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| Contact the Editor |  Please send your RDNews comments, suggestions & questions to Judy Morgan, MBA, RD |
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Greetings!
 This issue of RDNews was submitted by HMC's RD in the field, Kelly Scanlon. She attended a 1 week Nutrition Support Traineeship at the University of Virginia Health System. For more information visit their website. |
Enteral Nutrition:
Gastric Residuals & Head of Bed | by; Kelly Scanlon, RD
(Access a pdf of the Full Article or go to HMC Staff Site:RD Toolbox> Reference File> Medical Nutrition Therapy)
 Gastric residuals have been a routine procedure used to assess enteral nutrition tolerance despite little evidence that suggests it is a reliable method for measuring this.
Enteral nutrition is not the only contributing factor when looking at gastric residuals. Most of the contents above the pylorus are our own endogenous secretions. We secrete approximately 2000 ml of saliva and 2000-3000 ml of gastric secretions every day. This means that there are approximately 165 ml of secretions present above the pylorus every hour in a healthy individual. Residuals are likely to include a mix of these endogenous secretions, the tube feeding, medications & med flushes. If the amount of residual is <300 ml after observation, the patient's GI is likely emptying normally. Some argue that continuing to check residuals every 4 hours if patient has been emptying fine, should not be a nursing priority as it interrupts feedings and takes up time the nurses might need for more urgent issues. Better indicators of intolerance are the patient's stated feelings of fullness or observing abdominal distention.
Best practice is to keep the head of the bed > 30 degrees with patient in the proper position (not slouching). This is especially important in patients receiving nocturnal feedings. If patients are leaned back at night in the supine position there is a chance the top portion (fundus) of the stomach can fall over to one side of the spine, allowing feeding to pool thereby increasing risk for aspiration.
If patient is experiencing signs or symptoms of intolerance, first ensure patient is sitting up at least 30 degrees. Second, have them lean on their right side to allow gravity to aid in gastric emptying. |
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RD Tip |
Factors that May Increase or Decrease
Gastric Residual Volume
- Use of proton pump inhibitors
- Narcotics
- Placement of EN infusion (stomach vs. below pylorus)
- Patient position
- Gastric Emptying
- Medications Known to Delay Gastric Emptying: Anticholinergics, Atropin, Beta agonists, Calcitonin, Calcium channel blockers, Dexfenfluramine, Diphenhydramine, Ethanol, Glucagon, Interleukin-1, L-dopa, Lithium, Octreotide, Ondansetron, Narcotics, Nicotine, Potassium Salts, Progesterone, Tricyclic antidepressants, Selective Serotonin Reuptake Inhibitors
- Saliva production
- Atrophic Gastritis
- Ileal brake
- Hyperglycemia
- Sepsis
Appropriate Responses to an Elevated GRV
(Gastric Residual Volume)
- Confirm backrest elevation is > 30 - 40 degrees
- Assess for abdominal distension, discomfort, bloating, fullness, N/V
- Place patient on their right side for 15 - 20 minutes before checking a GRV again (to take advantage of gravity)
- Consider switching to a more calorically dense formula to decrease total volume infused
- Review & minimize all fluids given enterally
- Minimize use of narcotics
- Consider switching from bolus feedings to continuous feedings
- Recommend prokinetic therapy or a proton pump inhibitor
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| Dear Dietitian | These are some valuable tips for reviewing the nutritional status of our tube fed residents. Remember to look at the resident, check the pump settings and cleanliness, resident's position in bed and communicate with nursing regularly about any tolerance issues. Thank you for your enteral feeding expertise for your residents!
Sincerely,
Judy Morgan, MBA, RD HM Composite |
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Registered Dietitian Newsletter
