Checking Gastric Residuals in NICU

Love_2_Learn · Mar 28, 2008

I use a 5 or 10 ml syringe usually. I don't use a 1 or 3 ml.

Here is my reasoning: I understand that when pushing fluids through a syringe that the psi is much, much higher in a smaller syringe. This is why PICC and umbilical lines manufacturer's inserts say what size syringe is compatible with their product after testing was done before they were put on the market; eg, using a small 1 ml or 3 ml syringe to push fluids through a tiny PICC catheter can acutally cause the tip end of the catheter to fray inside the baby and possibly tear off a tiny piece that ends up floating around in the baby! (Check out the NANN guideline for PICC insertion and care at www.nann.org)

As far as the ng/og tubes go, I don't know if it makes that much of a difference but I do know that in my experience I am able to collect more excess air and fluid pulling with less force on the plunger. This also seems to make more sense when returning gastric contents back to the baby (The psi thing; I am concerned about the fluid coming out of the ng/og tube too forcefully when returning the contents to the baby that the rush of fluid could possibly injure the cells lining the stomach or something). I have found it difficult to pull back anything when using a 20 ml syringe on an og/ng tube.

The only time I use the smaller syringe is when delivering a medication through the ng/og tube and then I am very careful. I do not think the ng/og tubes are as fragile as the PICCs, etc; however, I do understand that the evidence shows that no matter how slowly and carefully a nurse pushes on the plunger of a smaller syringe the psi is still basically the same. The psi thing is strange because our initial thinking is that the smaller syringes would be more gentle but actually they are not... life is strange, isn't it?

SteveNNP, MSN, NP · Mar 28, 2008

Psi is most important when pushing meds through an extremely small lumen, such as in a PICC, so you don't rupture the delicate catheter .

With an OG/NGT, the lumen is larger, the plastic thicker and stiffer, and you're using more force to aspirate, not inject.

It all depends on the amount of "thumb pressure" the nurse uses. Just aspirate and return gently, and it doesn't matter what size syringe you use. I usually use whatever size syringe is being used to gavage feed the baby, up to a 20cc.

elizabells, BSN, RN · Mar 28, 2008

I use a 12, unless I know the baby and know that they have crazy gastric aspirates. That's not so much a residual, though, as like kids on ECMO who pour coffee out of their stomachs.

SteveNNP, MSN, NP · Mar 28, 2008

mmmmmm...... coffee.....:smilecoffeecup:

EricJRN, MSN, RN · Mar 28, 2008

We check them once the baby is on 20 mL/kg/day of feeds. Like Steve, we pretty much use the same size syringe to check residuals and feed the baby.

RainDreamer, BSN, RN · Mar 28, 2008

We don't routinely check residuals. We don't check unless there is feeding intolerance (increased girth, spits, loops, etc).

Although sometimes we get new people that are just used to always checking residuals ..... then they tell the MD/NNP what residuals they get, then the MD/NNP will specifically write "don't check residuals unless signs of feeding intolerance".

littleneoRN · Mar 29, 2008

We consistently check residuals and report them if they are at least half the feeding, bloody, bilious, etc. Otherwise they are refed and we continue feeding as ordered. I don't know much about the evidence in relation to feeding intolerance. But with some of the bigger preemies, the signs of NEC can be more subtle and insidious. In my relatively short experience I've seen kids get sick with NEC and the sole initial sign was a bilious preaspirate.

In answer to your other question, we always use 3 mL syringes. This was how I was oriented, and I've never even thought about before. Does anyone know if NANN has a competency on this?

RainDreamer, BSN, RN · Mar 29, 2008

Even though we don't routinely check residuals, we know if it's bilious or an abnormal color when we check placement. And if we get back green contents, then that'd obviously be a sign of feeding intolerance, and that would require checking residual.

We have a rather low incidence of NEC in our unit.

RNSC · Apr 22, 2008

Even though we don't routinely check residuals, we know if it's bilious or an abnormal color when we check placement. And if we get back green contents, then that'd obviously be a sign of feeding intolerance, and that would require checking residual.
We have a rather low incidence of NEC in our unit.

We just started this in my unit and its making me a little crazy. It seems to go against common nursing sense. :banghead: As LittleneoRn said a small bilious residual sometimes is the first subtle sign that you get. I know what the studies say but my experience is different.

RainDreamer, BSN, RN · Apr 22, 2008

We just started this in my unit and its making me a little crazy. It seems to go against common nursing sense. As LittleneoRn said a small bilious residual sometimes is the first subtle sign that you get. I know what the studies say but my experience is different.

Like I said, you know if there's bilious residual when you check placement.

SteveNNP, MSN, NP · Apr 22, 2008

Like I said, you know if there's bilious residual when you check placement.

But what about the 2nd, 3rd, and 4th feeds?

I agree with being able to assess for bilious residuals at the outset of the shift, but residuals are an integral part of monitoring gastric emptying and overall feeding tolerance. We advance feeds taking residuals into consideration.

And how does the RN know that the stomach is emptying fast enough? Sometimes I get >50% residuals back with no outward symptoms. If I had no idea, and fed a full feed on top of it, the kid's either going to puke it all up, or start showing s/s feeding intolerance.

When we start seeing loopiness, full abdomens, etc, the residuals over the last shift are usually taken into consideration when deciding course of treatment. The same for increased/bilious residuals alone, it helps us anticipate tx, and more closely monitor for further intolerance.

:typing