Managing Residuals, WakeMed 2008 Guidelines

Transcription

1 Managing Residuals, WakeMed 2008 Guidelines

2 Management of Aspirates: Background Early in life, gastric motility and muscle tone are decreased, possibly due to several reasons: increased gastrin, poorly developed feedback mechanisms (includ antrodouodenal activity); mucous also delays gastric emptying in first 24h Complicated by effect of milk (formula takes longer to empty than breastmilk), drugs, concomitant illness Note gastric capacity early on is only ~6 ml/kg

3 Management of Aspirates Unclear if they are predictive of serious disease (?NEC,? ileus for another reason) or if they are developmental/physiologic expectations when feeding the VLBW infant Likewise, no agreement on definition. Suggestions include Volume: 2ml, 3ml, 5ml/kg percentage of feed: 20%, 25%, 30%, 50% Quality of aspirate (green, milky, bloody) Don t look/measure at all

4 Management of Aspirates: WakeMed Protocol Check gastric aspirate prior to each gavage feed;do not check residuals in babies on continuous feeds. Management of residuals while on trophic feeds(</=20 ml/kg/d) Note that while receiving trophic feeds, infant may have large aspirates relative to feeding volume. If infant looks otherwise well, may accept up to 3 ml as normal. If residual is <50% volume, refeed and subtract from total ordered. If residual is >50% volume fed, discard and feed volume ordered if infant looks otherwise well. If two consecutive residuals >3 ml, notify MD. Consider stretching out intervals between feeds if residuals persist.

5 Management of Aspirates: Protocol Management of residuals after trophic feeds completed (>20 ml/kg/d): To be considered a significant residual, volume should be >50% feeding volume or >5ml/kg, whichever is smaller. 1. If aspirate is not significant, refeed and subtract volume from total. Give rest of feed to make up ordered feeding volume. 2. If aspirate is significant, but infant looks well otherwise, refeed residual and hold that feed. If significant aspirate found at next feed, contact MD.

6 Aspirate protocol: MD/NNP role Will be called for persistent significant aspirates or abnormal exam Feeds can only be held with order after exam by MD or NNP Use subsequent feeding intervals to assess if feeds need to continue to be held, or if they can can be restarted at full volume, or at half-level. Consider returning to ¾ volume after 2 feeds at half volume if aspirates decreased and infant continues to look well. Supplements and medications will not be restarted without a separate order

7 When to Notify MD/NNP Any abnormal exam, which may include: Non-specific signs of illness to include: lethargy decrease tone poor perfusion apnea/bradycardia glucose instability Abnormal abdominal exam distension discoloration tenderness visible loops of bowel absent bowel sounds unstable vital signs visible blood in aspirate or stool moderate/dark green residuals or emesis

8 Beware: aspirate management is unchartered territory Cobb/Carlo (Peds Jan 2004) noted that the day NEC was diagnosed, aspirate volume rose, and that >3.5 ml or 33% of feed may be associated with higher risk of NEC If infant has not been having residuals, and then starts, may indicate a new process is developing; or, if during feeding advancement, may not be ready for advanced volume/density Needs to be evaluated in context of whole baby, and common sense needs to apply