Editorial <\/p>\n\n\n\n
When children become critically ill and need invasive mechanical ventilation, making sure that they get the right amount of nutritional support is crucial, not only for the physiologic needs of delivering appropriate amounts of calories and protein, but also for the needs of the family, where feeding constitutes such an important part of childcare. Deliver too much enteral nutrition, and you may run the risk of complications, including aspiration or vomiting or gut diseases, such as necrotizing enterocolitis. Deliver too little enteral nutrition, and there may be inadequate calories contributing to delayed recovery.<\/p>\n\n\n\n
For many decades, the measurement of residual volumes in the stomach via gastric tubes helped tailor feeding strategies in critically ill children receiving mechanical ventilation. The practice required bedside staff to withdraw the stomach contents from a gastric tube and determine whether the amount found remaining in the stomach was large enough that tube feeds should be slowed down or stopped altogether. The practice was time-consuming and difficult to standardize because the optimal aspirate volume was unknown. Whether to routinely perform these assessments on all children has never been tested, with observational data showing no difference in nutritional outcomes comparing intensive care units in which residual volume measurement is routine vs those in which it is not.1<\/a><\/sup> Nonetheless, routine gastric residual volume testing persists in clinical practice in some regions of the world, without evidence to justify its widespread use.2<\/a><\/sup>,3<\/a><\/sup><\/a><\/p>\n\n\n\n In this issue of JAMA<\/em>, the GASTRIC-PICU trial answers this question.4<\/a><\/sup> Among 4700 children receiving invasive ventilation randomized to undergo no routine gastric residual volume (GRV) assessments and usual care assessments every 6 hours, not routinely assessing GRV was noninferior to routine assessments in the co\u2013primary clinical outcome of a composite of survival and duration of ventilator support (median [IQR] survival and days free of mechanical ventilation at 30 days, 25 [21-27] days in both groups; adjusted odds ratio, 0.95 [95% CI, 0.86-1.05]). The lower bound of the 95% CI fell within the prespecified noninferiority margin of 1\/1.2 (P<\/em>\u2009<\u2009.001). Conducted predominantly in the UK across 23 sites (with 1 site in Switzerland), the trial recruited a representative sample of critically ill children.<\/a><\/p>\n\n\n\n As expected, routine measurements of GRV led to more time without enteral feeding over the first 7 days. The no routine GRV assessment group achieved a higher percentage of children meeting energy requirements by 72 hours, the nutritional co\u2013primary outcome, although this is of unclear clinical significance. The assumed risks of not assessing GRV, namely higher rates of ventilator-associated pneumonia or necrotizing enterocolitis, were not observed in this large trial, suggesting that not measuring GRV is safe. As a pragmatic trial embedded in routine care, exhaustive data collection of decision-making about GRV measurement were not collected, which is appropriate for a trial of this nature. The 2 groups achieved good separation in terms of GRV measurement, protocol deviations were rare, and requests for withdrawal of data post enrolment were infrequent.<\/a><\/p>\n\n\n\n There are key populations in which the practice of GRV is untested. For example, children receiving noninvasive ventilation and premature infants were not included, and extrapolation of these data to those populations must be considered carefully. Determining how to best provide nutritional support to children with critical illness should now move on to further questions. Recent research prioritization work across the nutrition community about how to optimally feed children, examining target volume\u2013based approaches, strategies for bolus feeding, or optimizing the type of feeds, all may require evaluation.5<\/a><\/sup>,6<\/a><\/sup><\/a><\/p>\n\n\n\n For readers not familiar with the conduct of randomized trials in children with critical illness, the successful recruitment of 4700 patients is a tremendous feat. The processes by which the health system in the UK, particularly within its intensive care units, embed research within care should be emulated around the world. As the authors state, this is the largest-ever individually randomized trial conducted in pediatric intensive care units.<\/a><\/p>\n\n\n\n Before the reporting of this trial, many regions had already abandoned GRV measurement in the pediatric intensive care unit. There were observational data that suggested no benefit from its widespread implementation, and 2020 consensus statements suggested that it should not be routinely performed.7<\/a><\/sup> And yet, the practice broadly persisted, which led to the design and successful conduct of the GASTRIC-PICU trial. Looking ahead, there are likely dozens of other routine practices in clinical care that are unlikely to be useful and should be studied for possible deimplementation.8<\/a><\/sup> Taking a practice such as GRV assessment with little evidence into standard care then requires high-quality evidence for its subsequent deimplementation. The opposite, where high-quality evidence precedes bringing practices into standard care, should be the norm.<\/a><\/p>\n\n\n\n For children receiving invasive ventilation, the question becomes \u201cif observational data, position statements, and global practice variability were inadequate to lead to deimplementation of a practice, will a well-conducted, convincing randomized clinical trial lead to widespread practice change?\u201d That is the task for both the authors and the readers of GASTRIC-PICU, because the difficulties of deimplementing low-value care processes are well-documented.9<\/a><\/sup> Any study that has the possibility to remove unnecessary added labor to busy bedside staff caring for critically ill children should be celebrated. But the hard process of deimplementation, where old habits die hard, is still to come.<\/p>\n","protected":false},"excerpt":{"rendered":" Editorial Residual Myths in Feeding Critically Il […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31198"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=31198"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31198\/revisions"}],"predecessor-version":[{"id":31199,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31198\/revisions\/31199"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=31198"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=31198"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=31198"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}