[CK] Tube feeding -gradual + Q4HR residual. (250, 500 - residual => hold or stop) . 30cc -> q6hr 30cc/hr without 400 residual to goal.

2. Assess tolerance of tube feedings. A. Check stool amount and frequency daily.5 B. Check gastric residual every 4 hours during the first 48 hours of feeding in gastrically fed patients.

When goal rate is attained, it is possible to reduce gastric residual monitoring to every 6-8 hours in patients who are not critically ill.

Continue to assess gastric residuals in critically ill patients every 4 hours.

High or increasing gastric residuals often are symptoms of problems that are not associated with tube feeding. Therefore, it is important to investigate other causes of high-gastric residual volumes rather than simply holding the tube feeding.

The recommendations of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding gastric residuals are as follows:
 • If the gastric residual volume (GRV) is >250 mL after a second gastric residual check, consider a promotility agent in adult patients. 

 • A GRV >500 mL should result in holding enteral nutrition and reassessing patient tolerance by use of an established algorithm, including physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility agent use, if not already prescribed.

cf) Note signs and symptoms that may indicate GI intolerance, including abdominal distension, vomiting, diarrhea, or constipation; assess non-tube feeding factors that may contribute to gastrointestinal symptoms in patients on tube feeding (see Potential Problems and Preventive Actions, p 14-17) before changing type, amount, or rate of feeding.

UPTODATE:

Amount and rate — The daily amount of enteral nutrition is tailored to the nutritional and fluid needs of each patient. A calorie goal of 18 to 25 kcal/kg/d is a reasonable initial range to use to meet the needs of a critically ill patient of normal weight. In practice, it is generally considered acceptable that enteral feeding be initiated in critically ill patients at a rate of 10 to 30 mL/hour (for standard enteral formulations), so called "trophic" feeding, for six days and then incrementally increased to the target rate. It is our practice to initiate feeds at 25 to 30 percent of estimated goal rate. 

In patients who are subjectively more critically ill, we do not attempt to increase further toward goal until the fifth to seventh day of critical illness. In less critically ill patients, advancement is made toward goal as tolerated, based on gastrointestinal symptoms and physical examination (ie, presence of abdominal distension). 

We do not use gastric residuals, unless greater than 500 mL, as criteria for tolerance, and are working toward cessation of routinely checking gastric volume (see 'Monitoring' below). Provided the enteral nutrition is paused infrequently, for issues such as gastric distension, diarrhea, or vomiting, this suggested approach should result in the patient ultimately reaching a stable target rate within a reasonable period of time. 

START WITH 25cc/hr -> increase 25/hr q6hr unless residual >400. 

Or: low-volume enteral feeding consisted of initiating enteral feeding at approximately 10 to 30 mL per hour (approximately 30 percent of the maintenance target), continuing that rate for six days, and then advancing the infusion rate using the same protocol that was used in the full enteral feeding group. = better outcome with low rate. 

(30cc -> uptitrate 30cc q 6hr for now.)