EFFECT OF REINTRODUCTION OF GASTRIC ASPIRATE ON GASTRIC RESIDUAL VOLUME AMONG PATIENTS RECEIVING NASOGASTRIC/OROGASTRIC FEED ADMITTED IN ICUS

Jyoti Sharma 1 , Prabhjot Saini 2 , Shivani Kalra 3 and P. L. Gautam 4 . 1. College of Nursing, Dayanand Medical College and Hospital, Ludhiana, Punjab141001, India. 2. Professor, College of Nursing, Dayanand Medical College and Hospital, Ludhiana, Punjab141001, India. 3. Assistant Professor, College of Nursing, Dayanand Medical College and Hospital, Ludhiana, Punjab141001, India. 4. Professor & Head Critical Care Units, Dayanand Medical College and Hospital, Ludhiana, Punjab141001, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 6(3), 33-43 34 Studies have shown relationship between gastric emptying and reintroduction or discarding of the gastric aspirate to lower the risk of complications. Reintroduction of gastric aspirate lowers GRV. The number of mild and moderate gastric emptying delay episodes, doubles in those patients in whom gastric aspirate is discarded. 10 Patients in intervention group showed a slightly lower total mean GRV. The number of mild and moderate gastric emptying delay episodes was double in the discard group. 2 Delay in gastric emptying results in many complications. In a review of 253 patients receiving enteral nutrition via tube feedings, thirty patients (11.7%) experienced either gastrointestinal (6.2%), mechanical (3.5%), or metabolic (2.0%) complications. The most frequent cause for the failure to meet target feeding goals were slow gastric emptying as indicated by large volume gastric aspirates. 12 Some authors support instilling gastric aspirate in order to contribute to the maintenance of gastric juices and the electrolyte balance (sodium and potassium levels). Nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCl). Whenever a hydrogen ion is excreted, bicarbonate ion is gained in the extracellular space and some also concluded that returning of the gastric contents can lead to nausea & vomiting, diarrhea, clogging of tube and abdominal distension. 10,11,12 Another study rendered patients to be hypochloremic by the continuous withdrawal of gastric contents through an indwelling gastric tube attached to gastric suction. The serum sodium content fluctuated. The value dropped significantly in three patients, the decrease varying from 15to 22 mEq/liter. And the potassium content of the serum decrease in four of the five patients, the decrement varying from 0.9 to 1.5 mEq/liter. 13 This GED can be prevented by reintroduction of gastric aspirate. It is concluded that to return or to discard gastric aspirate is a controversial issue in the nursing practice and limited studies has been conducted regarding this issue. Evidence based guidelines for enteral nutrition curtailing the incidence of complications through managing gastric residual volumes, minimizing feeding interruption, maintain electrolyte level and prevent GED in critically ill patients are very much needed. 12 The current practice is discarding the gastric aspirate before each feed is continued. So the present study is planned to assess whether the reintroduction of gastric aspirate affects the gastric residual volume and maintenance of electrolytes balance. 10,11,12 Material and methods:-Research design:-A randomized control trial design was employed using "parallel group design" to carry out the study. Sampling technique:-Purposive sampling technique was used to draw population from target population then lottery method used for random distribution of subjects in experimental and control group. Trial design:-After obtaining informed consent; eligible patients were randomly assigned to both groups using parallel group design 1. A experimental group -gastric aspirate was reintroduced to the patient. 2. A control group-gastric aspirate was discarded.

Concealment and blinding:-
This was a double-blinded randomized control trial where neither the patients were known about the group to which they were assigned nor the staff nurses assisting in the procedure were known about groups. Furthermore, the amount of gastric residual volume (GRV) aspirated was recorded by an observer blinded about the groups assigned to the patients.
Randomization:-"Simple randomization method" i.e., lottery method was used to randomize the patients in experimental group and control group. Patients were having equal probability of being assigned to either of two groups. A parallel group design of randomized control was used in assigning the patients to each group. Further, a list of randomization numbers given to patients can be referred from annexure v.
Intervention:-1. By using purposive sampling technique subjects were drawn from target population. 2. Randomization done into two groups by using lottery method. 3. Subjects eligibility was established by using inclusion & exclusion criteria. 4. Informed consent was obtained from the subject"s relatives.
Experimental group:-1. Each subject was followed for 15 observations. 2. Assisted in Semi-fowler position. 3. Before feeding the aspirate stomach contents to check for GRV and reintroduction of gastric aspirate was done by investigator by following reintroduction criteria.
NG tube flushed before feeding to prevent clogging of tube. Feed was administered.
Bed elevated for 30-60 minutes after feeding. Document the amount of feed, amount of aspirate reintroduce, color of aspirate.

36
Control group:-1. Each subject was followed for 15 observations. 2. Assisted in Semi-fowler position. 3. Before feeding the aspirate stomach contents to check for GRV and routine practice was followed i.e. gastric aspirate discarded. 4. Feed was administered. 5. Bed elevated for 30-60 minutes after feeding. 6. Document the amount of feed, amount of aspirate, color of aspirate. 7. Then comparison and assessment of the pre-interventional and post interventional gastric residual volume among subjects was done in both groups. Data was analysed using descriptive statistics (percentage, mean and standard deviation) inferential statistics (χ 2 , t test). A p value of 0.05 was taken as a threshold to test the significance level.

Results:-
Socio-demographic profile of the subjects in experimental and control group:-Out of 82 subjects i.e. experimental (n 1 =42) with mean age 51.90± 11.62 and control group (n 2 =40) with mean age 46.3±14.99. Most of subjects were male, married, working, smoker and had a moderate life style pattern. While most of subjects belonged to urban area in experimental group and equal number of subjects in rural and urban area in control group. All the groups were statistically identical (p>0.05). Table Ι showed that the aspiration volume in both groups. The average aspiration volume in experimental group (8.13±26.89) was significantly lower than the control group (18.26±48.08), p=0.000 and feeding volume was 152.06±68.74 & 175.11±73.01 in experimental and control group respectively. The mean ratio in experimental and control group was 18.70 vs. 9.59 (lower the value, higher the aspiration volume). T test was applied to evaluate the difference of aspiration volume between both the groups. There was a significantly higher aspiration volume in control group (p=0.000) than in experimental group. Comparison of GED among experimental and control group as per relative risk and odd ratio:- Table ΙΙΙ showed that the Comparison of GED among experimental and control group as per relative risk and odds ratio. In control group relative risk of developing GED is 0.517 times while Odds of occurrence of GED in control group is 0.47 times the odds of occurrence in experimental group (RR and OR < 1, p=0.0001).

Gastric emptying delay in both groups:-
37 Table ΙV showed that the problems observed in patients after feeding in both groups. 04(9.52%) in experimental group and 02(5%) in control group complained of having nausea & vomiting, while 4 (9.52%) in experimental group and 2 (5%) in control group complained of abdominal distension. No other problems were documented or observed in both groups namely aspiration, diarrhea and clogging of tube. Table V showed that the mean abdominal girth of experimental and control group which was found to be (108. 30± 14.71 & 114.03± 12.99) respectively, depicting that average abdominal girth was found to be more in control group than experimental group (p=0.012).

Discussion:-
A randomized control trial was conducted on 82 subjects receiving nasogastric/orogastric feed and effects of reintroduction of gastric aspirate was assessed on GRV and results revealed that that the average aspiration volume in experimental group was 8.13±26.89 while in control group it was significantly higher i.e.18.26±48.08 (p=0.000). The mean ratio of gastric content reintroduction in experimental and control group was 18.70 vs 9.59 respectively. The present study revealed that GED was almost 50% fewer if the aspirated contents are reintroduced than when the contents are discarded. Study revealed that GED was higher in Control group than in experimental group with Mild GED (3.83% vs. 1.74%), Moderate GED (4.18% vs. 2.62 %) and severe GED (7.15% vs. 3.5%) respectively. The showed that there was a statistical significant difference between study & control groups in relation to gastric emptying delay on 7 th day, the study group had less mean level than control group, moreover, there was a statistical significant difference in pulse and respiration among control group before and after feeding procedure. 40 The present study shows that in control group RR of developing GED was 0.517 times while Odds of occurrence of GED in control group was 0.47 times the odds of occurrence in experimental group.( RR and OR < 1, p=0.0001). There was no supported or contradictory study about the RR and odds of occurrence of GED.
The present study also revealed that there was a significant association of electrolyte imbalance (Na + and K + ) with GED (p=0.000). GED was observed more in discard group as compared to reintroduction group (87 Vs 45). Normal serum sodium levels were observed to be more associated with GED in discard group than in reintroduction group (54 vs 34) respectively. Hypernatremia was associated with GED in discard group than reintroduction group (27 vs 0) respectively. Normal serum potassium levels in discard group (87 out of 87 ) was associated with GED as compared to 35 out of 45 in reintroduction group , similarly 10 out of 45 observations with hyperkalemia were associated with GED as compared to none in discard group. Thus the study revealed that GED was significantly associated with hyponatremia and hyperkalemia in reintroduction group and hypernatremia in discard group. of hyperglycaemia in oesophageal motility, decreasing inferior oesophageal sphincter pressure, the speed of the oesophageal peristalsis, and in the delay of gastric emptying and this was supported by the present study revealing that mean blood sugar levels in discard group was higher as compared to reintroduction group (169.75 ± 57.46 vs 157.66±55.65) respectively. Hyperglycemia was observed to be associated more with GED in discard group than reintroduction group (38 vs 21) which could be a probable cause of GED in control group than experimental group (p=0.196).