1. Emami Zeydi, Amir MSN, CCRN
  2. Sharafkhani, Mohammad MSN
  3. Armat, Mohammad Reza MSN


There are many challenges related to enteral feedings of the mechanically ventilated patient. Among the most often debated issues is the threshold for gastric residual volume before further feeding. This brief article considers the factors to be considered and reviews current thinking on the topic.


Article Content

NUTRITIONAL STATUS is an important factor in maintaining health and healing process, especially in critically ill patients during mechanical ventilation.1 It is believed that nutritional support is a key intervention in caring of patients in intensive care unit (ICU).2 Accordingly, enteral feeding through a nasogastric tube is crucial in maintaining adequate nutrition in such patients.3,4 However, many cases with deficient caloric intake because of feeding interruptions have been reported in ICUs.5


Inappropriate nutritional disruption in mechanically ventilated critically ill patients is associated with increased risk of serious infections, cardiac dysfunction, impaired respiratory epithelium regeneration, weakening respiratory muscles, and prolonged mechanical ventilation.1,6 It may also increase the ICU and hospital stay up to 30% and 50%, respectively.7 Stopping enteral feeding on the basis of high gastric residual volume (GRV) is among the most common reasons for nutritional interruptions.8


Although some studies indicate that GRV monitoring may cause enteral feeding interruptions, yet, more than 97% of critical care nurses use this method for measuring GRV mainly to critically ill patients against aspiration of gastric content.9-11 It is commonly believed that a large amount of GRV put the patients at risk of aspiration.5,12 However, lack of agreement on appropriate threshold of GRV to stop enteral feeding in mechanically ventilated critically ill patients has raised a question in this regard.13,14


A wide range of GRV threshold has been recommended. The Canadian critical care nutrition guideline has recommended a range of 250 to 500 mL, whereas other studies suggest volumes more than 200 mL, to stop the tube feeding.4,15 Also, a minimum value of 500 mL has been proposed by some studies.12,16 A regional survey revealed that the volume on which the decision to stop enteral feeding varied, and the GRV less than 300 mL was the accepted threshold.5 This inconsistency in threshold GRV, as well as the lack of consensus on standardization for withholding and resuming enteral feeding, has caused critical care nurses to decide stopping enteral feeding at the volumes ranging from 50 to at least 500 mL.8-17 For this, it is suggested that the GRV monitoring could be eliminated from the standards of care for critically ill patients under mechanical ventilation.13


Considering the importance of nutritional status of mechanically ventilated critically ill patients, and using GRV monitoring as a routine practice to stop or resume enteral feeding, and also inconsistency in appropriate GRV threshold, more studies are suggested to establish a narrower and widely accepted standard threshold for GRV to help health care providers in making better and confident decisions in this regard.




1. Heydari A, Emami Zeydi A. Is gastric residual volume monitoring in critically ill patients receiving mechanical ventilation an evidence-based practice? Indian J Crit Care Med. 2014;18:259-260. [Context Link]


2. Ros C, McNeill L, Bennett P. Review: nurses can improve patient nutrition in intensive care. J Clin Nurs. 2009;18:2406-2415. [Context Link]


3. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPEN J Parenter Enteral Nutr. 2009;37:227-316. [Context Link]


4. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enteral Nutr. 1992;16:99-105. [Context Link]


5. Ahmad S, Le V, Kaitha S, et al. Nasogastric tube feedings and gastric residual volume: a regional survey. South Med J. 2012;105:394-398. [Context Link]


6. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. WHO Chron. 1969;23:2369-2374. [Context Link]


7. Peev MP, Dante YD, Quraishi SA, et al. Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. JPEN J Parenter Enteral Nutr. 2014;20:1-7. [Context Link]


8. Peev MP, Dante YD, Quraishi SA, et al. Evaluation of delivery of enteral nutrition in mechanically ventilated Malaysian ICU patients. BMC Anesthesiol. 2014;14:127. [Context Link]


9. Moreira TV, McQuiggan M. Methods for the assessment of gastric emptying in critically ill, enterally fed adults. Nutr Clin Pract. 2009;24:261-273. [Context Link]


10. Zaloga GP. The myth of the gastric residual volume. Crit Care Med. 2005;33:449-450. [Context Link]


11. Kuppinger DD, Rittler P, Hartl WH, et al. Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies. Nutrition. 2013;29:1075-1079. [Context Link]


12. Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36:1386-1393. [Context Link]


13. Reignier J, Mercier E, Le Gouge A, et al. Effect 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. JAMA. 2013;309:249-256. [Context Link]


14. Heyland D, Cook DJ, Winder B, et al. Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med. 1995;23:1055-1060. [Context Link]


15. Elke G, Felbinger TW, Heyland DK. Gastric residual volume in critically ill patients: a dead marker or still alive? Nutr Clin Pract. 2015;30:59-71. [Context Link]


16. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33:277-316. [Context Link]


17. Edwards SJ, Metheny NA. Measurement of gastric residual volume: state of the science. Medsurg Nurs. 2000;9:125-128. [Context Link]


enteral feedings; gastric residual volume; mechanically ventilated patient