Gastric Residual Volumes – has the end come to routine checking or is caution still needed?
The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have recently published new nutrition guidelines for critical care in the USA: Taylor et al. 2016. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Critical Care Medicine 44(2): 390-438.
Within this document are a number of different recommendations for nutrition practices while caring for critically ill patients based on their interpretations of current research including the following statements about gastric residual volumes (GRV):
- “We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN.
- We suggest that, for those ICUs where GRVs are still utilized, holding EN for GRVs < 500 mL in the absence of other signs of intolerance should be avoided.”
Since the REGANE study (Montejo et al. 2010), there has been debate about what the threshold of acceptable gastric residual volumes should be within enteral nutrition protocols suggesting up to 500 mls is suitable. Research from Reignier et al. (2013) concluded that routine checking of GRVs did not increase the risk of mechanically ventilated patients developing ventilator associated pneumonia. In Issue 9 (Heyland and Dhaliwal 2013) of the NIBBLE Nutrition Information Byte ‘hot topics’ newsletter by the Canadian Critical Care Nutrition group, these two studies are explored with a feeling that it is too premature to completely abandon GRV monitoring at this time. They argue that the results of these research studies may not be generalizable to all critical care patient populations which is reflected in the GRV section of the May 2015 Canadian Clinical Practice Guidelines for critical care nutrition.
The European Society of Clinical Nutrition and Metabolism (ESPEN) clinical guidelines related to nutrition in intensive care have not been updated since this GRV research by Montejo et al. (2010) and Reignier et al. (2013) was published. My personal observation is that some individual intensive care units in the UK have been making local decisions to increase the thereshold for acceptable GRVs from traditional practice like 200 ml to higher amounts up to 400-500 mls but are still including routine monitoring of regular GRV checks for enterally fed patients. Like most critical care topics though, further research including larger trials and consideration for sub-groups (eg surgical patients, trauma, neuro and burns) is likely needed before a final conclusion can be made on whether GRV checking should remain routine or not done anymore. As such an engrained part of critical care nursing practice, it’s hard to imagine not aspirating GRVs at all during a 12 hour shift caring for mechanically ventilated patient but who knows what the future holds as further research develops.
Heather Baid is a critical care nurse who completed her pre-registration nursing degree and post-registration intensive care course in Canada where she is originally from. After moving to England in 2002, she has worked as an intensive care nurse, work-based learning facilitator for physical assessment and is now a senior lecturer at the University of Brighton. Heather’s main teaching roles at present are to lead the Intensive Care Pathway and contribute to physical assessment teaching for post-registration courses. Heather is also a part-time PhD student undertaking a grounded theory research study about sustainability in critical care practice.