Gastric residuals/ NG placement

[NICU_RNC, BSN, RN]

We are changing our practice to not routinely check gastric residuals unless other signs of feeding intolerance. For those of you who do this, before a feed how are you confirming your NG placement in an existing tube? Just checking the numbers to be sure it hasn't moved since it was placed? or checking for a bit of partially digested feed at the first feeding of your shift? something else? Thanks!

[babyNP., APRN]

We have this at a couple of the hospitals where I round. The nurses still look at residuals for purposes of identifying that the tube is in good position, but they don't document residual amounts. The idea is more to get away from being concerned over a large amount of residual that is most likely nothing in the absence of other signs. When we start/stop feeds for residuals and no other clinical symptoms, you increase the days of requiring parenteral nutrition which increases the risk of a line infection which increases the risk of morbidity/mortality.

[vintage_RN, BSN, RN]

We do not routinely check for residuals. That being said, I do check placement via aspiration prior to each feed. This means sometimes I do get residuals when I do that. Often when I tell the docs they give me hell for checking, but you have to check placement somehow!

[babyNP., APRN]

Vintage, what I would say to that if you came to me is- go ahead and check residuals for placement if you like- I just don’t need to know about it unless you have other concerns about the baby. Sorry they are being jerks

[TiffyRN, BSN, PhD]

The evidence has stubbornly refused to support the presence of residual as a valid way to verify placement. We've known this for years but coming up with feasible ways to verify placement have been a challenge since doing daily or more often xrays is not feasible or really safe (for infants or staff).

The facility where I work has been working on pH testing for the longest time having trouble finding a method that works. Finally a couple of months ago they implemented pH testing with nitrazine strips. One of the challenges with that is that one doesn't always get enough residual since you really need to get enough volume back to assure one is testing matter from the stomach and not fluid that has been sitting in the tube. For now, we're going with trying again with the next feeding, repositioning the tube, and using auscultation as a temporary measure. For myself, I've always been able to get enough residual to test within the first feed or two of a shift. Testing is done once per shift and PRN (when retaping or placing a new tube).

We'll see if/how this practice change affects our outcomes since we have already implemented many other measures such as not measuring residual, feeding early (at least trophically), and all human milk feeding for the smaller ones. Our NEC rates used to be quite unsatisfactory but now, especially after the all-human milk change, our rates are well below the average of other similar sized NICUs (according to VONN).