Metoclopramide Dosing in ICU Patients
The recommended dose of Metoclopramide (Perinorm) for ICU patients is 10 mg intravenously every 8 hours, with a maximum daily dose of 30 mg. 1
Pharmacology and Mechanism of Action
Metoclopramide is a dopamine receptor antagonist with unique properties:
- Increases lower esophageal sphincter pressure
- Accelerates gastric emptying rate
- Coordinates gastric-pyloric-small intestinal motor function 2
- Acts as an antiemetic by affecting the chemoreceptor trigger zone and enhancing intestinal motility 3
Dosing Guidelines for ICU Patients
Standard Dosing
- Initial dose: 10 mg IV
- Frequency: Every 8 hours
- Maximum daily dose: 30 mg 1
Administration Considerations
- Administer as slow IV push over 1-2 minutes
- Can be diluted in 50 mL of compatible solution for infusion
- For continuous infusion, dilute in D5W or normal saline
Duration of Therapy
- Parenteral metoclopramide should generally be limited to 1-2 days 2
- Transition to oral therapy when feasible
Clinical Applications in ICU
Metoclopramide is particularly useful in ICU patients for:
Gastric feeding intolerance:
- Recommended as a second-line prokinetic therapy after erythromycin
- Can be used in combination with erythromycin when single-agent therapy fails 1
Prevention of aspiration:
- Helps reduce gastric residual volumes
- Particularly beneficial in mechanically ventilated patients
Management of nausea and vomiting:
- Effective for post-operative nausea
- Used as adjunct therapy for patients receiving opioids 1
Special Considerations
Dose Adjustments
- Renal impairment: Reduce dose by 50% if CrCl < 40 mL/min
- Hepatic impairment: Reduce dose by 50% in severe hepatic dysfunction
- Elderly patients: Consider starting at lower doses (5 mg IV every 8 hours)
Monitoring
- Assess for extrapyramidal symptoms (acute dystonia, akathisia)
- Monitor QTc interval, especially with concurrent QT-prolonging medications
- Evaluate for signs of neuroleptic malignant syndrome
Potential Adverse Effects
Common adverse effects include:
- Drowsiness and sedation (10-20%)
- Restlessness and akathisia (10-20%)
- Fatigue and lassitude 2
Serious but rare adverse effects:
- Extrapyramidal symptoms (more common with high doses or prolonged use)
- Tardive dyskinesia (risk increases with duration of treatment)
- Neuroleptic malignant syndrome
Contraindications
Metoclopramide should be avoided in patients with:
- Gastrointestinal obstruction, perforation, or hemorrhage
- Pheochromocytoma
- History of seizure disorders
- Parkinson's disease
Clinical Pearls
- Effectiveness of prokinetics like metoclopramide decreases to one-third after 72 hours of use 1
- Consider discontinuing after 3 days if no clinical benefit is observed
- When used for feeding intolerance, consider post-pyloric feeding if large gastric residual volumes (>500 mL) persist despite metoclopramide therapy 1
- Avoid concurrent use with other dopamine antagonists to reduce risk of extrapyramidal effects
By following these dosing guidelines and monitoring recommendations, metoclopramide can be safely and effectively used in ICU patients to manage gastric motility issues and nausea/vomiting.