Setting the record straight on gastric residual volumes

Imagine you just sat down to your desk to work for the day, log in and see this email: 

“Hey, just an FYI that the patient in room 123 had a gastric residual of 150 ml, so I stopped his tube feeding. How should we proceed?”   

While you may have felt exasperated knowing this resulted in inadequate nutrition for your patient, someone else found it alarming and interpreted it as a sign of intolerance. Checking gastric residual volumes (GRV) always seems to be a topic of debate. When should we check the residual and when does the GRV prompt the need for interventions? Is this an opportunity to educate staff or to reevaluate the patient’s enteral nutrition regimen? 

What are GRV? 

GRV are the liquid drained from the stomach after administration of enteral feeding. They mainly consist of enteral formula, water and GI secretions. The GRV can vary based on many factors such as diameter of the feeding tube, patient positioning, tube tip positioning and method used to drain. It’s important to remember that a jejunal tube should never be used to check residuals, nor should a small-bore feeding tube. (They don’t call them gastric residual volumes for nothing. 😉)   

Why do we check GRV? 

The practice of checking GRV originated to reduce the risk of aspiration pneumonia. It then became common practice in ICUs to identify early feeding intolerance. However, there is very little evidence for its efficacy or indication it reduces aspiration pneumonia or similar enteral complications.¹

When should residuals be checked? 

Current guidelines from the Americal Society for Parenteral and Enteral Nutrition (ASPEN) recommend against using GRV as part of routine care. The practice of routinely checking GRV (for example, every 4 to 8 hours) has potential to cause more harm by increasing chances of tube clogging and inappropriate stopping of enteral feeding, resulting in inadequate nutrition delivery.²

My facility is firm on checking GRV – what else can I do? 

Provide education and present evidence-based guidelines. ASPEN suggests that, if a facility is hesitant to discontinue the practice of checking GRV, to avoid holding enteral feeding for a GRV less than 500 ml without other signs of intolerance.² GRV should not be used as a sole indicator for enteral intolerance. Rather, intolerance can be determined with a thorough physical exam, patient reports of nausea or abdominal discomfort, bowel patterns and/or radiologic evaluations. 

More and more facilities are modifying their policies around checking GRV. Routine checking provides very little clinical benefit and lacks standardization and validation. While many still need some convincing, the main thing we can all agree on is that routine monitoring of GRV will only lead to decreased delivery of enteral nutrition, negatively impacting clinical outcomes. So, before replying to the email message mentioned above, take a deep breath and use the opportunity to empower a concerned clinician with updated practice guidelines from a credible source.  

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References 

Yasuda H, Kondo N, Yamamoto R, et al. Monitoring of gastric residual volume during enteral nutrition. Cochrane Database of Systematic Reviews. 2021;2021(9).  

McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of Nutrition Support Therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). Journal of Parenteral and Enteral Nutrition. 2016;40(2):159-211.