Metoclopramide for post‐pyloric placement of naso‐enteral feeding tubes
Abstract
Background
Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalised patients who have adequate gastrointestinal function but who are unable to eat. Gastric feeding may be associated with higher rates of food aspiration and pneumonia than post‐pyloric naso‐enteral tubes. Thus, enteral feeding tubes are placed directly into the small intestine rather than the stomach, and the use of metoclopramide, a prokinetic agent, has been recommended to achieve post‐pyloric placement, but its efficacy is controversial. Moreover, metoclopramide may include adverse reactions, which with high doses or prolonged use may be serious and irreversible.
Objectives
To determine the effect of intravenous metoclopramide on post‐pyloric placement of the naso‐enteral tube in adults.
Search methods
Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10) which includes the CUGPD group's specialised register of trials, MEDLINE (1996 to 21 October 2014), EMBASE (1988 to 21 October 2014), LILACS (2005 to 21 October 2014) We did not confine our search to English language publications. Searches in all databases were updated originally in January 2005, then in November 2008 and again in October 2014. No new studies were found in 2008 or in 2014.
Selection criteria
We selected randomised controlled trials of adults needing enteral nutrition, who received intravenous or intramuscular metoclopramide to aid placement of transpyloric naso‐enteral feeding tubes, compared to placebo or no intervention.
Data collection and analysis
We used standard methodological procedures expected by The Cochrane Collaboration. All analyses were performed according to the intention‐to‐treat method. We present risk ratios (RR) with 95% confidence intervals (CI).
Main results
Four studies, with a total of 204 participants were included and analysed. The trials compared metoclopramide with placebo (two trials) or with no intervention (two trials). Metoclopramide was investigated at doses of 10 mg (two trials) and 20 mg (two trials). There was no statistically significant difference between metoclopramide versus placebo or no intervention administered to promote tube placement (RR 0.82, 95% CI 0.61 to 1.10). Metoclopramide at doses of 10 mg (RR 0.82, 95% CI 0.60 to 1.11) and 20 mg (RR 0.62, 95% CI 0.15 to 2.62) were equally ineffective in facilitating post‐pyloric intubation when compared with placebo or no intervention.
Authors' conclusions
In this review, we found only four studies that fitted our inclusion criteria. These were small, underpowered studies, in which metoclopramide was given at doses of 10 mg and 20 mg. Our analysis showed that metoclopramide did not assist post‐pyloric placement of naso‐enteral feeding tubes.
Ideally randomised clinical trials should be performed that have a significant sample size, administering metoclopramide against control, however, given the lack of efficacy revealed by this review it is unlikely that further studies will be performed.
PICOs
Plain language summary
Metoclopramide for accurate placement of naso‐enteral feeding tube
Background
When a person is unwell and is unable to eat (or to eat enough), the lack of nutrition can be a serious obstacle to recovery. In these circumstances, feeding through a feeding tube that enters through the nose and passes through the stomach to the small intestine beyond (a post‐pyloric naso‐enteral feeding tube), is an option.
Review question
Once the feeding tube has entered the digestive system, placing the feeding tube into the small intestine rather than the stomach is difficult. Metoclopramide (which is also an anti‐sickness medication), increases the rate at which the stomach empties, and has tested as a therapy to determine whether it assists with placement of post‐pyloric naso‐enteral feeding tubes.
Use of metoclopramide is controversial, as it may cause harms (adverse reactions), which may be serious and may include an irreversible neurological condition that can be caused by prolonged use, or high doses of metoclopramide.
Study characteristics
We originally searched for clinical trials in 2002; and again in 2008 and 2014. We identified four studies that investigated the use of metoclopramide in placement of post‐pyloric naso‐enteral feeding tubes. The trials included a total of 204 adult participants; 108 participants were treated with metoclopramide, and 96 were given a placebo or no treatment. All four studies were done in hospitals in the USA. The number of participants included in the trials varied from 105 to 10.
The trials were all performed before 1995. They were all small, and examined two different doses of metoclopramide (10 mg and 20 mg), delivered in two different ways (intravenously, and injected into muscle). The way in which they were conducted and reported was poor.
Key results
Analysis of the four trials revealed that metoclopramide did not have a clear beneficial on the placement of post‐pyloric naso‐enteral feeding tubes. No harms (adverse reactions) were reported, though it was not clear how thoroughly the people running the trials recorded them. No costs of treatment were reported.
Quality of the evidence
The quality of the evidence is very low. The four trials were too small to identify any effect clearly; they also used different doses of metoclopramide, (tested against placebo or no treatment). It is unlikely that further studies will be performed to establish whether metoclopramide is helpful in placement of post‐pyloric naso‐enteral feeding tubes.
Authors' conclusions
Summary of findings
| Metoclopramide for post‐pyloric placement of enteral feeding tubes | ||||||
| Patient or population: patients needing post‐pyloric placement of naso‐enteral feeding tubes | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Metoclopramide | |||||
| Failure rate of post‐pyloric placement of the enteral feeding tube assessed by abdominal radiograph | Study population | RR 0.82 | 204 | ⊕⊝⊝⊝ | ||
| 562 per 1000 | 461 per 1000 | |||||
| Moderate | ||||||
| 572 per 1000 | 469 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 Design limitation (risk of bias) | ||||||
Background
Description of the condition
Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalised patients who have adequate gastrointestinal function but who are unable to eat. Post‐pyloric naso‐enteral feeding tubes, that enter through the nasal passages and deliver food directly to the duodenum or jejunum, have lower incidence of complications compared to naso‐gastric tubes ‐ which deliver food to the stomach ‐ because of their lower rate of gastroesophageal reflux, regurgitation, excessive salivation and irritation of the mucosas. This can be uncomfortable for the patient and also increases the risk of aspiration of food, which can lead to pneumonia. Post‐pyloric feeding tube (catheter) placement is not straightforward, but is easier when using manoeuvres such as putting patients in the right‐sided lateral position or stimulating them to walk. A stimulating gastric motility drug such as metoclopramide has been used as an auxiliary therapy to promote tube placement. Metoclopramide could also be applied in cases where the tube has successfully entered the digestive system through the throat and into the oesophagus (gullet) and stomach but migration of the tube through the pyloric sphincter (between the stomach and duodenum) is delayed (Troncon 2000).
Description of the intervention
Metoclopramide is a gastrointestinal stimulant and anti‐sickness (antiemetic) drug, which increases the gastric emptiness (Sumner 1986). Metoclopramide has a local stimulating effect on gastric motility and causes the acceleration of gastric emptiness without any concomitant secretion of gastric acid. It is useful for treating gastroesophageal reflux and in disorders of gastric emptiness, but not in the paralytic ileum (Rang 1997).
One study has demonstrated that metoclopramide is useful in post‐pyloric feeding tube placement in diabetic patients, increasing the frequency of successful post‐pyloric intubation in these patients, but not in non‐diabetic patients (Kittinger 1987). In another small study comparing placebo, metoclopramide treatment after tube placement, and metoclopramide treatment before tube placement, duodenal intubation occurred in 90% of patients who received metoclopramide before feeding tube introduction (Kalfarentzos 1987). Metoclopramide is not effective when administered after tube introduction (Whatley 1984). Additionally, metoclopramide may be associated with adverse events, for example, Heiselman 1995 indicated that restlessness, drowsiness, agitation, rashes (urticaria) and occasional drug‐induced movement disorders (extrapyramidal reactions) may occur when using metoclopramide at a dose of 20 mg.
Why it is important to do this review
As there is no systematic review evaluating the effectiveness of parenteral metoclopramide, we will try to answer the following question: is metoclopramide effective and safe for the post‐pyloric placement of naso‐enteral feeding tubes?
Objectives
To determine the effect of intravenous metoclopramide on post‐pyloric placement of the naso‐enteral tube in adults.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) comparing metoclopramide with placebo or no intervention for the placement of naso‐enteral tubes. RCTs were included irrespective of publication status, language or blinding.
Types of participants
Participants were all adults (over 18 years of age) receiving parenteral metoclopramide for introduction of enteral feeding tube.
Types of interventions
Metoclopramide against placebo or no intervention.
Types of outcome measures
Primary outcomes
-
Success rate of post‐pyloric placement of the naso‐enteral feeding tube.
Secondary outcomes
Adverse reactions including:
-
depression;
-
high blood pressure;
-
decrease of libido;
-
headache;
-
skin rash;
-
fatigue;
-
fever;
-
hyperactivity;
-
insomnia;
-
nausea;
-
sedation;
-
tremor and agitation in the hand;
-
dyslalia (speech difficulties);
-
dysphagia (swallowing problems).
Search methods for identification of studies
Electronic searches
Trials were identified by searching:
-
Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10; Appendix 1), which includes the CUGPD group's specialised register of trials;
-
MEDLINE (1996 to 21 October 2014; Appendix 2);
-
EMBASE (1988 to 21 October 2014; Appendix 3);
-
LILACS (2005 to 21 October 2014; Appendix 4).
We did not confine our search to English language publications. Searches in all databases were updated in January 2005 and updated again in November 2008 and October 2014. No new studies were found by the searches in 2008, or in October 2014.
Searching other resources
We handsearched reference lists from trials selected by electronic searches to identify further relevant trials.
In addition, we contacted members of the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) review Group, experts in the field, editors of relevant journals and pharmaceutical companies involved in the production of metoclopramide to ask them to supply details of any outstanding clinical trials and relevant unpublished materials.
Data collection and analysis
Selection of studies
Two reviewers (CCRS and HS) applied the inclusion criteria to all potential randomised studies. For this updated review CB and CCRS reviewed the results of the updated searches and applied the inclusion criteria to all potential randomised studies.
Review authors were not blinded to the reporting of authors' names, journals, date of publication, sources of financial support or results.
Data extraction and management
Two reviewers (CCRS, HS with CB) independently extracted the following pre‐specified characteristics of all included RCTs. In case of discrepancy, the opinion of a fourth reviewer was sought in order to reach a consensus. We extracted data on the: methods, including diagnostic procedure, baseline evaluation of the adequate primary outcomes, and reliability of the outcome measures, complete follow‐up; the participants, including age, indication for naso‐enteral intubation, number of randomised patients; the intervention dosage, co‐intervention in the control group, and route and timing of administration; and outcomes, that is success rate of post‐pyloric placement into the duodenum and adverse reactions.
Assessment of risk of bias in included studies
In this updated review, we independently assessed the risk of bias of the included studies using the risk of bias assessment tool described in Chapter 8 of theCochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We compared the evaluations, and discussed and resolved any inconsistencies between the review authors' decisions.
We rated the following domains separately for each of the included studies as 'low risk of bias', 'high risk of bias', and 'unclear' when the risk of bias was uncertain or unknown:
-
generation of allocation sequence ('sequence generation');
-
concealment of allocation ('allocation concealment');
-
prevention of knowledge of the allocated interventions during the study ('blinding');
-
methods used to address incomplete outcome data;
-
selective outcome reporting;
-
other sources of bias that could put a study at high risk of bias, including whether a calculation of sample size was carried out.
These assessments are reported in the 'Risk of bias' table for each individual study in the 'Characteristics of included studies' section of the review, and in the 'Risk of bias in included studies' section of this review.
Measures of treatment effect
We presented dichotomous outcomes data as risk ratios (RR) with their associated 95% confidence intervals; these were analysed in Review Manager 5.3 using the Mantel‐Haenszel test and a random‐effects model (RevMan 2014), unless stated otherwise.
Unit of analysis issues
We did not expect any cross‐over trials, as it is unlikely that the participants would be crossed‐over to receive an alternative intervention.
If we encountered a multi‐armed study, we planned to use data only from the metoclopramide arm versus placebo.
Dealing with missing data
We attempted to contact investigators to retrieve missing data. We analysed all data by the intention‐to‐treat method.
Assessment of heterogeneity
We assessed clinical heterogeneity by examining the trial conditions, that is, the characteristics of the studies, the similarity between the types of participants, and the interventions.
Statistical heterogeneity was assessed both by calculation of standard Chi2 test and defined as significant when the P value was less than 0.1. When we found heterogeneity we explored the potential causes.
Assessment of reporting biases
We planned to carry out assessments of reporting bias when at least ten studies were included in a meta‐analysis, following the recommendations on testing for funnel plot asymmetry as described in section 10.4.3.1 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We planned to explore possible sources of asymmetry with an additional sensitivity analysis, but in this review we did not have enough included studies to make such analyses feasible.
Data synthesis
All analyses were performed according to the intention‐to‐treat method.
We used Review Manager (RevMan 2014), which is the software package provided by Cochrane Collaboration. For dichotomous variables, risk ratio was calculated by random‐effects model (DerSimonian 1986). If the overall results had been statistically significant, we planned to calculate the relative risk reduction (RRR), the number needed to treat for an additional beneficial outcome (NNTB) and the number needed to treat for an additional harmful outcome (NNTH).
Subgroup analysis and investigation of heterogeneity
We explored statistical heterogeneity differences in reported effects, methodological heterogeneity, differences in study design and clinical heterogeneity differences between studies in participants characteristics, interventions or outcome measures (Higgins 2011).
We made a post hoc decision to conduct subgroup analyses on the basis of metoclopramide dosage.
Sensitivity analysis
There were too few included studies in this review to permit sensitivity analysis.
Results
Description of studies
Results of the search
Nineteen potential studies were identified by electronic and manual searches up to October 2014. A further 58 potential studies were identified from electronic searches in 2014, but no new trials were identified for inclusion at this update (Figure 1).
Study flow diagram.
Included studies
We found four RCTs enrolling a total of 204 participants (Heiselman 1995; Kittinger 1987; Seifert 1987; Whatley 1984; Characteristics of included studies). Of the 204 participants, 108 were treated with metoclopramide, and 96 received placebo or no treatment. Participants designated to undergo treatment with metoclopramide were compared with those allocated to receive placebo or no treatment.
Participants
The studies included only adult participants. All four included studies were carried out in a secondary care environment, and all were conducted in the USA. Sample sizes varied from 105 in Heiselman 1995, to 70 in Kittinger 1987, 19 in Seifert 1987, and 10 in Whatley 1984.
The Heiselman 1995 study included patients in the critical care unit who required enteral nutrition. In Kittinger 1987 all the participants required feeding tube placement, but pregnant in‐patients and intensive care patients were excluded. In Seifert 1987 all patients requiring additional nutrition were eligible for the trial, except for pregnant in‐patients and patients currently receiving metoclopramide or neuroleptic patients. The Whatley 1984 study included patients that had previously had failed duodenal intubation. We also collected data on whether diabetic patients were included; Kittinger 1987 included diabetic patients, but this information was not provided in Heiselman 1995, Seifert 1987 or Whatley 1984.
Intervention
Metoclopramide was given intravenously in three studies (Heiselman 1995; Seifert 1987; Whatley 1984). In one study metoclopramide was given intramuscularly (Kittinger 1987). Two studies compared metoclopramide with placebo (Kittinger 1987; Seifert 1987), while in the other two studies the control group did not receive any intervention (Heiselman 1995; Whatley 1984).
Comparison
Metoclopramide versus placebo (Kittinger 1987; Seifert 1987), or no intervention (Heiselman 1995; Whatley 1984).
Outcomes
All studies analysed whether metoclopramide improved the success rate of post‐pyloric feeding tube placement. This was identified by ausculation and abdominal radiography in Heiselman 1995, and by abdominal radiography alone in Kittinger 1987, Seifert 1987 and Whatley 1984. Success rate of transport of pyloric tube placement was evaluated 45 minutes after placement in Heiselman 1995; four hours after insertion of the feeding tube in Seifert 1987 and Whatley 1984; and with an additional abdominal radiograph 24 hours later in some patients who received metoclopramide after feeding tube insertion. In Kittinger 1987, the success rate was evaluated by abdominal radiography one hour after insertion of the feeding tube.
Excluded studies
Fifteen studies did not fit the inclusion criteria and were not included in this systematic review (see Characteristics of excluded studies).
Risk of bias in included studies
The risk of bias of included studies is summarised in Figure 2 and Figure 3.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Allocation
Allocation concealment
There were no descriptions of allocation concealment in the included studies.
Generation of allocation sequence
Two studies used a random number table to generate the allocation sequence (Kittinger 1987; Whatley 1984). Heiselman 1995 and Seifert 1987 did not describe the allocation method used, they simply indicated that the studies were randomised.
Blinding
Two studies were described as double‐blind (Seifert 1987; Kittinger 1987), however full details of how this was achieved were not given in the published report of the Kittinger 1987 study. It is therefore unclear whether participants, personnel and outcome assessors were adequately blinded. In Seifert 1987, the participants, nurses investigators and radiologists were blinded to the treatment protocol. In the remaining two studies there was no description of double‐blind methods and we rated these as being at high risk of bias for this domain.
Placebo description
Two studies reported a placebo of identical appearance (Kittinger 1987, Seifert 1987).
Incomplete outcome data
Three studies did not have withdrawals or dropouts. One study had withdrawal and reasons of withdrawal were described, but the analysis was not performed on an intention‐to‐treat basis (Seifert 1987).
Selective reporting
We rated all studies as being at low risk for selective reporting, as outcomes were reported, however we did not have access to the original trial protocols and we were therefore unable to assess whether there were any unpublished outcomes.
Other potential sources of bias
Sample size calculation
Only one study reported sample size calculation (Heiselman 1995).
Effects of interventions
Metoclopramide versus control (placebo or no intervention)
Failure rate of post‐pyloric placement of enteral feeding tube
In an analysis comparing metoclopramide 10 mg with control (Heiselman 1995; Kittinger 1987), failure of post‐pyloric tube placement of the enteral feeding tube was observed in 41 out of 94 participants (43.7%) using metoclopramide compared with 43 out of 81 (53%) in the control groups. There was no statistically significant difference between the groups (RR 0.82, 95% CI 0.60 to 1.11; 175 participants; 2 studies; Analysis 1.1). In this comparison there was no statistically significant heterogeneity (Chi2 = 0.06, degrees of freedom (df) = 1, P value 0.81).
In an analysis of studies that used metoclopramide 20 mg versus control (Seifert 1987; Whatley 1984), failure of post‐pyloric tube placement was observed in 7 out of 14 participants in the metoclopramide group (50%) compared with 11 out of 15 in the control group (73%); this difference was not statistically significant (RR 0.62, 95% CI 0.15 to 2.62; 29 participants; 2 studies; Analysis 1.1). Heterogeneity was observed in this comparison (Chi2 = 3.48, df = 1, P value 0.06).
When we pooled all four trials independent of dosage, the failure rate was 44% (48/108) in the metoclopramide group compared with 56% (54/96) in the control group (RR 0.82, 95% CI 0.61 to 1.10; 204 participants; 4 studies; Analysis 1.1). In this comparison there was no statistically significant heterogeneity (Chi2 = 3.24, df = 3, P value 0.36).
Sensitivity analysis
As there were only four studies with a total of 204 participants, we did not perform sensitivity analysis or investigate publication bias using a funnel plot.
Adverse effects
Seifert 1987 reported that no adverse effects attributable to either metoclopramide or placebo were observed. Kittinger 1987 did not report any adverse effects. Whatley 1984 reported that there were no 'side effects' of metoclopramide noted in any participants. Heiselman 1995 noted that adverse effects could include drowsiness, anxiety, agitation and urticaria, and rarely extrapyramidal effects, but did not report adverse effects directly attributable to metoclopramide administered in the course of that study.
Discussion
Summary of main results
Whatley 1984 showed that metoclopramide improves gastric emptying by increasing the amplitude of gastric contractions while relaxing the pyloric sphincter and the duodenal bulb and recorded a significant increase in post‐pyloric intubation when metoclopramide was administered prior to the tube insertion. Although that study showed significant results, in our systematic review of four studies, we observed that metoclopramide was not effective in improving the success rate for post‐pyloric migration of the enteral tube.
Overall completeness and applicability of evidence
The four studies included in this systematic review demonstrate that metoclopramide, as administered, did not facilitate post‐pyloric intubation in adults. However, the RCTs included had small sample sizes, therefore, we cannot rule out a beneficial effect of metoclopramide. Just one RCT reported that metoclopramide was effective (Whatley 1984). Subgroup analysis in the Kittinger 1987 study, demonstrated that metoclopramide was effective only for people with diabetes mellitus and with evident neuropathy. The other two studies did not find any beneficial effect of metoclopramide (Heiselman 1995; Seifert 1987).
Statistical heterogeneity was found in the comparison of metoclopramide at a dosage of 20 mg. This may be explained by clinical heterogeneity between the studies. The failure rates between the two studies were very different. In the Seifert 1987 study there was a very similar rate between metoclopramide and placebo, whereas in the Whatley 1984 study, the failure rate was lower in the metoclopramide group, at 20%, compared with 100% of those receiving placebo. Other potential sources of heterogeneity were the poor methodological quality of the studies; use of placebo and double‐blinding in one study (Seifert 1987); and no intervention and no blinding for the control group in the other study (Whatley 1984).
None of our included studies provided detailed information about adverse effects. Only one study (Heiselman 1995) noted the types of adverse effects that can occur due to metoclopramide but did not report adverse effects directly attributable to metoclopramide administered in the course of that study.
People who are given metoclopramide, especially at doses of 20 mg, may experience adverse reactions which may include depression, high blood pressure, decrease of libido, headache, skin rash, fatigue, fever, hyperactivity, insomnia, nausea, sedation, drowsiness, agitation, and extrapyramidal reactions (impaired speech or impaired swallowing, unsteady gait, inflexibility of upper and lower members, tremor). A recent publication also warns of the risk of developing tardive dyskinesia, or involuntary and repetitive movements of the body, with long‐term or high‐dose use of metoclopramide (EMA 2013; FDA 2009).
Quality of the evidence
Potential sources of bias in studies analysing the effect of metoclopramide at the dosage 10 mg for post‐pyloric migration of the enteral tube are the timing and methods to evaluate the outcomes; differences in the positioning of patients during the passage of the tube; and ability and experience of the nurse or physician, since training is a factor associated with the successful passage of the naso‐enteral tube (Heiselman 1995). Since there were no differences between these studies in relation to timing, administration and dosage of metoclopramide, these explanations do not seem to justify the heterogeneity observed in these comparisons.
We should, therefore, emphasise that any conclusions we have drawn rely on only four primary studies that had a varying degree of bias due to limitations in trial design. The risk of bias should be considered when interpreting these results (Figure 2), and, given that the findings derive from studies with a high or unclear risk of bias, the findings reported in each study should be viewed with caution.
Overall, the quality of evidence in each comparison was rated as very low and the current body of evidence does not allow robust conclusions to be drawn concerning the efficacy of metoclopramide in assisting post pyloric placement of enteral feeding tubes.
Potential biases in the review process
We attempted to minimise publication bias by conducting exhaustive searches for trials, however only four studies fitted our inclusion criteria. These were published between 1984 and 1995, with none published since, so we were able to conduct only one meta‐analysis. Sensitivity analysis was not possible for primary outcome measures for studies at low risk of bias, as there were too few such studies to permit us to assess the results of the review in this way.
Agreements and disagreements with other studies or reviews
Whatley 1984 reported that metoclopramide treatment before tube placement was superior to no drug in a small study, however, in the analysis that we carried out using data from four randomised controlled trials including Whatley 1984, in this review, we concluded that metoclopramide was not effective in facilitating post‐pyloric placement of naso‐enteral feeding tubes.
A network meta‐analysis of RCTs of methods to promote placement of post‐pyloric feeding tubes, including prokinetic agents (metoclopramide and erythromycin) and gastric air insufflation, was published recently (Huang 2014). The findings of that analysis were broadly in agreement with our study, in that the authors concluded that none of the methods reached statistical significance and that the use of a prokinetic agent might induce more potential adverse reactions. The authors of Huang 2014 recommended that clinicians in clinical practice should no longer use prokinetic agents for this purpose in either paediatric patients or in patients without impaired gastric motility. They also stated that gastric insufflation seems to be clinically better for promoting bedside placement of post‐pyloric feeding tubes in adults but in their analysis the results for gastric insufflation did not reach statistical significance compared with other methods, and there are additional safety concerns with this method. It may in fact be that no technique is superior to the standard technique which is bedside placement performed blindly. The authors of Huang 2014 concluded that more large, well‐designed RCTs focusing on special populations were required to determine if there are methods that work better than endoscopic placement.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Comparison 1 Metoclopramide versus placebo or no intervention for post‐pyloric placement of enteral feeding tubes, Outcome 1 Failure rate of transpyloric placement of the enteral feeding tube assessed by abdominal radiograph.
| Metoclopramide for post‐pyloric placement of enteral feeding tubes | ||||||
| Patient or population: patients needing post‐pyloric placement of naso‐enteral feeding tubes | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Metoclopramide | |||||
| Failure rate of post‐pyloric placement of the enteral feeding tube assessed by abdominal radiograph | Study population | RR 0.82 | 204 | ⊕⊝⊝⊝ | ||
| 562 per 1000 | 461 per 1000 | |||||
| Moderate | ||||||
| 572 per 1000 | 469 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 Design limitation (risk of bias) | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Failure rate of transpyloric placement of the enteral feeding tube assessed by abdominal radiograph Show forest plot | 4 | 204 | Risk Ratio (M‐H, Random, 95% CI) | 0.82 [0.61, 1.10] |
| 1.1 Metoclopramide 10 mg | 2 | 175 | Risk Ratio (M‐H, Random, 95% CI) | 0.82 [0.60, 1.11] |
| 1.2 Metoclopramide 20 mg | 2 | 29 | Risk Ratio (M‐H, Random, 95% CI) | 0.62 [0.15, 2.62] |
