Monitoring
Measuring gastric residual volume (GRV) in excess of a threshold value has been used to monitor the risk for aspiration in tube-fed patients. Because the cutoff values for GRV that clearly indicate aspiration risks vary among studies, these assessments should be combined with clinical evaluation of feeding intolerance, which includes auscultation of bowel sounds and evaluation of abdominal distention.[44] Measures to reduce aspirations should be initiated when a GRV is >200 mL, and aspiration of gastric contents from any in-place nasogastric tube should be performed if anesthesia is imminent.[109]
The quality of evidence regarding measurement of GRV and its effect on parameters such as mortality, pneumonia, and length of stay is uncertain, and it is difficult to draw conclusions about the value of GRV in the clinical setting.[110] The practice of not monitoring GRV was not inferior to routine monitoring in regard to the outcome of ventilator-associated pneumonia in 452 intensive care unit (ICU) patients randomized in a noninferiority, open-label, multicenter trial conducted in adults requiring invasive mechanical ventilation for more than 2 days and given enteral nutrition within 36 hours after intubation at nine French ICUs.[111] Furthermore, in one study of 61 patients receiving mechanical ventilation and continuous enteral feeding, measurement of residual gastric volume by suctioning was inaccurate.[112]
The Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) do not endorse using GRV as part of routine monitoring in the ICU.[113] The European Society for Clinical Nutrition and Metabolism (ESPEN) does suggest delaying commencement of feeding if GRV is >500 mL in a 6-hour window but also acknowledges SCCM/ASPEN guidelines regarding routine monitoring.[114] Clinicians should consider these guidelines within the context of the individual patient, particularly in those at high risk for aspiration, who have ileus, esophageal dysfunction, or gastroparesis.
Because of the inert character of barium, long-term reactions and late toxicities are not usually expected, and complete radiologic clearance is the norm. There are no extensive data on long-term complications from massive barium aspiration, but case reports suggest that abnormalities can be seen on high-resolution computed tomography scan up to 1 year later.[108] Therefore, it is reasonable to obtain follow-up chest imaging during the year after barium aspiration.
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