Nutrition Support Blog: The End of the Beginning for Gastric Residuals
January 17, 2013
On November 10, 1942 Winston Churchill addressed the House of Commons on a momentous occasion. After several years of humiliating defeats around the globe at the hands of the Axis forces, the Commonwealth troops had defeated the German Afrika Korps at the battle of El Alamein. Churchill recognized that the war was far from over, but this first victory signaled a change, and he told the British people “Now this is not the end. It is not even the beginning of the end-- but it is, perhaps, the end of the beginning.”
In the January 16 edition of JAMA there is an article that may signal a similar change for the world of nutrition support, and as the editorial suggests, it really may be the “End of an Era”.
The study by Reignier1 et al randomized 449 mechanically ventilated medical-surgical ICU patients to either have their gastric residuals (GRV) checked, or not checked. The primary outcome of this noninferiority trial was the incidence of ventilator acquired pneumonia. The study results suggest that there were no apparent advantages for checking GRV, and some potential disadvantages, because the group that did not have residuals checked received more nutrition.
As always, there are details of this study that need to be scrutinized and debated. Nevertheless, as the editorial by Dr. Rice2 points out, the evidence casting doubt on the usefulness of checking residuals has been emerging for more than 2 decades. Considering that there was never any reasonable evidence that checking residuals improved outcomes or reduced GI intolerance during enteral feeding, one would hope that this additional study would signal the end of the practice of checking residuals. However, as always, it is amazingly difficult to change medical practices that are entrenched in tradition. Considering that we still hear about routine use of parenteral nutrition for patients with pancreatitis at many facilities, or that albumin and prealbumin are still being used to assess nutritional status, I suspect that we will need to continue to bring articles, and educate people even after we change the “official” unit protocols for residuals.
Even if we cannot yet declare victory against practice in opposition of the best available evidence, perhaps we are at the end of the beginning era of nutrition support, where we had to practice without any evidence at all.
“The truth is incontrovertible. Malice may attack it,
ignorance - may deride it, but in the end, there it is.”
- Winston Churchill
- Reignier J, et al. Effect of Not Monitoring Residual Gastric Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation and Early Enteral Feeding. JAMA 2013: 309(3), 249-256.
- Rice TW. Gastric Residual Volume, End of an Era. JAMA 2013: 309(3), 283-284.