Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled, double-blind study. Enteral feeding tube placement success with intravenous metoclopramide administration in ICU patients. When does metoclopramide facilitate transpyloric intubation?
We examined whether metoclopramide would improve the success rate of transpyloric intubation of a weighted Corpak feeding tube when fluoroscopic guidance is not used. Seventy patients were randomized in a prospective, double-blind fashion to receive either placebo (n = 35) or metoclopramide, 10 mg (n = 35) parenterally, administered immediately after the feeding tube was inserted. Tube location was determined independently by two observers who examined radiographs obtained after barium was instilled via the tube. There was no significant increase in the success rate of duodenal intubation in the total group following metoclopramide, 60%, compared to placebo, 49%. However, analysis of subgroups among the placebo-treated patients revealed that diabetes mellitus, but not other medical conditions, decreased the success rate for duodenal intubation, 20 vs 60% (p less than 0.05). Among diabetic patients, metoclopramide resulted in a significant increase in duodenal placement compared to placebo (p less than 0.05). We conclude that parenteral metoclopramide significantly increases the frequency of transpyloric intubation with small feeding tubes without fluoroscopic guidance in diabetic patients but not in nondiabetic patients. 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.
                Prospective, randomized trial.
                One hundred five medical and surgical ICU patients at a community teaching hospital.
                Patients were randomized to receive 10 mg of metoclopramide 10 min before tube insertion or no medication.
                Successful placement was stated as radiologically verified transduodenal tube location.
                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 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.
                Intravenous metoclopramide, 10 mg, administered 10 min prior to intubation with a small-bore feeding tube (10F), was ineffective in facilitating transpyloric intubation. Postpyloric feeding probably reduces the incidence of tracheobronchial aspiration and improves feeding tolerance. However, duodenal intubation is often unsuccessful in critically ill patients due to gastric atony. Metoclopramide improves gastric emptying. In a pilot study, 12 adult patients were administered 10 to 20 mg of intravenous metoclopramide after weighted nasal feeding tubes had failed to spontaneously pass distal to the pylorus. In no patient did metoclopramide induce transpyloric passage of the tube. A randomized prospective study involving 10 adult patients was conducted to examine the effect of preinsertion intravenous metoclopramide on transpyloric intubation. All patients had failed to achieve spontaneous duodenal intubation. Five patients received 20 mg of metoclopramide 10 min prior to nasal insertion of a weighed feeding tube. Five control patients received no premedication. Four metoclopramide patients achieved duodenal intubation immediately. In none of the control patients did transpyloric intubation occur (p = 0.048). Metoclopramide, administered after nasogastric intubation, is ineffective in promoting transpyloric advancement of feeding tubes. There is a significant increase in transpyloric intubation when metoclopramide is administered prior to tube insertion.
Metoclopramide enhanced the migration of naso-enteral tubes, but the results did not reach conventional statistical significance. The reasons may include: small studies, underpowered, varying doses, etc. In clinical practice, clinicians should no longer use metoclopramide for this purpose. However, more randomised clinical trials should be performed with a significant sample size, administering metoclopramide or not. The use of metoclopramide may include adverse reactions, such as depression, high blood pressure, decrease of libido, headache, skin rash, fatigue, fever, hyperactivity, insomnia, nausea, sedation, drowsiness, agitation, extrapyramidal reactions (impaired speech or impaired swallowing, unsteady gait, inflexibility of upper and lower members, tremor).