Gastric Residual Volume Research Articles

Effects of ultrasound monitoring of gastric residual volume on feeding complications, caloric intake and prognosis of patients with severe mechanical ventilation.

Monitoring of gastric residual is an important approach for assessing gastric emptying in patients with mechanical ventilation. By monitoring gastric contents, the enteral nutrition scheme can be adjusted in time to ensure feeding safety. To investigate the effects of ultrasound monitoring on the incidence of feeding complications, daily caloric intake and prognosis of patients with severe mechanical ventilation. To analyze the clinical significance of ultrasound monitoring of gastric residual volume (GRV) up to 250 mL to provide a theoretical basis for clinical practice. Patients admitted to the department of emergency medicine of the Affiliated Hospital of Nantong University from January 2018 to June 2022 who received invasive mechanical ventilation and continuous enteral nutrition support within 24-48 h after admission were enrolled in this study. Medical records for patients within 7 d of hospitalization were retrospectively analyzed to compare the incidence of feeding complications, daily caloric intake and clinical prognosis between patients with gastric residual ≥ 250 mL and < 250 mL, as monitored by ultrasound on the third day. A total of 513 patients were enrolled in this study. Incidences of abdominal distension, diarrhea, and vomiting in the < 250 mL and ≥ 250 mL groups were: 18.4% vs 21.0%, 23.9% vs 32.3% and 4.0% vs 6.5%, respectively; mortality rates were 20.8% vs 22.65%; mechanical ventilation durations were 18.30 d vs 17.56 d while lengths of stay in the intensive care units (ICU) were 19.87 d vs 19.19 ± 5.19 d. Differences in the above factors between groups were not significant. Gastric residual ≥ 250 mL was not an independent risk factor for death and prolonged ICU stay. However, target feeding time of patients in the ≥ 250 mL group was longer than that of patients in the ≥ 250 mL group, and caloric intake (22.0, 23.6, 24.8, 25.3 kcal/kg/d) for patients in the ≥ 250 mL group from the 4th day to the 7th day of hospitalization was lower than that of patients in the ≥ 250 mL group (23.2, 24.8, 25.7, 25.8 kcal/kg/d). On the 4th day (Z = 4.324, P = 0.013), on the 5th day (Z = 3.376, P = 0.033), while on the 6th day (Z = 3.098, P = 0.04), the differences were statistically significant. The use of ultrasound to monitor GRV and undertaking clinical interventions when the monitoring value is ≥ 250 mL has no significant effects on incidences of feeding complications and clinical prognostic outcomes, however, it significantly prolongs the time to reach target feeding, reduces the daily intake of calories during ICU hospitalization, and increases the risk of insufficient nutrition of patients. The accuracy and necessity of monitoring gastric remnants and monitoring frequencies should be investigated further.

Construction and application of prone position ventilation management scheme for severe COVID-19 patients.

Background: Prone position ventilation (PPV) can significantly improve oxygenation index and blood oxygen saturation in most (70%-80%) patients with acute respiratory distress syndrome. However, although PPV is not an invasive procedure, there are many potential PPV-related complications, such as nerve compression, crush injury, venous stasis (e.g., facial oedema), pressure sores, retinal damage, vomiting, and arrhythmia, with an incidence of up to 56.9%. Nursing managers have focused on reducing the occurrence of PPV-related complications and improving safety. Objective: To construct a prone ventilation management scheme for patients with severe coronavirus disease 2019 (COVID-19) and analyse its application effect. Methods: Based on a previous evidence-based study combined with the COVID-19 Diagnosis and Treatment Protocol (Trial Edition 9), a prone ventilation management protocol for severe COVID-19 was formulated and applied to COVID-19 patients in the intensive care unit of a designated hospital. A prospective self-control study was used to compare changes in the oxygenation index and other outcome indicators before and after the intervention. Results: The oxygenation index of patients after intervention (321.22 ± 19.77mmHg) was significantly higher (p < 0.05) than before intervention (151.59 ± 35.49mmHg). The difference in oxygenation index in different prone position ventilation durations was statistically significant (p < 0.05). Nursing quality evaluation indicators showed that the implementation rate of gastric residual volume assessment was 100% and the incidence of occupational exposure and cross-infection was 0%; the incidences of pressure ulcers, drug extravasation, and facial oedema were 13.64% (3/22), 4.54% (1/22), and 4.54% (1/22), respectively. The incidence of unplanned extubation, aspiration, and falls/falls was 0%.

Preoperative Ultrasound Assessment of Residual Gastric Volume in Patients with Delayed Gastric Emptying Undergoing Elective Surgeries

Abstract Background One of the main problems facing anesthesiologists during anesthesia is delayed gastric emptying which may contribute to pulmonary aspiration. Perioperative aspiration of gastric contents is a rare but serious complication of anesthesia. Pulmonary aspiration is involved in up to 9% of all anesthesia-related deaths. One of the main risk factors for aspiration is the presence of residual gastric fluid at the time of anesthetic induction. It was demonstrated that bedside utrasonography can provide reliable qualitative and quantitative information about the nature (fluid or solid) and volume of gastric content. Aim of the Work To provide a qualitative description of the sonographic appearance of the gastric antrum in fasted patients with delayed gastric emptying undergoing elective surgery by proposing a grading system of the gastric antrum based exclusively on qualitative findings and correlation with the quantitative predicted gastric volume by the known formula prescribed for persons without delayed gastric emptying. Patients and Method This cross-sectional study was conducted at Ain Shams University Hospitals. Using ultrasonography, gastric contents was evaluated in 85 patients, with delayed gastric emptying, scheduled for elective surgeries before induction of anesthesia. Results Our study involved 85 patients, with age ranging from 25-66 years old, 49 of them were females and 36 were males, with BMI ranging from 28-35 Kg/m2.The most common surgeries involved were general surgeries especially laparoscopic cholecystectomy, with associated comorbidities such as diabetes, hypertension, smoking, hypothyroid, chronic kidney disease, rheumatoid arthritis. Ultrasonography showed that 46 of patients were Grade 0 with stomach empty in both supine and right lateral decubitus (RLD) and 36 were Grade 1 with stomach empty in supine but contains fluid in RLD and 3 patients in Grade 2 were stomach contains fluid in both supine and RLD or contains solid content. Conclusion Bedside ultrasound is of a good value in estimating the gastric volume and content in patients with delayed gastric emptying.

A Comparison of Slow Infusion Intermittent Feeding versus Gravity Feeding in Preterm Infants: A Randomized Controlled Trial.

The transition to full enteral feeding is important for ensuring adequate growth in preterm infants. The aim of this study was to investigate the effects of two different intermittent feeding methods on the transition to full enteral feeding in preterm infants. A prospective, randomized controlled study was conducted in a neonatology and perinatology center. Preterm infants with a gestational age between 24 + 0/7 and 31 + 6/7 were included in this study. They were divided into two groups: the SIF (slow infusion feeding) group and the IBF (intermittent bolus feeding) group. In the SIF group, feed volumes were administered over one hour using an infusion pump through an orogastric tube, with feeding occurring every three hours. The IBF group received enteral feeding using a gravity-based technique with a syringe through an orogastric tube, completed within 10 to 30 min. The primary outcome was the achievement of full enteral feeding and the occurrence of feeding intolerance. A total of 103 infants were enrolled in the study (50 in SIF and 53 in IBF). The time to achieve full enteral feeding did not differ significantly between the two groups (p = 0.20). The SIF group had significantly fewer occurrences in which gastric residual volume exceeded 50% (p = 0.01). Moreover, the SIF group had a significantly shorter duration of non-per-oral (NPO) status than the IBF group (p = 0.03). It is our contention that the use of the SIF method as an alternative feeding method is appropriate for infants with feeding intolerance and those at high risk of feeding intolerance.

A single-centre observational study of delayed defaecation in brain-injured patients in an adult intensive care unit

BackgroundThe incidence of delayed defaecation is high in enterally fed ventilated patients in intensive care units (ICUs). Those with brain injury may be harmed by increased intracranial pressure if delayed defaecation leads to abdominal distension. There are no studies evaluating a bowel guideline in the treatment of delayed defaecation in ventilated brain-injured ICU patients. ObjectiveThe objective of this study was to assess the incidence and clinical associations of delayed defaecation and level of compliance to an ICU bowel guideline. MethodsData were collected on ventilated adult patients with brain injury admitted for more than 3 days to one New Zealand ICU over a 2-year period. ResultsData were analysed for 117 patients; 56 (48%) who defaecated within 3 days of ICU admission (Group one) and 61 (52%) with delayed defaecation after 3 days (Group two). Compliance with the bowel guideline was low. Only 1 of 61 patients who should have had a rectal examination did so, and only 7 of 61 patients who should have had an aperient on day 3 did so. All seven received Movicol®, which was not part of the guideline. Use of aperients and enemas was found to be associated with stool passage (odds ratio: 93; 95% confidence interval: 5.2–1668; p = 0.002). Patients with delayed defaecation had longer ICU stays (mean 7.1 ± 4 SD vs 5.9 ± 3 days, p = 0.07) and more often had high gastric residual volumes after day 4 (27/61 vs 14/56; p = 0.003). No differences were seen between the groups in the incidence of ventilator-associated pneumonia, bacterial infections, diarrhoea, vomiting, duration of mechanical ventilation, or mortality. ConclusionDelayed defaecation was common, and compliance with the guideline was low. Movicol® and phosphate enemas were effective in stool production.

Safety and outcome of early enteral nutrition in patients receiving extracorporeal membrane oxygenation

To explore the benefits and risks of early enteral nutrition (EN) in patients receiving extracorporeal membrane oxygenation (ECMO). A single center retrospective review was performed including patients receiving ECMO for more than 24h from May 2014 to July 2021. A total of sixty-five patients were enrolled, of which thirty-six patients (55.4%) received early EN. On ECMO day 3rd, 7th and 14th, the median energy intake through EN in the early EN group was 500kcal (IQR:300, 880), 1000kcal (IQR: 500, 1500) and 1000kcal (500, 1500), representing 29.7%, 66.7% and 66.7% of energy target, respectively. Thirteen (36.1%) patients had EN intolerance in the early EN group, which is significantly lower than that in the delayed EN group (82.8%, P<0.001). The most common reasons for EN intolerance were abdominal distention (22.2%), followed by elevated gastric residual volume (8.3%) in the early EN group. Forty-three (66.1%) patients successfully weaned off ECMO, with higher rate in the early EN group than in the delayed EN group (80.6% vs 48.3%, p=0.006). Nineteen patients (52.8%) survived in the early EN group, which is also significantly higher than that in the delayed EN group (20.7%, P=0.008). Patients receiving early enteral nutrition significantly reduced the mortality rate and the adjusted mortality hazard ratio was 0.22 (95%CI:0.10, 0.47). Early EN was safe and well-tolerated and can reduce the in-hospital mortality of patients receiving ECMO. For patients receiving ECMO, EN started with hypocaloric doses within 48h of ECMO initiation is recommend.

Clinical efficacy of enteral nutrition feeding modalities in critically ill patients: a systematic review and meta-analysis of randomized controlled trials.

In intensive care units (ICUs), both continuous and intermittent feeding are commonly used for early enteral nutrition (EN). However, whether continuous feeding is a preferable feeding modality compared to intermittent feeding remains unclear. Therefore, this meta-analysis assessed the clinical efficacy of both EN feeding modalities in critically ill patients. The PubMed, Embase, and Cochrane Library databases were searched from their inception dates to December 29, 2022. The search did not involve language restrictions (PROSPERO CRD42022371756). Randomized controlled trials (RCTs) comparing the clinical efficacy and safety of continuous feeding and intermittent feeding in critically ill patients in ICUs were included. We included 13 RCTs involving 785 patients. Compared with intermittent feeding, continuous feeding was associated with a lower mortality rate (relative risk [RR], 0.68; 95% confidence interval [CI], 0.47, 0.98; p = 0.04) but a higher risk of constipation (RR, 1.57; 95% CI, 1.02, 2.43; p = 0.04). Trial sequential analysis (TSA) for mortality rate presented a cumulative Z-curve crossing the traditional boundary, but the curve did not cross the TSA boundary for benefit. No significant differences were found in the aspiration/pneumonia rate (RR, 1.19; 95% CI, 0.51, 2.75; p = 0.69), diarrhea rate (RR, 0.82; 95% CI, 0.58, 1.16; p = 0.26), or increased gastric residual volumes (RR, 1.05; 95% CI, 0.58, 1.90; p = 0.86) between the groups. Despite the low certainty of evidence, compared with intermittent feeding, continuous feeding may reduce the mortality rate in critically ill patients in ICU. Additional studies are needed to provide more evidence and validate the findings.

Ultrasound assessment of gastric residual volume in patients over 60 years of age undergoing gastroscopy under sedation: a prospective cohort study.

We aimed to assess the accuracy of ultrasonographic measurement of the antral cross-sectional area (CSA) in the preprocedural evaluation of gastric contents and volume in fasted patients > 60 yr of age scheduled for gastroscopy under sedation. We included n = 81 patients > 60 yr of age and n = 79 younger controls scheduled to undergo elective gastroscopy in a prospective cohort study. A gastric ultrasound examination was performed to measure the antral CSA in both semisitting and right lateral decubitus (RLD) positions. Afterward, patients were graded using the Perlas qualitative grading scale. The actual gastric volume was endoscopically suctioned. Full stomach was defined as gastric volume > 1.5 mL·kg-1 and/or the presence of solid particles. We constructed receiver operating characteristic curves to determine the accuracy of ultrasonographic measurement of RLD CSA to detect a gastric volume > 1.5 mL·kg-1 and calculated the diagnostic test attributes of RLD CSA for the identification of a gastric volume > 1.5 mL·kg-1 RESULTS: The incidence of full stomach was 8/81 (9.8%) in patients > 60 yr of age and 1/79 (1.2%) in young patients (risk difference, 8.6%; 95% CI, 1.3 to 15.8; P=0.03). The cut-off value of RLD CSA was 10.4 cm2 for the detection of gastric volume > 1.5 mL·kg-1 in patients > 60 yr of age, with a sensitivity of 75%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 98.6%. Patients > 60 yr of age scheduled for gastroscopy under sedation had a higher incidence of a full stomach detected with ultrasound compared with a younger cohort, which is potentially associated with a higher aspiration risk. We calculated a cut-off value of RLD CSA for detecting gastric volume in patients > 60 yr of age of approximately 10 cm2, which may help to quickly assess patients at risk of aspiration. www.chictr.org.cn (ChiCTR2100048994); registered 19 July 2021.

Evidence based – Enteral feeding algorithm for Neurosurgery ICU/Ward

Enteral feeding is a procedure that is in practice internationally by nurses. Providing enteral feeding to the patients is an art and science of nursing that follows careful steps and principles. Nurses role is not only confined to administering enteral feed but also of educating, giving instructions to the family members, directing caregivers and significant others regarding initiating and maintaining enteral feeding, so that continuity of nutritional care is maintained even in the home setting. Once the patient is admitted in neurosurgical ICU, hemodynamic stability of the patient is utmost important, as hemodynamic instability of the patient may preclude the safe initiation of EN in the critical care patients. Initial stabilization is the key for patient survival followed by maintenance therapy like drugs, mobilization, position, continuous monitoring and nutrition. For determining the need of enteral feeding especially for neurosurgical and neurological patients three things should be given utmost importance i.e. Swallowing deficit, Unconsciousness (Level of consciousness) and Nutritional requirement. Can be easily remembered as pneumonic SUN.Confirming tube position is one of the critical step in effective enteral feeding practice in spite of that it has given least importance. It is recommended to confirm the tube position immediately after ryles’ tube insertion through radiologic methods which may be not feasible sometimes, therefore bedside methods can also be adopted Auscultation methods and Aspiration method are the most widely used method among all the bed side methods for confirming tube placement. Gastric residual volume is the amount aspirated from the stomach following administration of the enteral feed. An aspirate among of less than 500ml in 4-6 hours or less than 50% of last enteral feed is safe and indicates that GIT is functioning. Most patients nicely tolerate enteral feeding via gastric tube while few patients has delayed gastric emptying and high GRVs as a result of sedation, pain medications, hypothermia, decreased movement and the effect of being critically ill. Intolerance of enteral feeding is defined as more than 500ml or more than 50% of last enteral feeding. Though enteral feeding is the most popular procedure for ICU Nursing officer, but it is the most crucial in terms of deciding patient outcome. Effective enteral feeding requires through knowledge of initiation and maintenance of enteral feeding. Thus, this article propose simple algorithm to follow. Effectively delivering nutrition to the patient requires the help of dietitian and physician/surgeon to deal with its challenges that comes along with this golden feeding technique.

Controlled enteral nutrition in critical care patients – A randomized clinical trial of a novel management system

Nutritional therapy is essential to ICU care. Successful early enteral feeding is hindered by lack of protocols, gastrointestinal intolerance and feeding interruptions, leading to impaired nutritional intake. smART+ was developed as a nutrition management feeding platform controlling tube positioning, reflux, gastric pressure, and malnutrition. This study evaluated the potential of this new ICU care platform to deliver targeted nutrition and improve ICU outcomes. Critically ill patients ≥18 years-old, mechanically ventilated and enterally fed, were randomized to receive ESPEN-guideline-based nutrition or smART+-guided nutrition for 2-14 days. Primary endpoint was average deviation from daily targeted nutrition determined via calculation of energy targets per calorimetry. Secondary endpoints included gastric residual volumes, length of stay (LOS) and length of ventilation (LOV). smART+achieved a mean deviation from daily targeted nutrition of 10.5% (n=48) versus 34.3% for control (n=50), p<0.0001. LOS and LOV were decreased in the smART+group versus control (mean LOS: 10.4 days versus 13.7; reduction 3.3 days, adjusted HR 1.71, 95% CI:1.13,2.60, p=0.012; mean LOV: 9.5 days versus 12.8 days reduction of 3.3 days, adjusted HR 1.64, 95% CI:1.08-2.51, p=0.021). Feeding goals were met (within ±10%) on 75.7% of days for smART+versus 23.3% for control (p<0.001). No treatment-related adverse events occurred in either group. The study was stopped due to success in a planned interim analysis of the first 100 patients. The smART+Platform improved adherence to feeding goals and reduced LOS and LOV versus standard of care in critically ill patients. NCT04098224; registered September 23, 2019.

Feasibility and Utility of Routine Point of Care Gastric Ultrasonography in Patients Undergoing Upper Gastrointestinal Endoscopy Procedures: A Prospective Cohort Study.

Previous studies have indicated that point-of-care ultrasonography (POCUS) of the gastric antrum can predict the adequacy of fasting before surgery and anesthesia. The aim of this study was to evaluate the utility of gastric POCUS in patients undergoing upper gastrointestinal (GI) endoscopy procedures. We performed a single-center cohort study in patients undergoing upper GI endoscopy. Consenting patient's gastric antrum was scanned before anesthetic care for endoscopy to determine the cross-sectional area (CSA) and qualitatively determine safe and unsafe contents. Further, an estimate of residual gastric volume was determined using the formula and the nomogram methods. Subsequently, gastric secretions aspirated during endoscopy were quantified and further correlated with nomogram and formula-based assessments. No patient required a change in the primary anesthetic plan except for using rapid sequence induction in those with unsafe contents on POCUS scans. Qualitative ultrasound measurements consistently determined safe and unsafe gastric residual contents in 83 patients enrolled in the study. Unsafe contents were determined by qualitative scans in 4 out of 83 cases (5%) despite adequate fasting status. Quantitatively, only a moderate correlation was demonstrated between measured gastric volumes and nomogram (r = .40, 95% CI: 0.20, 0.57; P = .0002) or formula-based (r = .38, 95% CI: 0.17, 0.55; P = .0004) determinations of residual gastric volumes. In daily clinical practice, qualitative POCUS determination of residual gastric content is a feasible and useful technique to identify patients at risk of aspiration before upper GI endoscopy procedures.

Enteral Nutrition Safety and Outcomes of Patients with COVID-19 on Continuous Infusion of Neuromuscular Blockers: A Retrospective Study.

Intravenous infusions of neuromuscular blocking agents (NMBAs) and prone positioning are recommended for acute respiratory distress syndrome (ARDS) due to COVID-19. The safety of enteral nutrition (EN) during these treatments is unclear. This study assessed EN tolerance and safety during NMBA infusion in proned and nonproned patients with ARDS due to COVID-19. This retrospective study evaluated patients who were admitted to a tertiary-care ICU between March and December 2020, had ARDS due to COVID-19, and received NMBA infusion. We assessed their EN data, gastrointestinal events, and clinical outcomes. The primary outcome was gastrointestinal intolerance, defined as a gastric residual volume (GRV) ≥500 ml or 200-500 ml with vomiting. We compared proned and nonproned patients. We studied 181 patients (mean age 61.2 ± 13.7 years, males 71.1%, and median body mass index 31.4 kg/m2). Most (63.5%) patients were proned, and 94.3% received EN in the first 48 hours of NMBA infusion at a median dose <10 kcal/kg/day. GRV was mostly below 100 ml. Gastrointestinal intolerance occurred in 6.1% of patients during NMBA infusion and 10.5% after NMBA discontinuation (similar rates in proned and nonproned patients). Patients who had gastrointestinal intolerance during NMBA infusion had a higher hospital mortality (90.9% versus 60.0%; p=0.05) and longer mechanical ventilation duration and ICU and hospital stays compared with those who did not. In COVID-19 patients on NMBA infusion for ARDS, EN was provided early at low doses for most patients, and gastrointestinal intolerance was uncommon in proned and nonproned patients, occurred at a higher rate after discontinuing NMBAs and was associated with worse outcomes. Our study suggests that EN was tolerated and safe in this patient population.

Using Machine-Learning to Assess the Prognostic Value of Early Enteral Feeding Intolerance in Critically Ill Patients: A Retrospective Study.

The association between gastrointestinal intolerance during early enteral nutrition (EN) and adverse clinical outcomes in critically ill patients is controversial. We aimed to assess the prognostic value of enteral feeding intolerance (EFI) markers during early ICU stays and to predict early EN failure using a machine learning (ML) approach. We performed a retrospective analysis of data from adult patients admitted to Beilinson Hospital ICU between January 2011 and December 2018 for more than 48 h and received EN. Clinical data, including demographics, severity scores, EFI markers, and medications, along with 72 h after admission, were analyzed by ML algorithms. Prediction performance was assessed by the area under the receiver operating characteristics (AUCROC) of a ten-fold cross-validation set. The datasets comprised 1584 patients. The means of the cross-validation AUCROCs for 90-day mortality and early EN failure were 0.73 (95% CI 0.71-0.75) and 0.71 (95% CI 0.67-0.74), respectively. Gastric residual volume above 250 mL on the second day was an important component of both prediction models. ML underlined the EFI markers that predict poor 90-day outcomes and early EN failure and supports early recognition of at-risk patients. Results have to be confirmed in further prospective and external validation studies.

Comparative preoperative sonological assessment of gastric contents in patients with chronic kidney disease versus those with normal renal function - A prospective observational study.

Though the role of fasting preoperative gastric ultrasound has been validated in different patient populations, namely, obese, pregnant and diabetics, it has not been explored in patients with chronic kidney disease (CKD). This prospective, observational study compared the fasting sonological assessment of gastric contents in patients with CKD versus those with normal renal function scheduled for elective surgery. After ethical approval and trial registration were obtained, preoperative gastric ultrasound was done in 115 CKD patients and 115 with normal renal function. Qualitative and quantitative assessment of residual gastric volume was done. Also, the patients were administered the Porto Alegre Dyspeptic Symptoms Questionnaire (PADYQ) to evaluate gastroparesis objectively. The researcher was not blinded to the patient groups. Data analyses were done using the Statistical Package for Social Sciences (SPSS) for Windows software (version 22.0). Gastric volumes exceeding 1.5 ml/kg or particulate or solid contents were found in 57 patients with CKD and 36 patients with normal renal function (P = 0.004). The PADYQ scores were 6.54 ± 8.49 for CKD and 2.15 ± 5.71 for normal renal function (P < 0.0001) groups. CKD patients had a higher age (P < 0.001), lower body mass index (P = 0.005) and higher incidence of diabetes mellitus (P < 0.001). There were no incidents of gastric aspiration. Renal dysfunction contributes to delayed gastric emptying. PADYQ can also help identify those at high risk of gastroparesis. Combining the questionnaire and preoperative gastric ultrasound must be considered in these patients to ensure optimum safety.

Routine versus no assessment of gastric residual volumes in preterm infants receiving enteral feeding via intermittent feeding tubes: a randomized controlled trial

Objective To evaluate whether eliminating routine gastric residual volume (GRV) assessments would lead to quicker attainment of full feeding volumes in preterm infants. Study design This is a prospective randomized controlled trial of infants ≤32 weeks gestation and birthweight ≤1250 g admitted to a tertiary care NICU. Infants were randomized to assess or not assess GRV before enteral tube feedings. The primary outcome was time to attain full enteral feeding volume defined as 120 ml/kg/day. The Wilcoxon rank sum test was used to compare the days to reach full enteral feeds between the two groups. Results 80 infants were randomized, 39 to the GRV assessing and 41 to the No-GRV assessing group. A predetermined interim analysis at 50% enrollment showed no difference in primary outcome and the study was stopped as recommended by the Data Safety Monitoring Committee. There was no significant difference in median days to reach full enteral feeds between the two groups [GRV assessment: 12d (5) vs. No-GRV assessment:13d (9)]. There was no mortality in either group, one infant in each group developed necrotizing enterocolitis stage 2 or greater. Conclusion Eliminating the practice of gastric residual volume assessment before feeding did not result in shorter time to attain full feeding.

Preoperative clear fluid fasting and endoscopy-measured gastric fluid volume in children.

In light of new recommendations to shorten clear fluid fasting time before anesthesia, our study aimed at exploring residual fluid volume in the stomach after different fasting times. We intended to perform direct endoscopic aspiration of stomach contents under vision, as part of routine gastroscopy assessment. Hereby we would be able to quantify true residual gastric fluid volume and acidity in children and measure their correlation with fasting times. The study was performed as a single-center, prospective study in pediatric perioperative day care at a university-affiliated tertiary care center. Aspiration of gastric fluid contents was performed in anesthetized children aged 1-18 years undergoing an elective gastroscopy. Recorded data included patient fast time, last meal content, last clear fluid content, and aspirated gastric volume and pH, as well as patient characteristics. We included 253 gastroscopies, performed in 245 children. Mean fasting time for clear fluids was 6.9h (range 1h 40 min - 18 h 35 min) (SD 4.5). Mean age was 9.8 years (SD 5.1) and mean body weight was 33.2kg (SD 18.7). Mean residual gastric volume was 12 mL (0-90) (SD 13.5) or 0.34 mL/kg (SD 0.37) and mean pH was 1.5 (SD 0.9). No significant correlation was observed between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight (r= -.103, p= .1), nor between clear fluid fasting time and the pH of the residual gastric fluid (r= -.07, p= .3). In more than half of the patients the residual gastric volume was less than 10mL, unrelated to fasting time. In children undergoing gastroscopy, we could not demonstrate any association between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight. Since we did not see a clinically relevant association between clear fluids fasting time and gastric residual volume, this study may support the recommendation to shorten clear fluids fasting time.

To Correlate the Impact of Disease Severity on Gastric Residual Volume among the Critically Ill Patients

To Correlate the Impact of Disease Severity on Gastric Residual Volume among the Critically Ill Patients

Gastrointestinal Motility Disorders Correlate with Intracranial Bleeding, Opioid Use, and Brainstem Edema in Neurosurgical Patients.

Gastrointestinal (GI) motility disorders may be directly associated with the intensity of acute brain injury, edema of the brainstem, and opioid use in neurosurgical patients. In this retrospective study, patient demographic characteristics, computed tomography (CT) scans, the occurrence of gastroparesis, constipation, and opioid use were registered during the intensive care unit (ICU) stay and correlated with days of mechanical ventilation, length of ICU stay, and survival. Gastroparesis was defined as residual gastric volume > 250mL per day, and constipation was defined as the absence of stool for 3days or more during the ICU stay. Of 207 neurosurgical patients screened, 69 adult patients who spent more than 4days in the ICU were included in the study. Gastroparesis was observed in 48 (69.6%) patients, constipation was observed in 67 (97.1%) patients, and stress ulcers were observed in 4 (5.8%) patients. Patients with brainstem edema (n = 57, 82.6%) had the first stool evacuation later compared with patients with no edema (8 [interquartile range (IQR) 5.25-9.75] vs. 3.5 [IQR 2.25-4] days; P < 0.001). In the logistic regression analysis, factors that were associated with GI dysmotility were central nervous system (CNS) bleeding (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.26-20.8, P = 0.02), opioid use > 19.3 morphine equivalents (ME) per day (OR 5.37, 95% CI 1.1-27.1, P = 0.04), and brainstem edema (OR 4.9, 95% CI 1.1-21.6, P = 0.04). A receiver operating characteristic curve analysis confirmed that the cutoff value of > 6.78 ME per day was a good predictor determining GI dysmotility, with 89.5% sensitivity and 72.7% specificity (95% CI 0.67-0.88, area under the curve 0.784, Youden index 0.62, P = 0.001). Poor survival correlated with lower Glasgow Coma Score values (ρ = - 520, P < 0.001), CNS bleeding (ρ = 0.393, P < 0.001), associated cardiac diseases (ρ = 0.279, P < 0.001), and cardiorespiratory arrest on admission (ρ = 0.315, P < 0.001), but not with GI dysmotility (ρ = 0.175, P = 0.402). Significant correlation was registered between brainstem edema, gastrointestinal dysmotility, and opioids. CNS bleeding was the most important single factor influencing GI dysmotility. Further studies with opioid and nonopioid sedation may distinguish the influence of acute brain lesions versus drugs on GI dysmotility.

Factors Associated with Interruptions of Enteral Nutrition and the Impact on Macro- and Micronutrient Deficits in ICU Patients

Feeding interruptions in critical care patients are often unjustified. We aimed to determine the causes, duration, and frequency of enteral nutrition interruptions (ENIs) and to assess macronutrients and antioxidant deficits according to European Society of Parenteral Enteral Nutrition (ESPEN) guidelines. We prospectively enrolled Intensive Care Unit (ICU) patients admitted for more than 48 h with an inability to orally eat from April to December 2019. The type of enteral nutrition, the number of calories administered, the time of feeding initiation, the reasons for delaying feeding, and the causes for ENI were recorded. 81 patients were enrolled, with a median duration of ENIs of 5.2 (3.4-7.4) hours/day. Gastric residual volume (GRV) monitoring-a highly controversial practice-was the most common cause of ENI (median duration 3 (2.3-3) hours/day). The mean energy intake was 1037 ± 281 kcal/day, while 60.5% of patients covered less than 65% of the total energy needs (1751 ± 295 kcal/day, according to mean Body Mass Index (BMI)). The median daily protein intake did not exceed 0.43 ± 0.3 gr/kg/day of the actual body weight (BW), whereas ESPEN recommends 1.3 gr/kg/day for adjusted BW (p < 0.001). The average administration of micronutrients and antioxidants (arginine, selenium, zinc, vitamins) was significantly less than the dietary reference intake (p < 0.01). ENIs lead to substantial caloric, protein, and antioxidant deficits.

Assessment of residual gastric volume using point-of-care ultrasonography in adult patients who underwent elective surgery

BackgroundAspiration pneumonitis remains a dreaded complication that may lead to almost 9% of anaesthesia-related deaths. The presence of gastric contents has always been a contributing factor to an increased risk of aspiration. Preoperative gastric ultrasound has been suggested as a modality for determining residual volume in special populations and conditions. We conducted an observational study to determine the gastric residual volume in preoperative patients of elective surgery with gastric ultrasound and to study its correlation with patient factors.MethodsWe enrolled 411 patients in the age group of 18–80 with ASA-PS I and II having BMI less than 35 kg/m2. Patients with prior gastrointestinal surgery and parturients were excluded from the present study. Gastric antrum in both supine and right lateral decubitus positions was measured using USG in the immediate preoperative period, and gastric residual volume was calculated, which was subsequently correlated with various patient factors.ResultsOn qualitative assessment, 97 and 118 patients were observed to have distended stomachs in the supine and right lateral decubitus positions, respectively. On quantitative assessment, 336 had safe GRV, 60 patients were classified as having a low risk of aspiration (GRV < 1.5 ml/kg) while 13 had a high risk of aspiration (> 1.5 ml/kg). Eight patients with a fasting duration of more than ten hours and five who fasted between 6 and 10 h had a gastric residual volume of more than 1.5 ml/h. Patients who were premedicated with histamine blockers had a statistically significant higher antral cross-sectional area (p-value − 0.022*) and GRV (p-value − 0.018*) in the right lateral decubitus position compared to patients who had taken proton pump inhibitors (PPIs). As BMI increased, there was a statistically significant (p-value < 0.001) increase in mean antral CSA in both supine and right lateral decubitus positions. There was a statistically significant association found between type 2 diabetes (p-value 0.045*) with antral grade.DiscussionPatients can have significant residual volume (> 1.5 ml/kg) despite adequate fasting, and preoperative gastric ultrasound can help in assessing the same and guiding perioperative airway management. PPIs are more effective in reducing gastric residual volume as compared to histamine blockers. Patients with a BMI of more than 30 and type 2 diabetes mellitus have significant correlation with increased gastric residual volume mandating preoperative gastric ultrasound assessment for effective management.ConclusionsPatients with BMI over 30 and type 2 diabetes may benefit from POCGUS to guide perioperative airway management by stratifying GRV.Trial registration Name of registry-Clinical Trial Registry of India. Trial registration number-2020/03/024083. Date of registration-19.3.2020. URL-http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=39961&EncHid=&userName=