GASTRIC-PICU: routine gastric residual checks can go

Design

pragmatic multicentre randomised noninferiority trial with a co-primary superiority nutritional outcome

Population

4,700 children aged 0-16 receiving invasive ventilation and starting enteral feeds in 24 paediatric intensive care units; 4,460 analysed, median age 8 months

Primary outcome

composite of survival and ventilator-free days at 30 days (noninferiority); percentage meeting energy requirements by 72 hours (superiority)

Effect

median 25 ventilator-free days in both arms, adjusted OR 0.95 (95% CI 0.86-1.05); energy requirements met 80.3% versus 76.8%, adjusted difference 3.2 points (1.3-5.2), p<0.001

Measuring gastric residual volume every six hours in ventilated children is near-universal, interrupts feeding, and has never been shown to prevent anything. GASTRIC-PICU randomised 4,700 children aged 0 to 16 across 23 UK and one Swiss paediatric intensive care units to usual care with six-hourly assessment, or to no routine assessment with feed tolerance judged on clinical signs alone.

On the clinical co-primary outcome — a composite of survival and ventilator-free days at 30 days — not measuring was noninferior, with a median of 25 days in both groups and an adjusted odds ratio of 0.95 (95% CI 0.86-1.05); the per-protocol analysis agreed. On the nutritional co-primary outcome, children in the no-measurement group met a higher proportion of their energy requirements by 72 hours: 80.3% against 76.8%, an adjusted difference of 3.2 percentage points (1.3-5.2, p<0.001).

This is a large, pragmatic, multicentre trial answering a question about routine practice, and the answer is clean: the measurement costs feeding and buys nothing. The nutritional gain is modest in size, but it is on top of a safety result, not traded against one. The reasonable change is to stop routine six-hourly aspiration and to define instead what clinical signs of intolerance the unit will act on — vomiting, abdominal distension, discomfort — so that abandoning the number does not leave a vacuum.

• Stop routine six-hourly gastric residual volume checks in ventilated children
• Write down which clinical signs of feed intolerance trigger action, so the assessment is replaced rather than dropped
• Keep measuring where there is a specific concern — this trial removed the routine, not the option
• Expect feeds to reach target sooner; check that feeding protocols do not reintroduce interruptions elsewhere
• The trial was in children; do not extrapolate the result to adult intensive care

The statistics, in plain English

This is a noninferiority design, so the question is not whether stopping was better but whether it was not meaningfully worse. An adjusted odds ratio of 0.95 with an interval from 0.86 to 1.05 sits close to 1.0 and within the trial's noninferiority margin, and the per-protocol analysis agreeing with intention-to-treat matters here, because in noninferiority trials protocol deviations bias towards a false conclusion of noninferiority. The nutritional difference of 3.2 percentage points is real but small; with 4,460 children analysed, small differences become statistically detectable whether or not they change anything for a patient.

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