How to advance tube feeding rate in a patient with nausea?

From the Guidelines

To advance tube feeding rates in a patient experiencing nausea, start by temporarily reducing the current rate by 25-50% until symptoms improve, as recommended by the most recent and highest quality study 1. When a patient is experiencing nausea while receiving tube feeding, it is crucial to address the issue promptly to prevent complications such as malnutrition, dehydration, and electrolyte imbalances.

• The initial step should be to reduce the current tube feeding rate by 25-50% to alleviate the nausea, as high feeding rates can exacerbate nausea and vomiting.
• Administer antiemetics 30 minutes before feeding, such as ondansetron 4-8mg every 8 hours, metoclopramide 10mg every 6 hours (unless contraindicated by bowel obstruction), or prochlorperazine 5-10mg every 6 hours, to help control nausea.
• Once nausea is controlled, gradually increase the feeding rate by 10-20ml/hour every 8-12 hours as tolerated, ensuring that the patient can handle the increased volume without experiencing adverse effects.
• Consider switching to a lower osmolality formula or one with less fat content, as these may be better tolerated and reduce the risk of nausea and vomiting.
• Continuous feeding rather than bolus administration often reduces nausea, as it provides a steady supply of nutrients and minimizes the risk of gastric distension.
• Ensure proper positioning with the head elevated at least 30 degrees during and after feeding to minimize reflux and reduce the risk of aspiration.
• Monitor for signs of feeding intolerance such as abdominal distension or increased gastric residual volumes, and adjust the feeding regimen accordingly.
• If nausea persists despite these interventions, consider post-pyloric feeding tube placement to bypass the stomach, as this can help reduce nausea and vomiting by delivering nutrients directly into the small intestine. These approaches work by addressing the underlying causes of nausea while maintaining nutritional support, as gastric distension, delayed emptying, and high osmolality can trigger the chemoreceptor trigger zone and vomiting center in the medulla, as supported by the ESPEN guidelines on clinical nutrition in surgery 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Tube Feeding Rate Advancement in Patients with Nausea

• The patient is currently receiving a tube feeding rate of 40 mL per hour continuously, with a Q6 hour rate increased by 10 mL/hr, but was paused due to nausea and set to resume at 20 mL/hr with a rate increase of 10 mL/hr Q4hrs.
• To advance the tube feeding rate in a patient with nausea, it is essential to consider the underlying cause of nausea and the patient's overall health status.
• Studies have shown that antiemetic medications such as ondansetron and metoclopramide can be effective in reducing nausea and vomiting in various clinical settings 2, 3, 4, 5, 6.
• However, the specific context of tube feeding and nausea requires careful consideration of the patient's nutritional needs and the potential risks of advancing the feeding rate too quickly.

Antiemetic Medications for Nausea

• Ondansetron and metoclopramide are two commonly used antiemetic medications that have been studied in various clinical trials 2, 3, 4, 5, 6.
• A study published in the Annals of Emergency Medicine found that ondansetron and metoclopramide were similarly effective in reducing nausea and vomiting in adult emergency department patients 3.
• Another study published in the American Journal of Perinatology found that subcutaneous metoclopramide and ondansetron were effective in reducing nausea and vomiting in pregnant women 4.
• A meta-analysis published in the International Journal of Oncology found that ondansetron was more effective than metoclopramide in preventing chemotherapy-induced nausea and vomiting 6.

Considerations for Advancing Tube Feeding Rate

• When advancing the tube feeding rate in a patient with nausea, it is crucial to monitor the patient's tolerance and adjust the rate accordingly.
• The patient's nutritional needs and the potential risks of advancing the feeding rate too quickly must be carefully considered.
• Antiemetic medications such as ondansetron and metoclopramide may be used to help manage nausea and vomiting, but their effectiveness and potential side effects must be carefully evaluated 2, 3, 4, 5, 6.