RE: [Critical Care Nutrition] Digest for - 2 updates in 2 topics

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MacEachern, Judy

Mar 30, 2016, 12:27:47 PM3/30/16

Margot - Re: GRV - we never check them routinely (hasn't been our practice in > 15 y)


Karen - Re: ND tubes and free water.  I wonder if the reference to 150 mL free water was based on that old case report (>10 y ago) where large boluses of distilled water were administered in a jejunally fed burn patient? We give 150-200 mL boluses of sterile water for the treatment of hypernatremia in stable ICU patient (i.e., not hypernatremia that may occur during fluid resuscitation from HONK/HHS or DKA).


Judy MacEachern RD CDE

Guelph General Hospital


From: []
Sent: Wednesday, March 30, 2016 1:10 AM
To: Digest recipients
Subject: [Critical Care Nutrition] Digest for - 2 updates in 2 topics

·         Digest for - 1 update in 1 topic - 1 Update

·         Free water boluses via naso-duodenal Feeding tubes - 1 Update

violam <>: Mar 17 09:31AM -0700

I do not have a sense of what ICUs are currently doing. We have one RCT in
section 5.6 of our CPGs 'Strategies to Optimize the Delivery of EN:
discarding GRVs
which I have attached. The RCT investigated whether GRVs should be returned
or discarded.
We have updated the poll on the Critical Care Nutrition homepage to learn
what usual practice is at ICUs globally.
On Thursday, March 10, 2016 at 8:33:17 AM UTC-5, guidodallacqua wrote:

KAREN <>: Mar 29 12:39PM

Hi, our MICU is placing more naso-duodenal feeding tubes. I remember reading several years ago that free water boluses should be limited to 150 cc, but a quick search didn't yield any guidelines. Anybody have any references or suggestions? Thanks, Karen Tufano RD
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Mar 31, 2016, 8:06:11 AM3/31/16

Thanks for your response Judy, I think my question is should there by a volume limit to the amount of bolus given at one time into the duodenum? The docs are ordering 400 c.c. boluses, which seems to me  like too much at once. Thanks, Karen
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Sent: Wednesday, March 30, 2016 12:27:36 PM
Subject: RE: [Critical Care Nutrition] Digest for - 2 updates in 2 topics
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Luciana Sutanto

Apr 2, 2016, 5:36:13 PM4/2/16
Hi Karen.  The aim to limit the bolus is to avoid reflux (risk of aspitarion). Bolus 400-500 mL still OK for patients if the patient in head up position (45 degrees),  gaster can enlarge until a volume of 1 L. Note: if we give a bolus, after some time the the volume in the gaster will increase due to the secretion of gastric juice. 
I, myself don't give too much bolus (>300mL), with consideration of patient comfort. Hope this can help. LUCY


Drover, Dr. John W.

Apr 3, 2016, 11:34:46 PM4/3/16

Hi Karen,

I am not aware of good data to identify what the maximum volume of a bolus that can be safely delivered into the SB. It would be modified by how quickly it is delivered. I have not qualms about delivering 250ml as a push would probably be OK with volumes up to 500ml delivered over an hour but that is just comfort, not evidence. Perhaps you could generate the empiric evidence of safety by monitoring the volume of boluses given and any complications experienced.



John W. Drover, MD, FRCSC, FACS, CCPE
Professor and Head
Department of Critical Care Medicine
Queen’s University
Program Medical Director, Critical Care Program
Davies 2
Kingston General Hospital
76 Stuart Street
Kingston, Ontario
K7L 2V7
Phone 613-549-6666 ext 6335
Fax 613-548-1325


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Apr 4, 2016, 2:55:04 PM4/4/16

Thank you Lucy and Dr. Drover!

From: <> on behalf of Drover, Dr. John W. <dro...@KGH.KARI.NET>
Sent: Sunday, April 3, 2016 11:34 PM
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