2019 Research Forum

Florisse Gutierrez, RN ∙ Victoria Kleinknight, RN ∙ Tina Lawhon, RN ∙ Miranda Arnold, RN Can infants in the NICU setting reach full feedings quicker without routine monitoring of gastric residuals? GASTRIC RESIDUALS IN THE NICU

INTRODUCTION

The methodology of our project was designed with a review of current practices in Kern Medical’s NICU, review of literature, and evidenced- based opinion/practice. Research was found through online publications and other hospital’s policies. Online publications included literature from peer-reviewed journals, electronic databases, and websites. Terms used for searching included NICU, neonatal, gastric residual/aspirate, NEC, feeding intolerance/tolerance, and enteral feedings. All research gathered and used was published within the last five years. Data collected from review of current practice was analyzed and a graph was created to display the findings. MATERIALS AND METHODS

CONCLUSIONS Based on the data collected from research articles, we concluded that there is no apparent evidence showing it is necessary to routinely check for gastric residuals prior to every feeding. However, further research is needed to confirm if all benefits outweigh the risks. As stated in our research, the consequences that are associated with routinely checking for gastric residuals can be more harmful to neonates than helpful. There are many reliable methods that can be utilized to prevent feeding intolerance/ NEC in neonates, such as the focused assessment skills of the nurse. While it as the intention of our project to collect data from the implementation of a feeding protocol at Kern Medical NICU and compare it to current evidence based practice, there is not one available at this time. This project has brought attention to the need for a feeding protocol. Further research and discussion must take place before a specific procedure can be permanently used. It is our recommendation that a policy is developed to standardize the monitoring of gastric residual, based on current best evidence based practice. Based on our current practice review, it is evident that there is a variation amongst our staff’s nursing practice. In addition to the inconsistency amongst nursing practice, each neonatologist practices individual methods that conflict, leading to increased confusion for staff. We aim to implement a feeding protocol that physicians and staff can follow to provide consistent and safe patient care. Below is an example of a feeding algorithm, in which we hope to similarity follow in the future. REFERENCES Abiramalatha, T., Thanigainathan, S., & Ninan, B. (2018). Routine monitoring of gastric residual for prevention of necrotising enterocolitis in preterm infants. Cochrane Database of Systematic Reviews,(1), 1-10. doi:10.1002/14651858.cd012937 Kaminski, M. M., Clancy, K. L., & Steward, D. K. (2014). Dilemmas Surrounding Interpretation of Gastric Residuals in the NICU Setting. ICAN: Infant, Child, & Adolescent Nutrition,6(5), 286-294. doi:10.1177/1941406414539005 Li, Y., Lin, H., Torrazza, R. M., Parker, L., Talaga, E., & Neu, J. (2014). Gastric Residual Evaluation in Preterm Neonates: A Useful Monitoring Technique or a Hindrance? Pediatrics & Neonatology,55(5), 335-340. doi:10.1016/j.pedneo.2014.02.008 Lindquist Beauman, S. (2017, July). Neonatal Gastric Feeding Tubes, Part 2: Confirming Gastric Tube Placement. Retrieved from https://blog.neonatalperspectives.com/2017/07/19/neonatal-gastric-feeding- tubes-part-2-confirming-gastric-tube-placement/ Seattle Children’s Hospital. (2018, November). Gastric residuals in the preterm infant [Web log post]. Retrieved from https://www.seattlechildrens.org/healthcare-professionals/education/continuing- medical-nursing-education/neonatal-nursing-education-briefs/gastric-residuals/ Thomas, S., Singh, B., Rochow, N., Chessell, L., Wilson, J., Cunningham, K., . . . Fusch, C. (2014). Gastric Residuals In Preterm Infants As Predictor Of Tolerance To Early Enteral Feeds (grip Trial). Archives of Disease in Childhood,99(2), 37-37. doi:10.1136/archdischild-2014-307384.110 Torrazza, R. M., Parker, L. A., Li, Y., Talaga, E., Shuster, J., & Neu, J. (2014). The value of routine evaluation of gastric residuals in very low birth weight infants. Journal of Perinatology,35(1), 57-60. doi:10.1038/jp.2014.147 ACKNOWLEDGMENTS Thank you to those listed below for participating in our project and helping us further reach for excellence in neonatal nursing care. • Florisse Gutierrez, RN • Victoria Kleinknight, RN • Tina Lawhon, RN

Based on infants receiving NG/OG enteral feedings, does the use to a standardized feeding protocol, in which gastric residuals are only checked when two of more clinical signs and symptoms of feeding tolerance are noted, allow for early detection of NEC and/or reduce interruptions in the establishment of full feedings; in comparison to routine monitoring of gastric residuals prior to each feeding? Necrotizing enterocolitis (NEC): a disease located in the wall of the intestines, in which bowel inflammation and death occur secondary to bacterial infection or hypoxia; possibly progressing to bowel perforation and sepsis. The premature infants gastrointestinal system has decreased length, immature motility patterns, and inadequate digestive capabilities when compared to term infants. NEC affects 7-11% of very low birth weight infants, while holding a 10- 30% mortality rate. Current evidenced based practice is putting an emphasis on initiating enteral feeds and achieving full volume feed as early as possible. Associated complications of delayed feedings include more days on total parenteral nutrition (TPN) with central/peripheral IV lines in place, leading to higher risk of infection and parenteral nutrition-associated liver disease. Gastric residual or aspirate include stomach contents found prior to the next feeding. Gastric residuals may contain milk, gastric acid, and digestive enzymes. Aspirates may vary depending on a variety of factors such as, infant positioning, placement of gastric tube, type of milk, milk temperature, duration of feeding, and medications being given. Gastric residuals may determine how feedings are initiated and advanced. There is lack of consensus as to how we should monitor and interpret gastric residuals. Providers may delay feeds based on residual volumes and characteristics. Checking gastric residuals may also damage the gastric mucosa and alter natural flora. Another concern is what to do with gastric residuals once aspirated. Should the aspirate be given back by slow push/gravity, discarded, or subtracted from next feeding, and how do we determine the right decision? Checking gastric residuals is a common nursing assessment used to identify early signs of feeding intolerance. The use of monitoring gastric residual without uniform guidelines may lead to unnecessary delay in the initiation of enteral feeding, interruption in the establishment of full feedings, and contribute to other associated complications. Studies show infants reach full feedings approximately two weeks earlier when gastric residuals are no longer routinely assessed. • Review the current practice of Kern Medical NICU • Strengthen assessment skills for NEC • Identify consequences of routinely monitoring gastric residuals • Develop a standardized feeding protocol • Increase infant weight gain • Decrease delay in reaching full feeds • Decrease hospital stay time • Decrease costs and complications associated with IV therapy and TPN OBJECTIVES

RESULTS

At Kern Medical, we selected 6 questions for the NICU nurses to answer in order to review our current practice. The data collected was used to evaluate our current practice in comparison to evidence based practice. Before every single feeding, 40% of nurses check for gastric residual. If bilious residual is aspirated and the neonate has no other signs of feeding intolerance, 55% of nurses are still concerned. When asked what percentage of feeding aspirated in gastric residual would be a significant amount, 70% of nurses agreed 50% of the feeding was of concern. With various methods used to check for NG/ OG placement, auscultating for placement was the most reliable method for 50% of nurses. 80% of nurses agreed that gastric residuals should be checked if the baby is symptomatic for feeding intolerance. Symptoms include abdominal distention, discoloration, bowel loops, emesis, and signs of sepsis/infection. Once gastric residual is aspirated, 100% of nurses agreed the residual should be returned to the neonate if it resembled digested milk. If the residual appeared bilious or bloody, it should be discarded. Lastly, several nurses mentioned that in the process of checking for gastric residual, nurses should not aspirate forcefully and stop immediately once resistance is met.

• Miranda Arnold, RN • Dianne Nicholls, NNP • Marie Bennett, RN • Pam Gavin, RN • Kern Medical NICU RNs • Eva Flanagan, RN-BSN, RNC, NICU Clinical Supervisor

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