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I. PROBLEM

The nurse alerts you that a bloody gastric residual has been obtained in an infant. Gastric residuals (also known as a gastric aspirates) can be abnormal in appearance or abnormal in volume. Gastric aspiration is a procedure by which the stomach is aspirated with an oral or nasogastric tube. The procedure is typically performed before each feeding or at a predetermined interval during continuous feeding to verify correct orogastric/nasogastric tube placement, to assess if feedings are being tolerated and digested (feeding intolerance), and to prevent aspiration of contents of the stomach (prevent ventilator-associated pneumonia). The color is noted. The amount of residual is measured and recorded as the gastric residual. Once a standard procedure in the neonatal unit, performing routine gastric residuals is now controversial because of the lack of consensus and supporting evidence. Because there is lack of evidence and recommendations, each neonatal intensive care unit (NICU) should develop a standardized protocol to determine the role of gastric residuals in their unit. Recent reviews have found the following:

  1. There is no formal consensus on the definition of an abnormal gastric residual. Definitions include a percentage of previous feedings (range 20%–50%), a preset volume of the previous feeding (range 2–5 mL), or a preset volume based on body weight (>2 mL/kg to >5 mL/kg). The most common definition used of an abnormal gastric residual is >50% of the previous feeding.

  2. It is not a reliable indicator of the placement of the feeding tube. Straw-colored gastric aspirates can be seen from a nasogastric tube abnormally placed in the respiratory system.

  3. It does not give an accurate estimate of gastric contents. The volume of the gastric contents is influenced by body position, size of feeding tube, technique, temperature of feed, and viscosity. Abdominal ultrasound has been recommended as an alternative method of measurement of gastric contents.

  4. There is lack of evidence that increased residuals indicate feeding intolerance. Some neonatologists will equate gastric residuals with feeding intolerance. The amount or characteristic of the gastric residual is not predictive of feeding intolerance.

  5. The use of gastric residuals prolongs the time to reach full feeds. The response to a gastric residual can cause interruption of enteral feeding, delay in achieving full enteral feedings, prolonged use of TPN, and decreased growth. A recent review found omitting the evaluation of prefeed gastric residuals in extremely premature infants increased the delivery of enteral nutrition and improved weight gain.

  6. It is not an indication of necrotizing enterocolitis. Studies show there is a possible increased volume of gastric residuals prior to necrotizing enterocolitis (NEC), but there is no definition of the exact volume to guide decisions. Recent survey of 173 physicians from 26 countries showed that neonatologists do rely on increased gastric residuals and abdominal distension to help diagnose NEC.

  7. Although refeeding is supported in adults (ie, returning the tube feed residual), there is no evidence in neonates.

  8. An isolated gastric residual in very low birthweight ...

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