estimating gastric residual volume (grv) in critically...
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ESTIMATING GASTRIC RESIDUAL VOLUME (GRV) IN CRITICALLY ILL PATIENTS
Dr dr Luciana Sutanto MS SpGK - INDONESIA
GASTRIC VOLUME
The cells of gastric gland secrete about 2.500 mL of gastric juice daily [Ganong W, 2001]
In fasting patient, stomach can secrete up to 50 mL of gastric juice an hour [Guyton A,1986, Greenfield S, et all. BMJ 1997]
Empty gaster: 80 mL [Johnson & George, 1994]
NO12345678910111213
Mean Fast3 ¼ h2 ½ h2 ½ h2 ½ h
2 h2 ½ h2-3 h2-3 h½ h2 h
2-3 h2 ¼ h1 ½ h
Mean Fast9 h
16 ½ h13 ½ h14 ½ h
12 h12 h>8 h>8 h>8 h11 h
11 ½ h13 h13 h
AUTHORMiller et al (UK) 1983Maltby et al (Canada) 1986Sutherland et al (Canada) 1987Hutchinson et al (Canada) 1988McGrady et al (UK)1988Agarwal et al (India) 1989Scarr et al (Canada) 1989Maltby et al (Canada) 1991Ross et al (USA) 1991Mahiou et al (France)1991Lam et al (Hong Kong) 1993Phillips et al (UK) 1993Søreide et al (Norway) 1993
INTAKEtoast + tea/coffee
water 150mlwater 150ml
coffee/juice 150mlwater 100mlwater 150ml
coffee/juice 150mlcoffee/juice no limit
water 225mlclear liquid 1000ml
water 150mlclear liquid, no limitwater 300-450ml
GASTIC VOLUME
GASTROINTESTINAL WATER MOVEMENT GANONG, 2005
Volume secreted/day mL Saliva 1 500 Stomach 2 500 Bile 500 Pancreas 1 500 Intestine 1 500 Total 7 500
GASTRIC EMPTYING OF 300 ML OF WATER DIGESTIVE DISEASES AND SCIENCES, 2005
GASTRIC EMPTYING OF A SOLID MEAL DIGESTIVE DISEASES AND SCIENCES, 2005
GASTRIC EMPTYING OF 200 ML ORAL NUTRITIONAL SUPPLEMENTS (ONS)
SUTANTO, ET ALL, 2011, PHILSPEN ONLINE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
0"
50"
100"
150"
200"
250"
300"
350"
400"
1" 2" 3" 4" 5" 6"
Series1"
Series2"
Series3"
Series4"
Series5"
Series6"
Series7"
Series8"
Series9"
EMPTY DRINK 200 ML 30’ 60’ 90’ 120’
VOLUME (mL)
ORAL NUTRITIONAL SUPPLEMENS (ONS) CLINICAL NUTRITION (2006) 25: 180–186
DEFINITION ! Supplementary oral intake of dietary food for special medical purposes in addition
to the normal food. ONS are usually liquid but they are also available in other forms like powder, dessert-style or bars. Synonyms used in literature: sip feeds.
• Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract).
• Implement enteral feeding protocols with institution-specific strategies to promote delivery of EN.
• Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN.
• Start parenteral nutrition early when EN is not feasible or sufficient in high-risk or poorly nourished patients.
BUNDLE STATEMENTS
JPEN, 2016: 40(2):159–211.
MCCLAVE, ET ALL. J PARENTER ENTERAL NUTR 2009 33: 277-316.
Holding EN for gastric residual volumes < 500 mL in the absence of other signs of intolerance should be avoided. (Grade: B)
In all intubated ICU patients receiving EN, the head of the bed should be elevated 30°-45°. (Grade: C)
For high-risk patients or those shown to be intolerant to gastric feeding, delivery of EN should be switched to continuous infusion. (Grade: D)
Agents to promote motility such as pro kinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan) should be initiated where clinically feasible. (Grade: C)
Diverting the level of feeding by post-pyloric tube placement should be considered. (Grade: C)
FACTORS REGULATING GASTRIC MOTILITY & EMPTYINGIN ICU PATIENTS
medications (opioid agonists, dopamine), hyperglycemia electrolyte disturbances ischemia/hypoxia burns, trauma, surgery, sepsis, increased intracranial pressure the administration of calorically dense or hyperosmolar formulas.
Fruhwald S, et all. Intensive Care Med. 2006;33:36–44. Chapman, et all. Curr Opin Crit Care. 2007;13:187–94. 20. MacLaren. Pharmacotherapy. 2000;20:1486–98. Metheny, et all. Heart Lung. 2004;33:131–145.
GASTRIC RESIDUAL VOLUME STATUS ICU PATIENT IN 24 HOURS
➤ Josefina Junizar, Luciana B.Sutanto, Dita Aditianingsih ➤ Poster presentation in MDA-AODA meeting, Malaysia, 2016 ➤ ICU Ciptomangunkusumo Hospital, Jakarta
High Residue Normal Residue
GASTRIC RESIDUAL VOLUME STATUS ICU PATIENT IN 48 HOURS
➤ Pittara Pansawira, Luciana B.Sutanto, Dita Aditianingsih ➤ Poster presentation in AICNU meeting, Colombo, 2016 ➤ ICU Ciptomangunkusumo Hospital, Jakarta
%
High Residue Normal Residue
24 hours 48 hours
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ADD
Conclusion: The paracetamol absorption test may be normal in patients with relatively high gastric residual volumes. These patients may continue to receive enteral nutrition.
FACTOR REGULATING GASTRIC MOTILITY & EMPTYING IN ICU PATIENTS
HYPERGLYCAEMIA
GASTRIC DYSMOTILITY
Gastric smooth muscle contraction disorder
Stimulates vagal afferent pathways
Causesosmotic diuresis
Hypokalemia
Increases ROSproduction
Cel apoptosis
FACTOR REGULATING GASTRIC MOTILITY & EMPTYING IN ICU PATIENTS
HYPOPERFUSION
The inflammatory response in the intestinal muscularis externa
Local activation of transcription factors,regulatory cytokines & chemokines
DYSMOTILITY
MUCOSAL DAMAGE INDEX IN GUT FOLLOWING RESUSCITATION AFTER HEMORRHAGIC SHOCK. CHANG, ET ALL. WORLD J GASTROENTEROL 2005
271±31 µm in the control to 204±23 µm in the 24 h groupin ileum. As compared to the control group, the mucosalthickness at 24 h diminished by 25.2%, 23.6%, 23.4% and24.5% respectively, namely from 547±23 µm to 418±28µm in jejunum, 483±45 µm to 364±35 µm in ileum. Themucosal thickness of colon was not markedly changed ineach time point group (F = 0.296, P = 0.936, Table 1).
Table 1 Morphometric assessment of small Intestine and colon indifferent time points after shock resuscitation
Villous height (µm) Mucosal thickness (µm)Group
Jejunum Ileum Jejunum Ileum Colon
Con 310±30 270±22 545±13 482±19 633±58Exp(h) 0 309±24 271±31 547±23 483±45 651±65
1 297±29 244±25a 523±18a 445±26a 639±603 278±24a 210±27a 501±27a 420±31a 674±58
6 264±19a 228±32a 470±31a 394±27a 664±71 12 252±25a 220±18a 433±19a 380±33a 652±69
24 231±28a 204±23a 418±28a 364±35a 631±78
Values are mean±SE; n = 5 rats in control group, n = 7 in each experiment group.aP<0.05 vs control group.
Mucosal damage index in small intestine and colonControl samples taken from small intestine and colonexhibited a minor grade of damage at each time point group.In the experimental group, the 0th h after shock resuscitationshowed moderate damage with the values of the mucosaldamage index being 1.4 in jejunum, 1.6 in ileum and 0.6 incolon. The value was significantly elevated in the 1st h group
and the 3rd h group with their damage grade being 2.6 injejunum, 2.8 in ileum and 1.2 in colon, then it droppedgradually at the 6th h (0.8, 1.0, and 0.6, respectively in theabove three areas). In the 12th h, all mucosal damage anddegradation were nearly closer to that in the control group.For the mucosal thickness change, the damage in colon wassignificantly less (Figure 3).
Figure 3 Mucosal damage index in small intestine and colon followingresuscitation after hemorrhagic shock. Bars are mucosal damage index, thecolor represented different sites.
Effect of L/M and the LPS testIntestinal permeability to macromolecules, as measured bythe urinary concentration of L and M, was significantlyincreased in experimental group rats. The value of L/Mwas elevated following the time, and reached the peak from3 to 6 h (0.063±0.012, 0.098±0.011 respectively, P<0.001),
Figure 2 Electron microscopic examination of ileum following ischemia-reperfusion injury after resuscitation of hemorrhagic shock. The apoptosis and necrosis weremain manifestation in the intestinal mucosal injury. A: Many enterocytes show compaction and segregation of chromatin against the nuclear envelope, but stillpreserve mcrovilli and intact mitochondria; B: Showing the appearance of membrane blebs which cause detachment from the basement membrane; C: Someenterocytes show the swelling of mitochondria and endoplasmic reticulum, scarce and lodging microvilli; D: the opening of tight junction among the cells. Originalmagnification: ×2 500 (A, B), ×4 000 (C,D).
A
C D
B
Muc
osal
dam
age
inde
x
Control 0 1 3 6 12 24 Time (h)
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Jejunum
Ileum
Colon
5488 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol September 21, 2005 Volume 11 Number 35
COLOR OF GASTRIC RESIDUE
COLOR
Hemorrhagic
Bloodstained/coffee-ground type
Green
Light yellow
Clear
INTERPRETATION
: Blood
: Blood
: Bile
: Normal color
: Normal color
CONCLUSION
➤ Measure gastric residue before starting enteral nutrition and every four hour, for the first 5 days (ICU)
➤ Measure gastric residue every 12 hours on days 6–20
➤ High gastric residue: ≥150 mL /single aspirate
➤ IV administration of metoclopramide or erythromycin should be considered in patients with intolerance to enteral feeding e.g. with high gastric residue
CONCLUSION➤ Maintain blood glucose level 70 - 180 mg/dL
➤ Maintain blood Potassium level 4 mEq/L
➤ Maintain hemodynamic: MAP >65
GASTRIC RESIDUAL VOLUME 510 ML IN 24 HR
Volume
HOUR
mL
1
20
75
150
225
300
0 4 8 12 16 20 24/0
TERIMA KASIHAICNU 2016, Colombo