What can be given to a patient with persistent burping and unsettling feeling associated with tube feeds to manage her symptoms and maintain nutrition?

Managing Tube Feed Intolerance in a Post-Extubation Patient

For a patient experiencing burping and unsettling feelings with tube feeds, metoclopramide 10 mg IV every 6 hours is recommended to improve gastric emptying and reduce symptoms while maintaining adequate nutrition. 1

Assessment of the Situation

This 74-year-old patient presents with several important clinical factors:

• Recent masticator space infection requiring surgical drainage
• Post-extubation status after 3 days of intubation
• Currently receiving tube feeds (Vital 1.5) at 35 mL/hour
• Experiencing burping and unsettled feeling with feeds

First-Line Management Approach

1. Medication therapy:

   • Administer metoclopramide 10 mg IV every 6 hours to improve gastric emptying 1
   • Metoclopramide works by enhancing gastric emptying through augmenting esophageal peristalsis and gastric antral contractions 2

2. Feeding adjustments:

   • Temporarily reduce the rate of tube feeding to 20-25 mL/hour
   • Consider switching to a lower osmolality formula if symptoms persist 3
   • Gradually increase back to goal rate as tolerated

3. Patient positioning:

   • Maintain head elevation at minimum 30° during and for 30 minutes after feeding to reduce reflux risk 3, 4
   • This position helps prevent gastroesophageal reflux and potential aspiration

If First-Line Approach Fails

If symptoms persist despite the above interventions:

1. Increase metoclopramide to 20 mg IV every 6 hours 5
2. If still ineffective, consider adding erythromycin 250 mg IV every 6 hours in combination with metoclopramide 5
3. Consider changing to continuous feeding rather than bolus feeding 3

Monitoring and Precautions

• Monitor for metoclopramide side effects including drowsiness, extrapyramidal reactions, and restlessness 6
• Be particularly cautious with metoclopramide in elderly patients, as they are more susceptible to adverse effects
• Check gastric residual volumes regularly; if >200 mL, reassess feeding regimen 5
• Monitor fluid status, electrolytes, and signs of aspiration 4

Important Considerations

• Ensure proper tube position before continuing feeds 3
• Review all medications for potential causes of gastrointestinal intolerance 3
• Flush the feeding tube with 30 mL water before and after medication administration to prevent clogging 3

Potential Pitfalls

1. Overlooking tube position: Ensure tube is properly positioned to avoid improper feeding delivery 3

2. Ignoring medication-related causes: Many liquid medications contain sorbitol which can cause gastrointestinal symptoms 3

3. Failing to recognize serious complications: Persistent symptoms may indicate more serious issues like ileus that require further evaluation 3

4. Long-term metoclopramide use: While effective for short-term management, prolonged use increases risk of tardive dyskinesia, especially in elderly patients 6

By following this approach, you should be able to manage the patient's symptoms while maintaining adequate nutrition through the tube feeding regimen.