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Enteral Feeding Tube Placement Success With Intravenous Metoclopramide Administration in ICU Patients
Enteral Feeding Tube Placement Success With Intravenous Metoclopramide Administration in ICU Patients Darell E. Heiselman, DO, FCCP; Thomas Hofer, RN, PhD; and Robin R. Vidovich, RN Objective: The purpose of this study was to determine if intravenous push metoclopramide would facilitate immediate transpyloric passage of a small-bore feeding tube without fluoroscopy or endoscopy. Design: Prospective, randomized trial. Patients: One hundred five medical and surgical ICU patients at a community teaching hospital. Interventions: Patients were randomized to receive 10 mg of metoclopramide 10 min before tube insertion or no medication. Measurement: Successful placement was stated as radiologically verified transduodenal tube location. Results: A 54% success rate was shown with administration of the drug with 46% success for the control. Chi square analysis of the success rate showed no significant
critically ill ICU patients are often in need of safe and efficient nutritional support. Enteral feeding is superior to intravenous total parenteral nutrition with regard to cost and risk of infection. Most clinicians prefer postpyloric placement of feeding tubes to gastric placement, believing that it may help avoid aspiration and that feedings may be better tolerated. However, there is a high rate of gastric atony in the critically ill patient population 1 which renders duodenal tube location problematic. Whatley et al, 2 evaluating the spontaneous duodenal passage of weighted feeding tubes , reported a 95% success rate for general ward surgical patients but only a 61 % success rate for critical care patients. Metoclopramide stimulates GI smooth muscle by antagonizing the inhibitory neurotransmitter dopamine and by augmenting acetylcholine release. 3 The medication facilitates peristalsis and gastric emptying4 and could be of additional utility in the duodenal intubation of the critically ill patient for enteral feeding . The primary purpose of this study was to determine if premedication with intravenous metoclopra*From Akron General Medical Center, Akron, Ohio (Drs. Heiselman, Hofer, and Ms. Vidovich) ; and Northeastern Ohio Universities College of Medicine. Manuscript received July 28, 1994; revision accepted November 7.
1686
relationship between administration of metoclopramide and successful tube placement (p=0.38). Increasing years of physician training was the only variable associated with successful placement (p=0.003). No association was found between successful tube placement and presence of endotracheal tube, tracheostomy, or cervical immobility, nor any interaction of metoclopramide with these variables. Conclusion: Intravenous metoclopramide, 10 mg, administered 10 min prior to intubation with a small-bore feeding tube (lOF), was ineffective in facilitatingtranspyloric intubation. (CHEST 1995; 107:1686-88) Key words: critical care medicine; enteral nutrition; gastrointestinal intubation; metoclopramide
mide, 10 mg , facilitates the transpyloric passage of a small-bore feeding tube without the use of fluoroscopic or endoscopic guidance in critically ill patients. SUBJECTS AND MATERIALS
Clinical Data A convenience sample of 105 intubations was evaluated in this study; patients were enrolled based on the following criteria: (1) admission to the critical care unit, (2) the need for enteral nutrition, and (3) an age of at least 18 years. Exclusion criteria were: (1) upper GI hemorrhage, gastric malignancy, pheochromocytoma, gastroparesis, gastric outlet obstruction, or active GI disease affecting normal upper tract anatomy or motility; (2) surgery for peptic ulcer disease, vagotomy, or surgery affecting normal upper tract anatomy or motility; (3) prescriptions for metoclopramide, MAO inhibitors, tricyclic antidepressants, sympathomimetic amines, terbutaline sulfate, norepinephrine bitartrate, isoproterenol hydrochloride, albuterol, or medications which interact with metoclopramide; and (4) known adverse reactions to metoclopramide. The majority of exclusions were made due to upper GI tract surgery or active bleeding. Informed consent by the patient or the patient's family was waived by the hospital human subjects review committee since the procedure was considered to be a standard medical practice in the ICU. Patients meeting study criteria were randomly assigned to the treatment group (n=59) or a control group (n=46). The treatment group received 10 mg of metoclopramide by slow intravenous push 10 mins prior to attempted tube placement, and the control group received no medication before attempted tube placement. Clinical Investigations in Critical Care
Data collected included factors that could adversely affect gastric intubation such as cervical fixation or presence of an endotracheal tube. Level of physician training was also noted to assess the effect of experience on successful placement. According to protocol, a prenieasured lOF, 43-inch Corpak (Corpak, Wheeling, III) feeding tube was placed in a preduodenal position, as confirmed by auscultation of the left upper quadrant. Next, the patient was placed on his right side at 90 degrees, and the Corpak was advanced another 20 em with a twisting, corkscrew motion. Tentative determination of correct position was made by auscultation of the right upper abdominal quadrant. Definitive verification of transpyloric location was ascertained by a kidney and upper bladder x-ray taken 45 min after tube advancement.
Statistical Analysis Data were analyzed using Epi Info, Version 5, (USD, Stone Mountain, Ga). Chi-square analysis was used for comparing the success rate by the dichotomous variables. Analysis of variance was used to compare the success rate by level of physician training. A power analysis showed that 57 patients per group would allow detection of a difference of 25% in success rate with an alpha error of 0.05 and a power of 0.80. RESULTS
The relationship between metoclopramide premedication and the procedure success is presented in Table 1. An 8% difference in success rate, 54% success with metaclopramide vs a 46% success rate in the control group, was ., not statistically significant (p=0.38). The 95% confidence interval of +28% to -12% with this sample size would not allow detection with certainty of a smaller difference in success rates of less than 28%. The factor of increasing years of physician training was the only variable associated with successful passage of the tube (p=0.003). There was no association between successful passage of the tube and the presence of an endotrachial tube, tracheostomy, or cervical immobility, nor any interaction of metoclopramide with these other variables. DISCUSSION
Metoclopramide aids in gastric emptying and therefore, in theory, could possibly aid the passage of nasoduodenal feeding tubes through the stomach and into the duodenum . However, metoclopramide at a dosage of 10 mg, administered 10 mins prior to the insertion of a small-bore feeding tube (10F, Corpak) showed no definite benefit in facilitating transpyloric intubation in our study. The various protocols for duodenal intubation with parenteral metoclopramide have been delineated according to times of administration of medication. The drug can be administered prior to insertion of the feeding tube or after the feeding tube already has been placed in the stomach. In the latter protocol, which specifies postinsertion medication, Whatley et al,5 in a pilot study, had no successful Entriflex tube (Biosearch Medical Products; Somerville, NJ) pass-
Table 1-Success Rate of Transpyloric Tube Placement
for Intravenous Metoclopramide Premedicated Group and Control Group
Metoclopramide
Success
Failure
Total
Yes
32 (54%) 21 (46%)
27 (46%) 25 (54%)
59 (100%) 46 (100%)
No
ings with a group of 12 general surgical and surgical critical care patients. Kittinger et al 6 administered the medication intramuscularly after Corpak tube insertion into the stomach and had no significant increase in successes for a noncritical patient sample of 35; however, one exception in that study was a significant increase in successful placements in the subset of patients with diabetes mellitus. 6 Thus, these findings seem to indicate that time of administration is not a crucial variable in facilitating successful transpyloric intubation. The preinsertion medication protocol was followed in another small sample study by Whatley et al,5 which examined predominantly ICU patients receiving 20 mg of metoclopramide prior to feeding tube intubation. These researchers showed a statistically significant rate (p=0.048) of duodenal intubation with metoclopramide premedicated patients (n=5) but not control subjects (n=5). They suggested that pharmacologically induced gastric peristalsis, operationalized before enteral tube insertion, greatly facilitates duodenal intubation in ICU patients. However, this positive association with metoclopramide and successful transpyloric intubation may be erroneous due to the limited size of the sample population. Another possibility for the contrasting results of our study and the Whatley et al5 study may be the metoclopramide dosage. We examined the standard dose of 10 mg, feeling that an increase in dosage to 20 mg intravenously would run the risk of increased incidence of side effects. Potential adverse effects include drowsiness, anxiety, agitation, and urticaria, and although rare, extrapyramidal effects can also occur. 3 Nevertheless, it could be argued that doubling the dose accounts for an increased rate of postpyloric feeding tube placement. This hypothesis, however, does not concur with a recent trial completed by Lord et al/ which compared the standard 10-mg dose (n=25) to a 20-mg dose (n=50) and found that there was no statistically significant difference in successful tube placement between the two groups. Small-bore weighted nasoduodenal feeding tubes appear to be effective in providing nutrition to the critically ill, especially those with gastric atony. Although the patient with gastric atony may better tolerate tube feedings with the tube advanced into the duodenum, there has been recent evidence that CHEST /107 161 JUNE, 1995
1687
postpyloric placement offers no significant protection from aspiration in enterally fed patients.8 Developing safe, cost-effective methods of placing duodenal feeding tubes without the need for fluoroscopy or endoscopy in this subgroup remains an important goal. Unfortunately, we were unable to demonstrate a significant benefit of intravenous metoclopramide in facilitating the duodenal placement of feeding tubes; therefore, we feel its use is neither cost-effective nor justified in terms of potential side effects. ACKNOWLEDGMENT: Many thanks to the Office of Biostatistics and the Department of Internal Medicine at Northeastern Ohio University College of Medicine for their assistance with statistical analysis and to all of the intensive care medical and nursing staff at Akron General Medical Center for making this research project a success. R EFERENCES
1 Silen W, Skillen J. Gastrointestinal response to injury and infection. Surg Clin North Am 1976; 56:945-52
1688
2 Whatley K, Turner W, Dey M, et al. Transpyloric passage of feed ing tubes. Nutritional Support Services 1983; 3:18-21 3 Albibi R, McCallum RW. Metoclopramide: pharmacology and clinical application. Ann Intern Med 1983; 98:86-95 4 Margieson GR, Sorby WA, Williams HB. The action of 'metoclopramide' on gastric emptying: a radiologic assessment. Med J Aust 1966; 2:1272-74 5 Whatley K, Turner WW, Dey M, e t al. When does metoclopramide facilitate transpyloric intubation? J Parenter Enteral Nutr 1984; 6:679-81 6 Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled, double-blind study. J Parenter Enteral Nutr 1987; 11:33-7 7 Lord LM , Weiser-Maimone A, Pulhamus M, et al. Comparison of weighted vs. unweighted enteral feeding tubes for efficacy of transpyloric intubation. J Parenter Enteral Nutr 1993; 17:271-73 8 Strong RM, Condon SC, Solinger MR, et al. Equal aspiration rates from postpyloris and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. J Parenter Enteral Nutr 1992; 16:59-63
Clinical Investigations in Critical Care
critically ill ICU patients are often in need of safe and efficient nutritional support. Enteral feeding is superior to intravenous total parenteral nutrition with regard to cost and risk of infection. Most clinicians prefer postpyloric placement of feeding tubes to gastric placement, believing that it may help avoid aspiration and that feedings may be better tolerated. However, there is a high rate of gastric atony in the critically ill patient population 1 which renders duodenal tube location problematic. Whatley et al, 2 evaluating the spontaneous duodenal passage of weighted feeding tubes , reported a 95% success rate for general ward surgical patients but only a 61 % success rate for critical care patients. Metoclopramide stimulates GI smooth muscle by antagonizing the inhibitory neurotransmitter dopamine and by augmenting acetylcholine release. 3 The medication facilitates peristalsis and gastric emptying4 and could be of additional utility in the duodenal intubation of the critically ill patient for enteral feeding . The primary purpose of this study was to determine if premedication with intravenous metoclopra*From Akron General Medical Center, Akron, Ohio (Drs. Heiselman, Hofer, and Ms. Vidovich) ; and Northeastern Ohio Universities College of Medicine. Manuscript received July 28, 1994; revision accepted November 7.
1686
relationship between administration of metoclopramide and successful tube placement (p=0.38). Increasing years of physician training was the only variable associated with successful placement (p=0.003). No association was found between successful tube placement and presence of endotracheal tube, tracheostomy, or cervical immobility, nor any interaction of metoclopramide with these variables. Conclusion: Intravenous metoclopramide, 10 mg, administered 10 min prior to intubation with a small-bore feeding tube (lOF), was ineffective in facilitatingtranspyloric intubation. (CHEST 1995; 107:1686-88) Key words: critical care medicine; enteral nutrition; gastrointestinal intubation; metoclopramide
mide, 10 mg , facilitates the transpyloric passage of a small-bore feeding tube without the use of fluoroscopic or endoscopic guidance in critically ill patients. SUBJECTS AND MATERIALS
Clinical Data A convenience sample of 105 intubations was evaluated in this study; patients were enrolled based on the following criteria: (1) admission to the critical care unit, (2) the need for enteral nutrition, and (3) an age of at least 18 years. Exclusion criteria were: (1) upper GI hemorrhage, gastric malignancy, pheochromocytoma, gastroparesis, gastric outlet obstruction, or active GI disease affecting normal upper tract anatomy or motility; (2) surgery for peptic ulcer disease, vagotomy, or surgery affecting normal upper tract anatomy or motility; (3) prescriptions for metoclopramide, MAO inhibitors, tricyclic antidepressants, sympathomimetic amines, terbutaline sulfate, norepinephrine bitartrate, isoproterenol hydrochloride, albuterol, or medications which interact with metoclopramide; and (4) known adverse reactions to metoclopramide. The majority of exclusions were made due to upper GI tract surgery or active bleeding. Informed consent by the patient or the patient's family was waived by the hospital human subjects review committee since the procedure was considered to be a standard medical practice in the ICU. Patients meeting study criteria were randomly assigned to the treatment group (n=59) or a control group (n=46). The treatment group received 10 mg of metoclopramide by slow intravenous push 10 mins prior to attempted tube placement, and the control group received no medication before attempted tube placement. Clinical Investigations in Critical Care
Data collected included factors that could adversely affect gastric intubation such as cervical fixation or presence of an endotracheal tube. Level of physician training was also noted to assess the effect of experience on successful placement. According to protocol, a prenieasured lOF, 43-inch Corpak (Corpak, Wheeling, III) feeding tube was placed in a preduodenal position, as confirmed by auscultation of the left upper quadrant. Next, the patient was placed on his right side at 90 degrees, and the Corpak was advanced another 20 em with a twisting, corkscrew motion. Tentative determination of correct position was made by auscultation of the right upper abdominal quadrant. Definitive verification of transpyloric location was ascertained by a kidney and upper bladder x-ray taken 45 min after tube advancement.
Statistical Analysis Data were analyzed using Epi Info, Version 5, (USD, Stone Mountain, Ga). Chi-square analysis was used for comparing the success rate by the dichotomous variables. Analysis of variance was used to compare the success rate by level of physician training. A power analysis showed that 57 patients per group would allow detection of a difference of 25% in success rate with an alpha error of 0.05 and a power of 0.80. RESULTS
The relationship between metoclopramide premedication and the procedure success is presented in Table 1. An 8% difference in success rate, 54% success with metaclopramide vs a 46% success rate in the control group, was ., not statistically significant (p=0.38). The 95% confidence interval of +28% to -12% with this sample size would not allow detection with certainty of a smaller difference in success rates of less than 28%. The factor of increasing years of physician training was the only variable associated with successful passage of the tube (p=0.003). There was no association between successful passage of the tube and the presence of an endotrachial tube, tracheostomy, or cervical immobility, nor any interaction of metoclopramide with these other variables. DISCUSSION
Metoclopramide aids in gastric emptying and therefore, in theory, could possibly aid the passage of nasoduodenal feeding tubes through the stomach and into the duodenum . However, metoclopramide at a dosage of 10 mg, administered 10 mins prior to the insertion of a small-bore feeding tube (10F, Corpak) showed no definite benefit in facilitating transpyloric intubation in our study. The various protocols for duodenal intubation with parenteral metoclopramide have been delineated according to times of administration of medication. The drug can be administered prior to insertion of the feeding tube or after the feeding tube already has been placed in the stomach. In the latter protocol, which specifies postinsertion medication, Whatley et al,5 in a pilot study, had no successful Entriflex tube (Biosearch Medical Products; Somerville, NJ) pass-
Table 1-Success Rate of Transpyloric Tube Placement
for Intravenous Metoclopramide Premedicated Group and Control Group
Metoclopramide
Success
Failure
Total
Yes
32 (54%) 21 (46%)
27 (46%) 25 (54%)
59 (100%) 46 (100%)
No
ings with a group of 12 general surgical and surgical critical care patients. Kittinger et al 6 administered the medication intramuscularly after Corpak tube insertion into the stomach and had no significant increase in successes for a noncritical patient sample of 35; however, one exception in that study was a significant increase in successful placements in the subset of patients with diabetes mellitus. 6 Thus, these findings seem to indicate that time of administration is not a crucial variable in facilitating successful transpyloric intubation. The preinsertion medication protocol was followed in another small sample study by Whatley et al,5 which examined predominantly ICU patients receiving 20 mg of metoclopramide prior to feeding tube intubation. These researchers showed a statistically significant rate (p=0.048) of duodenal intubation with metoclopramide premedicated patients (n=5) but not control subjects (n=5). They suggested that pharmacologically induced gastric peristalsis, operationalized before enteral tube insertion, greatly facilitates duodenal intubation in ICU patients. However, this positive association with metoclopramide and successful transpyloric intubation may be erroneous due to the limited size of the sample population. Another possibility for the contrasting results of our study and the Whatley et al5 study may be the metoclopramide dosage. We examined the standard dose of 10 mg, feeling that an increase in dosage to 20 mg intravenously would run the risk of increased incidence of side effects. Potential adverse effects include drowsiness, anxiety, agitation, and urticaria, and although rare, extrapyramidal effects can also occur. 3 Nevertheless, it could be argued that doubling the dose accounts for an increased rate of postpyloric feeding tube placement. This hypothesis, however, does not concur with a recent trial completed by Lord et al/ which compared the standard 10-mg dose (n=25) to a 20-mg dose (n=50) and found that there was no statistically significant difference in successful tube placement between the two groups. Small-bore weighted nasoduodenal feeding tubes appear to be effective in providing nutrition to the critically ill, especially those with gastric atony. Although the patient with gastric atony may better tolerate tube feedings with the tube advanced into the duodenum, there has been recent evidence that CHEST /107 161 JUNE, 1995
1687
postpyloric placement offers no significant protection from aspiration in enterally fed patients.8 Developing safe, cost-effective methods of placing duodenal feeding tubes without the need for fluoroscopy or endoscopy in this subgroup remains an important goal. Unfortunately, we were unable to demonstrate a significant benefit of intravenous metoclopramide in facilitating the duodenal placement of feeding tubes; therefore, we feel its use is neither cost-effective nor justified in terms of potential side effects. ACKNOWLEDGMENT: Many thanks to the Office of Biostatistics and the Department of Internal Medicine at Northeastern Ohio University College of Medicine for their assistance with statistical analysis and to all of the intensive care medical and nursing staff at Akron General Medical Center for making this research project a success. R EFERENCES
1 Silen W, Skillen J. Gastrointestinal response to injury and infection. Surg Clin North Am 1976; 56:945-52
1688
2 Whatley K, Turner W, Dey M, et al. Transpyloric passage of feed ing tubes. Nutritional Support Services 1983; 3:18-21 3 Albibi R, McCallum RW. Metoclopramide: pharmacology and clinical application. Ann Intern Med 1983; 98:86-95 4 Margieson GR, Sorby WA, Williams HB. The action of 'metoclopramide' on gastric emptying: a radiologic assessment. Med J Aust 1966; 2:1272-74 5 Whatley K, Turner WW, Dey M, e t al. When does metoclopramide facilitate transpyloric intubation? J Parenter Enteral Nutr 1984; 6:679-81 6 Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled, double-blind study. J Parenter Enteral Nutr 1987; 11:33-7 7 Lord LM , Weiser-Maimone A, Pulhamus M, et al. Comparison of weighted vs. unweighted enteral feeding tubes for efficacy of transpyloric intubation. J Parenter Enteral Nutr 1993; 17:271-73 8 Strong RM, Condon SC, Solinger MR, et al. Equal aspiration rates from postpyloris and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. J Parenter Enteral Nutr 1992; 16:59-63
Clinical Investigations in Critical Care