Paediatric intensive care nurses' decision‐making around gastric residual volume measurement

Abstract

BackgroundMeasuring gastric residual volume (GRV) to guide enteral feeding is a common nursing practice in intensive care units, yet little evidence supports this practice. In addition, this practice has been shown to potentially contribute to inadequate energy delivery in intensive care, which remains a problem in critically ill children.. AimsWe aimed to explore paediatric intensive care nurses' decision-making surrounding this practice. MethodsA cross-sectional electronic survey in a single mixed general and cardiac surgical PICU in the UK. ResultsThe response rate was 59% (91/154) and responding nurses were experienced, with a mean PICU experience of 10.5 years (SD 8.09). The three main reasons for stopping or withholding enteral feeds were: the volume of gastric residual volume obtained (67%), the appearance of this gastric aspirate (40%) and the overall clinical condition of the child (23%). Most 2 nurses reported checking GRV primarily to determine 'feed tolerance' (97%) as well as confirming feeding tube position (94%). Nurses' perceived harms from high GRV were: the risk of pulmonary aspiration (44%), malabsorption of feeds (20%) and the risk of vomiting (19%). GRV was measured frequently in this PICU, with 58% measuring GRV before every feed, 27% measuring 4 hourly and 17% measuring 6 hourly.The majority of nurses (84%) stated they would be worried or very worried if they could not measure GRV routinely. ConclusionsPICU nurses' decision-making surrounding initiating and withholding enteral feeds, and determining 'feed tolerance' remains heavily based on GRV. PICU nurses' have significant fears around patient harm if they do not measure GRV routinely. Relevance to clinical practiceThis nursing practice is likely to be one of the factors that impair the delivery of enteral nutrition in critically ill children and as such its validity and usefulness needs to be challenged and studied in future research.

A review of feeding intolerance in critically ill children

“…These include gastric residual volumes (GRV), vomiting, diarrhea, abdominal distention and pain/discomfort, and the use of serum lactate [41,46]. However, evidence to support each of these as an indicator of feeding intolerance is weak or absent, and in critically ill children, a multitude of non-feedrelated factors can produce these signs and symptoms.…”

“…We did not formally appraise the quality of these papers, as our aim was to describe the definition and use of the term feeding intolerance. A further 32 papers were review or discussion papers [n = 6] [2, 6,13,18,46,47], surveys [n = 5] [16,40,41,43,44], research papers which support this review but are not included in papers which defined feeding intolerance [n = 19] [3, 8, 11, 12, 14, 15, 17, 24, 25, 27, 30-32, 36, 38, 39, 42, 49], and guidelines [n = 2] [4,26] where feeding intolerance was mentioned or discussed.…”

Gastric residual volume measurement in the intensive care unit: an international survey reporting nursing practice

“…Possibly, these are nurses not following or being unaware of current guidelines. Although our study focused on practices in adult ICUs, paediatric ICU (PICU) nurses were also shown to frequently measure GRV (Tume et al, ). In a single‐centre survey in the United Kingdom with 91 participating nurses, 58% measured GRV before every feed, 27% every 4 h and 17% every 6 h. The majority of participants (84%) stated that they would be worried or very worried if GRV would not be measured routinely.…”

Gastric residual volume measurement in British neonatal intensive care units: a survey of practice

“…22 Furthermore, when decision-making is based on volume, clinicians fail to consider the impact of gastric secretions produced during the digestion process. 23 This study has limitations. First, as with any survey, responses may not reflect actual practice.…”