Don't check residuals?

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OK, so this isn't specific to the ICU, but I'll ask anyway.....

A couple weeks ago we received a communication in our mailbox that stated that the policy for checking residuals on tube feeds had changed. In a PEG tube, we re no longer supposed to check residuals. We are supposed to check residuals in NG-tubes, but only stop the tube feeding if residuals exceed 200 mL. I thought this was strange, and continue to check residuals out of habit.

So....the other night, I'm standing in the hallway preparing meds for my patient, and I hear in the next room a patient coughing repeatedly for about 30 seconds. I don't know what made me question it, it just seemed weak, rhythmic, and didn't seem to be producing anything. So, I knew the patient's nurse was in a nearby room, and I told her about it. We go into the room, the patient is profusely diaphoretic, and is on a tube feeding via PEG. We immediately stop the tube feeding, check the blood sugar, call rapid response, and start suctioning her orally and doing deep NT suctioning. We clearly get gastric contents from the lungs....she had aspirated. We pulled all the residuals from her stomach and get 300 mL!! The TF had been running at 55 mL/hr, so she had been backing up for at least 6 hours! Thank goodness I had to give meds to a nearby patient at that time (midnight). Apparently, she was fine 30 minutes prior to that during vitals, and the next set of vitals wouldn't have been for 4 hours! She was at the end of a hallway, and unless someone was making rounds, she probably wouldn't have been heard for a while.

Clearly, this is a case where checking residuals would have clued us in that there was a potential problem brewing. What is your hospital's policy? What would be the harm in checking residuals on everything? What evidence could there possibly be for giving a directive NOT to check residuals? We have raised this as an issue to the powers that be, but are awaiting a response. What do you think?

Thanks.

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I'd discover what committee made up that policy and question them directly. Shoot someone off an e-mail.

Doesn't matter how it is given, our continuous tube feeds protocol says patients are to have residuals checked Q4H at the minimum.

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Specializes in medical-surgical.

wow, that's terrible. check residual q4hrs is in our policy and even on the order sheet!

I would like to hear who made this change and why....

keep us posted!

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Specializes in Critical Care.

^ exactly what everyone else said. Residuals Q4H all day every day, regardless of whether it's an NGT, OGT or PEG. Aspiration is one of my 'things' that i hate to see people get. I think it is preventable in most cases (I know it's not 100% but there ARE things we can do to help prevent it and I also know there are people who 'silently aspirate). MHO

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I did a quick search to see if I could find info supporting the directive NOT to check residuals, and this is what I found:

http://www.nwmdgp.org.au/pages/after_hours/GPRAC-CIS-07.html

"Checking residual gastric contents volume is only performed if there are indications to do so, such as vomiting, tolerance and absorption problems. If the residual volume is consistently more than 150ml request the resident’s GP or dietician conduct a review of the feeding regime.

Whilst a single high residual volume prompts concern about feeding intolerance and indicates a need to closely monitor further residual volumes, often the next residual volume is normal. Automatically postponing or ceasing tube feeding puts the resident at risk of inadequate nutrition [6]."

However, later in the article, it states to prevent aspiration, routinely check residuals.

*****

Some other interesting information I found was that part of routine PEG care is to rotate the tube 180 - 360 degrees daily. I'm assuming to prevent adhesions? Has anyone heard of this? Is this a common practice in your facility? I'm going to have to ask our GI PA about that one.

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I was always taught in school, hold tf if the residual was 2x the rate. Now our facility has changed its policy to hold if residual is =/> 200 cc. My patient the other night had tf @ 45 cc/hr, his residual, 110, I held it for an hour. He was sedated and had been previously paralyzed.

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The only time I don't check residuals is when the pt. has a Dobhoff tube (usually post-pyloric, and too small to aspirate gastric contents from---the tube will collapse). Otherwise, I check residuals Q4hr. on all pts with NGT's, and pts with PEGs who have had absorption issues.

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Specializes in Critical Care.

Our Pulm/CCM docs are citing new research stating not to bother holding TF for residuals less than 500 mL.

Yes, 500.

Naturally, we nurses kindly disagree. I'm looking forward to reviewing the cited studies.

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We are to check residuals on NG/OG and PEGs q4h as well. I wonder why they are differentiating them?

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I think the differentiation has to do with what kind of pt. population you're dealing with. I work in a burn/trauma sicu and by the time our patients get PEG's, they're mostly stable and ready to go off to rehab, have been on goal tube feeds for a while with no issues with absorption and no clinical changes otherwise. The NGT/OGT is used during the acute stage when you should check residuals Q4...

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Specializes in Dialysis.

If a patient has delayed gastric emptying you may occassionally pull a high residual but it doesn't mean the patient isn't tolerating the feedings. Our bodies are not designed to have a steady trickle of fluid into our stomachs. We bolus food when we eat which stretches our gut- something continuous feeds don't do. We had far fewer malnourished patients when we bolus fed but that is more labor intensive. Keeping the HOB elevated is more important in preventing aspiration than measuring residuals.

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i would love to see some EBP on this

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