Nutrition and metabolic support

Feed intolerance, gastric residuals and post-pyloric feeding

Reviewed Nov 2026·2 references
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Define intolerance, use a GRV threshold of 500 mL/6 h, give prokinetics, consider post-pyloric feeding and reduce aspiration risk.

Definition
Feed intolerance: vomiting, GRV > 500 mL/6 h, distension, or diarrhoea preventing delivery of targets. Routine GRV monitoring is optional in ASPEN; ESPEN suggests delaying EN if GRV > 500 mL/6 h.

At the bedside

  1. 1

    Exclude serious causes

    Bowel obstruction, ischaemia, ileus, raised IAP, electrolyte disturbance, opioids, hyperglycaemia.

  2. 2

    GRV > 500 mL/6 h

    Pause or reduce feed rate, re-infuse up to 500 mL, start prokinetic.

  3. 3

    Prokinetics

    Erythromycin 100-250 mg IV q8h (first choice) or metoclopramide 10 mg IV q8h, or both; review after 24-72 h.

  4. 4

    Post-pyloric feeding

    If intolerance persists despite prokinetics, or high aspiration risk: nasojejunal tube (endoscopic, fluoroscopic or bedside electromagnetic).

  5. 5

    Aspiration prevention

    Head-up 30-45°, continuous rather than bolus feeds, oral care, minimise sedation.

  6. 6

    Diarrhoea

    Check C. difficile, laxatives, sorbitol-containing drugs, antibiotics; continue EN; consider soluble fibre or peptide formula.

Gastric intolerance

Erythromycin

IV
Dose
100-250 mg every 8 h for 24-72 h

Gastric intolerance

Metoclopramide

IV
Dose
10 mg every 8 h
Red flag · call your senior now
New distension with large GRVs, hypotension and lactate rise: stop EN and image the abdomen (bowel ischaemia/obstruction).
Pitfall
Stopping feeds for small GRVs (< 500 mL) - leads to underfeeding.
Pitfall
Long-term prokinetics (> 3-4 days): tachyphylaxis and side effects.
Pearl
Diarrhoea is rarely due to the feed itself - look for drugs and infection first.

References

  1. 1

    Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38:48-79.

  2. 2

    Compher C, Bingham AL, McCall M, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2022;46:12-41.

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