, 95%CI 0.73-1.29, P = 0.84) or the rate of ventilator-associated pneumonia (RR = 1.03, 95%CI 0.74-1.44, P = 0.85). There were also no differences in the duration of mechanical ventilation (MD = 0.09, 95%CI, -0.99 to 1.16, P = 0.88) or intensive care unit length of stay (MD=-0.18, 95%CI, -1.52 to 1.17, P = 0.79).

CONCLUSION

Except for an increased risk of vomiting, the absence of monitoring gastric residual volume was not inferior to routine gastric residual volume monitoring in terms of feeding intolerance development, mortality, and ventilator-associated pneumonia in intensive care patients. There is encouraging evidence that not measuring gastric residual volume does not induce additional harm to the patients. More multicenter, randomized clinical trials are required to verify these findings.

A review of feeding intolerance in critically ill children

Ensuring optimal nutrition is vital in critically ill children and enteral feeding is the main route of delivery in intensive care. Feeding intolerance is the most commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition, yet the definition for this remains inconsistent, nebulous, and entirely arbitrary. Not only does this pose problems clinically, but research in this field frequently uses feeding intolerance as an endpoint and the heterogeneity in this definition makes the comparison of studies difficult and meta-analysis impossible. We reviewed the use of, and definitions of, the term feed intolerance in pediatric intensive care research papers in the last 20 years. Gastric residual volume remains the most common factor used to define feed intolerance, despite the lack of evidence for this. Healthcare professionals would benefit from further education to improve their awareness of the limitations of the markers to define feeding intolerance, and the international PICU community needs to agree a consistent definition of this phenomenon to improve consistency in both practice and research.Conclusion: This paper will provide a narrative review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. What is Known?: • Feeding intolerance is a commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition. • There is no agreed definition for feeding intolerance in critically ill children. What is New?: • This paper provides an up to date review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. • Despite no evidence, gastric residual volume continues to drive clinical bedside decisions about enteral feeding and feeding tolerance.

Gastric residual volume measurement in the intensive care unit: an international survey reporting nursing practice

BACKGROUND

Gastric residual volume measurement is routinely used to evaluate the feeding tolerance and gastro-oesophageal reflux in patients receiving enteral feeding therapy in the intensive care unit. However, little supportive evidence for this intervention is available as the usefulness of gastric residual volume measurements in patients receiving enteral feeding therapy in the intensive care is controversial.

AIM

The aim of this study was to assess the practice of intensive care unit nurses related to gastric residual volume measurement in patients receiving enteral nutrition.

METHODS

A survey was conducted among a sample of intensive care unit nurses (n = 832) from four hospitals in Turkey (n = 182) and attendees of the Annual Congress of the Flemish Society for Critical Care Nurses in Flanders, Belgium (n = 650). The survey instrument was developed by the researchers based on the related literature.

RESULTS

A total of 480 nurses completed the questionnaire (response rate = 73%). Gastric residual volume is measured by 98·0% of respondents, with wide variations in the frequency of measuring. A 50-200 mL gastric residual volume is considered problematic by 45·5% (n = 183) of the participants, and only 18·4% (n = 81) reported their practice to be based on a current guideline. Strikingly, more experienced intensive care unit nurses appear to perform gastric residual volume measurements more commonly than their less experienced colleagues (p = 0·004), while the practice is more often reported to be performed in Belgium than in Turkey (p < 0·001).

CONCLUSION

Gastric residual volume management could be improved by applying current evidence to daily nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Our results show that increased awareness of these guidelines by nurses is needed to reduce inefficient use of working time and resources, streamline clinical practices and improve patient outcomes. Current gastric residual volume measurement guidelines and up-to-date, relevant training should be provided to nurses.

Measuring gastric residual volumes in critically ill burn patients - A systematic review

PURPOSE

Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient.

METHODS

PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded.

RESULTS

26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk.

CONCLUSIONS

We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.

Providing nutritional support for patients in critical care

The provision of nutritional support for patients who are critically ill is complex and multifaceted, in part because of the variety and complexity of potential clinical presentations. This article explores the importance of providing nutritional support for patients who are critically ill and explains the pathophysiology of nutrition in altered health states. It discusses nutritional screening and assessment, the various routes of nutrition administration and the nursing considerations involved in providing nutritional support in critical care.

Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.

Routine gastric residual volume measurement and energy target achievement in the PICU: a comparison study

Critically ill children frequently fail to achieve adequate energy intake, and some care practices, such as the measurement of gastric residual volume (GRV), may contribute to this problem. We compared outcomes in two similar European Paediatric Intensive Care Units (PICUs): one which routinely measures GRV (PICU-GRV) to one unit that does not (PICU-noGRV). An observational pilot comparison study was undertaken. Eighty-seven children were included in the study, 42 (PICU-GRV) and 45 (PICU-noGRV). There were no significant differences in the percentage of energy targets achieved in the first 4 days of PICU admission although PICU-noGRV showed more consistent delivery of median (and IQR) energy targets and less under and over feeding for PICU-GRV and PICU-noGRV: day 1 37 (14-72) vs 44 (0-100), day 2 97 (53-126) vs 100 (100-100), day 3 84 (45-112) vs 100 (100-100) and day 4 101 (63-124) vs 100 (100-100). The incidence of vomiting was higher in PICU-GRV. No necrotising enterocolitis was confirmed in either unit, and ventilator-acquired pneumonia rates were not significantly different (7.01 vs 12 5.31 per 1000 ventilator days; p = 0.70) between PICU-GRV and PICU-noGRV units.

CONCLUSIONS

The practice of routine gastric residual measurement did not significantly impair energy targets in the first 4 days of PICU admission. However, not measuring GRV did not increase vomiting, ventilator-acquired pneumonia or necrotising enterocolitis, which is the main reason clinicians cite for measuring GRV. What is known: • The practice of routinely measuring gastric residual volume is widespread in critical care units • This practice is increasingly being questioned in critically ill patients, both as a practice that increases • The likelihood of delivering inadequate enteral nutrition amounts and as a tool to assess feeding tolerance What is new: • Not routinely measuring gastric residual volume did not increase adverse events of ventilator acquired pneumonia, necrotising enterocolitis or vomiting. • In the first 4 days of PICU stay, energy target achievement was not significantly different, but the rates of under and over feeding were higher in the routine GRV measurement unit.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Paediatric intensive care nurses' decision-making around gastric residual volume measurement

BACKGROUND

Measuring gastric residual volume (GRV) to guide enteral feeding is a common nursing practice in intensive care units, yet little evidence supports this practice. In addition, this practice has been shown to potentially contribute to inadequate energy delivery in intensive care, which remains a problem in critically ill children.

AIMS

We aimed to explore paediatric intensive care nurses' decision-making surrounding this practice.

METHODS

This is a cross-sectional electronic survey in a single mixed general and cardiac surgical PICU in the UK.

RESULTS

The response rate was 59% (91/154), and responding nurses were experienced, with a mean PICU experience of 10·5 years (SD 8·09). The three main reasons for stopping or withholding enteral feeds were: the volume of GRV obtained (67%), the appearance of this gastric aspirate (40%) and the overall clinical condition of the child (23%). Most nurses reported checking GRV primarily to determine 'feed tolerance' (97%) as well as confirming feeding tube position (94%). Nurses' perceived harms from high GRV were: the risk of pulmonary aspiration (44%), malabsorption of feeds (20%) and the risk of vomiting (19%). GRV was measured frequently in this PICU, with 58% measuring GRV before every feed, 27% measuring every 4 h and 17% measuring every 6 h. The majority of nurses (84%) stated they would be worried or very worried if they could not measure GRV routinely.

CONCLUSIONS

PICU nurses' decision-making surrounding initiating and withholding enteral feeds and determining 'feed tolerance' remains heavily based on GRV. PICU nurses have significant fears around patient harm if they do not measure GRV routinely.

RELEVANCE TO CLINICAL PRACTICE

This nursing practice is likely to be one of the factors that impair the delivery of enteral nutrition in critically ill children, and as such, its validity and usefulness needs to be challenged and studied in future research.

Nutrition in the critically ill patient

PURPOSE OF REVIEW

To summarize recent relevant studies regarding nutrition during critical illness and provide recommendations for clinical practice.

RECENT FINDINGS

Recently acquired knowledge regarding nutritional status and risk assessment, body composition, gastric residual volume, prokinetics, tube positioning, enteral vs parenteral nutrition, nutritional dose and timing of initiation, pharmaconutrition, dysbiosis and probiotics are discussed.

SUMMARY

Body composition especially lean body mass is associated with clinical outcomes. The modified NUTrition Risk in the Critically ill score was validated for nutritional risk assessment and identifies patients that benefit from higher nutritional intake; however, caloric restriction decreases mortality in refeeding syndrome. Gastric residual volume monitoring is debated, as abandoning its application doesn't worsen outcome. There is no consensus regarding benefits of gastric vs postpyloric tube placement. Current prokinetics temporarily reduce feeding intolerance, new prokinetics are developed. Enteral remains preferable over parenteral nutrition, although no inferiority of parenteral nutrition is reported in recent studies. Studies imply no harm of hypocaloric feeding when protein requirements are met. Optimal protein provision may be more important than caloric adequacy. Pharmaconutrition confers no superior outcomes and may even confer harm. Dysbiosis is frequently encountered and associated with worse outcomes. Probiotics reduce infectious complications, but not mortality, and may contribute to earlier recovery of gut function.