residual volumes and the REGANE study

[Linda DeStefano]

Hi all,

I wanted to ask you and other experts about the most recent ASPEN
guidelines, particularly related to accepting gastric residual volumes
(GRV’s) up to 500ml.

When I reviewed the ASPEN guideline carefully, they refer to the
summary of studies in the ASPEN D2 section. Of those, Other than the
REGANE study, I only found one study that used 400ml versus 200ml
residuals but there were only 20 patients in each arm. The other
reference, which was “in press” at the time of the publication of the
guidelines looks like it was the Spanish REGANE study where they used
“prophylactic prokinetics” in ALL study subjects. The prokinetic
issue, ironically wais not included when I only read the abstract of
the study. They even state that “we cannot exclude a beneficial effect
of metoclopramide in improving diet tolerance in our patients”. Also
the study was done on patients on a ventilator with a protected
airway, so it cannot be generalizable to patients who are not on a
ventilator, right?

So really with what I am finding so far, GRV limits of 500 without
using prokinetics is not in the literature and has not been studied
and therefore can not really be called "evidence-based practice", but
I am hoping you can help direct me. Many of our providers don’t like
metoclopramide due to potential side effects, so we can't standardize
that way where I practice.

Also, am I correct to note that in the REGANE study, they did not show
any statistically significant benefits to using 500ml (i.e.
improvement in length of stay, days on ventilator, mortality, etc).
They only found about 100kcal more was delivered the first week in the
500ml group?

Would you also do me a favor and forward this to Dr. Martindale,
McClave, and Beth Taylor if you have their contact info. I would so
much appreciate it! I am very interested to know if I am missing a
large study that used 500ml without the use of prokinetics.

Sincerely,

Linda DeStefano, NP, FCCM

Saddleback Memorial Medical Center

Laguna Hills, CA

(949) 452-3408 or

(949) 837-4500 beeper # 13237

[Daren Heyland]

Hi Linda
Good questions and controversial topic.
With respect to the REGANE study, I agree there is not clinical advantage to
500 ml and the use of motility agents and most medical patients makes this
study difficult to interpret. Most strikingly, there nutritional adequacy
was in the 80's in both groups from early on (day 1, 2) so I don't know what
they are doing different in spain but again , I don't know if there findings
are generalizable.

There is evidence that GRV's >500 or vomiting is associated with
significantly worse outcomes (Mentec study, CCM) so I do not advocate use of
such a high GRV.

I find the presense of a high GRV of >150 indiciative of delayed gastric
emptying. Knowing that the patient has delayed gastric emptying makes me do
things differently (ad motility agents, small bowel tubes, make sure head of
bed up) so I still advocate checking residula volumes. Having said that , a
low residual volume threshold will interfere with your ability to feed
patients so somewhere between 200-300 ml is probably a balance of safety and
efficacy.

I am totally for using metaclopramide at the start of initiating EN or as
treating high GRVs. Don't see many side effects in early phase of critically
ill mechanically ventilated, sedate patients. We are currentl desgining a
study using a novel motilin agonist to prove that this apparoach is
beneficial. Right now, there is limited evidence of its efficacy (Pinella,
JPEN, many years ago).

All these studies are also cited on our website if you want the specific
recommendations.

I don't know if anyone else has an comment....
Daren

Hi all,

Sincerely,

Linda DeStefano, NP, FCCM

Saddleback Memorial Medical Center

Laguna Hills, CA

(949) 452-3408 or

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[Gabriele]

Hi everybody,
I agree with Daren....Metoclopramide is safe and it works.
We generally use it as "on need drug" when GRV is higher the 250 ml.
In the nutrition protocol, we are discussing, Metoclopramide
administration is related to GRV. If GRV is less than 100 ml
Metoclopramide is not adinistrated. We try to reduce the drug use
according to the lower dose we need for reduce GRV in order to prevent
desensibilization which is described by some Authors. This is the
reason why we do not start Metoclopramide unless GRV is higher than
250 ml.

I would put your attention and asking your opinion on the use of
opioids antagonist to reduce GRV. I'm not confident with this drug for
reducing GRV but I found an increasing number of papers on this topic.
I send to the moderator a Chocrane on a surprisig evidence on
Alvimopam (opioids antagonist). Does anybody use it or has any
experience on the use of this drugs for GRV control ?

Thanks
Gabriele Bassi M.D.
General ICU, Trauma Centre and Burn Unit
Niguarda Hospital, Milano, Italy

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[Lauren]

Here is the article Dr. Bassi is referring to:
http://www.criticalcarenutrition.com/docs/googlegroup/cochrane_ileusparaliticus.pdf

Cheers,
Lauren

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[gokcen garipoglu]

hi all.

ı'm a dietician in military hospital in turkey.

thanks for sharing, ı fallow e-mails, but ı can't write because of my english.

it's not  very vell, sory for this.

ı wonder , how do you measure GRV, while feeding continue (24 hours )

thanks...

 

2011/6/20 Lauren <mur...@kgh.kari.net>

[Susan Helmrich]

Hi,
We aspirate the feeding tube every 4 hours to measureGRV. If the volume is less than 200 mls we return the contents manually  back to the stomach via the feeding tube .
Hope this helps
Susie

[Daren Heyland]

Hi

I think what the regane study showed us is that in hemodynamically stable medical ICU patients, you can push up the GRV to 500. having said that, in busy, mixed ICUs where you have sick patients, surgical patients, medical patients all mixed together, you probably want something that is safe for all. I think a feeding protocol that requires checking GRV every 4-6 hrs and uses a threshold of >250 but less than 400 is probably safe for most ICU patients. I still worry that 500 is too much for real sick ICU patients and of course, we can do harm by promoting regurgitation, aspiration and pneumonia. Better to be safe than sorry!
cheers

Daren

 

 

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[gokcen garipoglu]

hi.

thanks for answer susan.

you mean, stop feeding,no wait and aspirate to GR for every 4 hour.

2011/9/29 Susan Helmrich <shelm...@gmail.com>