{"id":665,"date":"2013-02-01T15:44:31","date_gmt":"2013-02-01T20:44:31","guid":{"rendered":"https:\/\/med.virginia.edu\/ginutrition\/?p=665"},"modified":"2026-06-01T19:45:56","modified_gmt":"2026-06-01T23:45:56","slug":"february-2013-e-journal-club","status":"publish","type":"post","link":"https:\/\/med.virginia.edu\/ginutrition\/2013\/02\/01\/february-2013-e-journal-club\/","title":{"rendered":"February 2013 E-Journal Club"},"content":{"rendered":"

Greetings,<\/strong><\/p>\n

February weather in C\u2019ville has been more volatile than usual, with some days downright balmy, then dropping to near zero (Fo<\/sup>) in the Blue Ridge during a Winter backpacking trip the next week.\u00a0 Work has been more consistent than the weather, although the fates somehow know to provide more consults when your peers are away at a Clinical Nutrition Week, or if you are trying to get out of town on a Friday!\u00a0 Our February journal club was on one of our favorite topics \u2013 the \u201cart and science\u201d of checking residuals in the ICU.<\/p>\n

February Citation:<\/strong><\/p>\n

Reignier<\/span> J, Mercier E, Le Gouge A, et al. Effect<\/span> of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial.\u00a0 JAMA. 2013;309(3):249-56.<\/p>\n

Summary:\u00a0<\/strong><\/p>\n

This study was a randomized, multicenter, non-inferiority trial in 449 mechanically ventilated patients comparing routine gastric residual volume (GRV) monitoring (250mL cut-off) versus not checking GRV at all during enteral nutrition (EN).\u00a0 Patients were from medical and medical-surgical ICU\u2019s with ultimately more than 90% of the patient\u2019s admitted with a medical diagnosis.\u00a0 EN was provided via a 14-Fr NG with continuous feeding of 20-25 kcals\/kg\/day for the first 7 days and then 25-30 kcals\/kg thereafter.\u00a0 Feedings were started at the goal flow rate within 36 hours of being intubated.\u00a0 The study was not blinded, although the committee that diagnosed VAP was blinded to group allocation.<\/p>\n

The primary outcome of the study was the proportion of patients with at least 1 episode of ventilator associated pneumonia (VAP).\u00a0 There were a host of secondary study outcomes including the cumulative incidence and total number of VAP episodes, microorganisms causing VAP, emesis, EN intolerance, prokinetic treatment, diarrhea, SOFA score variations, albumin and C-reactive protein (CRP), ICU acquired infections, proportion of patients meeting calorie targets, cumulative calorie deficit, duration of mechanical ventilation, ICU and hospital lengths of stay, and ICU, 28, & 90 day mortality rates.<\/p>\n

Inclusion and Exclusion Criteria were:<\/strong><\/p>\n

Inclusion criteria<\/em>:<\/p>\n

Patients over 18 years admitted to 9 ICUs between May 2010 and March 2011, expected to require > 48 hours of mechanical ventilation, and started on EN via a nasogastric tube < 36 hours after intubation.<\/p>\n

Exclusion criteria<\/em>:<\/p>\n

Abdominal surgery within the past month, Hx esophageal, duodenal, pancreatic, or gastric surgery, bleeding from esophagus, stomach, or bowel, contraindications to prokinetics, EN via a jejunostomy or gastrostomy, pregnancy, treatment-limiting directives, current inclusion in another trial of VAP prevention or EN tolerance.<\/p>\n

Major Results:<\/strong><\/p>\n

Data from this study was analyzed in two ways \u2013 via a \u201cmodified intention to treat\u201d (excluded data from the 3 patients that withdrew consent), and per-protocol (excluding 7 control and 19 intervention patients who did not complete full protocol).<\/p>\n

In the primary outcome (proportion with at least 1 episode VAP) there was no significant difference between the two groups (modified ITT as well as the per-protocol populations). \u00a0In the modified ITT analysis there was 16.7% in the intervention group and 15.8% in the control group who had at least 1 VAP episode (difference, 0.9%; 90% CI, \u22124.8% to 6.7%)\u00a0 In the secondary outcomes:<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 There was no significant difference in cumulative VAP, total VAP or microorganisms identified between the two groups.<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Significantly more vomiting episodes were reported in the intervention group than in the control group (90 versus 60 episodes, P<\/em>=.003; per-protocol P<\/em>=.002).<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Proportion of patients meeting the group specific definition of EN intolerance was higher in the control group, resulting in more prokinetic use.<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Calorie target was achieved in a higher proportion of patients in the intervention group than in those in the control group P<\/em> .001; per-protocol P<\/em> .001.<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Consequently, patients in the intervention group had a lower cumulative calorie deficit from day 0 – 7 compared with patients in the control group.<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Incidence of other secondary outcomes were not significantly different between groups.<\/p>\n

Author\u2019s Conclusions:<\/strong><\/p>\n

1)\u00a0\u00a0 A protocol of enteral nutrition management without GRV monitoring is not inferior to a similar protocol including GRV monitoring in terms of protection against VAP.<\/p>\n

2)\u00a0\u00a0 GRV monitoring leads to unnecessary interruptions of enteral nutrition delivery with subsequent inadequate feeding and should be removed from the standard care of critically ill patients receiving invasive mechanical ventilation and early enteral nutrition.<\/p>\n

Evaluation:<\/strong><\/p>\n

This study has the strengths of being randomized with blinded allocation into groups and blinded VAP diagnosis.\u00a0 Additionally, it was a multicenter design with a relatively large N (for VAP as an outcome) with patients from a variety of hospital types, although primarily a medical population.\u00a0 One unavoidable limitation is that it is not feasible to use a double-blind design for a study of his type, and the authors address the issues related to a nonblinded study in the discussion section.\u00a0 The 10% non-inferiority boundary was relatively broad, however, the actual difference in VAP between the two groups was very similar.\u00a0 The number of patients in this study was too small to reliably detect modest changes in outcomes such as mortality.<\/p>\n

Although the no-residuals group received more nutrition, the difference in the median cumulative 7-day nutrition deficit between the two groups was very modest \u2013 about 200 calories in a week.\u00a0 Obviously, some individual patients may be underfed much more than the group median.\u00a0 In addition, facilities that use a smaller diameter feeding tube than 14-french may see a larger impact on nutrition delivery, because checking GRV leads to increased occlusion of small bore feeding tubes (1).<\/p>\n

One aspect of this study that will likely lead to some ongoing discussion was the fact that emesis occurred significantly more often when GRV were not checked.\u00a0 The incidence of VAP did not seem to be affected by the occurrence of emesis, which is consistent with the 2010 REGANE study (2) which compared 200 with a 500 mL residual cut-off.\u00a0 Of course, there is no way to know if it was the GRV checks that resulted in less vomiting, or that GRV checks resulted in greater use of prokinetic medications, or just the act of periodically interrupting feedings and providing less enteral formula that was responsible.\u00a0 However, in selected unintubated patients that are critically ill, who are unable to protect their airway or complain of nausea, the data suggest that a more conservative initial monitoring or feeding advancement strategy should be considered.<\/p>\n

Our Take Home Message (s)<\/strong><\/p>\n

1.\u00a0\u00a0 Checking gastric residuals decreases the amount of nutrition provided to critically ill intubated patients, without any measurable improvement in patient outcome.<\/p>\n

2.\u00a0\u00a0 Checking and \u201ctreating\u201d gastric residuals in critically ill patients that receive early feedings started at goal flow rate results in less episodes of vomiting, but no differences in VAP incidence.<\/p>\n

Reference<\/strong><\/p>\n

    \n
  1. Powell KS, Marcuard SP et al.\u00a0 Aspirating gastric residuals causes occlusion of small-bore feeding tubes.\u00a0 JPEN 1993 May-Jun;17(3):243-246.<\/li>\n
  2. Montejo<\/span> JC, Mi\u00f1ambres E, Bordej\u00e9 L, et al\u00a0 Gastric residual volume during enteral nutrition in ICU patients: the REGANE<\/span> study.\u00a0 Intensive Care Med. 2010;36(8):1386-93.<\/li>\n<\/ol>\n

     <\/p>\n

    Other News on the UVAHS GI Nutrition Website:<\/u><\/em><\/strong> (www.ginutrition.virginia.edu<\/a>):<\/strong><\/p>\n

    \u00a0<\/em><\/strong><\/p>\n

    Upcoming Webinars 2012\/2013:<\/strong><\/p>\n

    –March 26th<\/sup>:\u00a0 Building Collaboration Between Nutrition and Physical Therapy to Improve Patient Outcomes<\/p>\n

    –April 16th<\/sup>:\u00a0 Nutrition Support for the Adult CF Patient<\/p>\n

    –May 14th<\/sup> :\u00a0 The Role of Fiber in Nutrition Support<\/p>\n

    –June 18th<\/sup>:\u00a0 Food Allergies in the Pediatric Patient<\/p>\n

    Check out What\u2019s New<\/strong>:<\/p>\n

    –\u201c Resources for the Nutrition Support Clinician<\/a>\u201d<\/p>\n

    Latest Practical Gastroenterology article<\/strong>:<\/p>\n

    –Rogers, C. Nutritional Management of the Adult with Cystic Fibrosis \u2013 Part I. \u00a0Practical Gastroenterology 2013;XXXVII(1):10.<\/p>\n

    –Rogers, C. Nutritional Management of the Adult with Cystic Fibrosis \u2013 Part II. \u00a0Practical Gastroenterology 2013;XXXVII(2):13.<\/p>\n

     <\/p>\n

    Joe Krenitsky MS, RD<\/p>\n

    Carol Rees Parrish MS, RD<\/p>\n

    PS \u2013 Please feel free to forward on to friends and colleagues.<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

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