The
Protocol
Main Features the PEP uP Protocol
 All patients will receive Peptamen 1.5 initially
 All patients will start on Beneprotein®
 2 packets (14 g) mixed in 120ml water administered bid via NG
 All patients will be given metoclopramide on Day 1 of enteral
feeding
 10 mg IV q 6h
*Reassess formula, protein supplement, and motility agent daily*
Get PEPPED UP!
Option 1: Begin Volume-Based feeds.
• 24 hour period begins at XXXXh daily.
• Patients receive Peptamen 1.5 initially.
• Day 1: start feeding at 25 ml/hr
• Day 2: Feeding rate determined by 24hr target volume
• Consult dietitian to calculate 24hr target volume (if RD not
available, use weight based goal until patient assessed)
• Determine hourly rate as per Volume Based Feeding Schedule
• Monitor gastric residual volumes as per Gastric Feeding
Flowchart and Volume Based Feeding Schedule
Get PEPPED UP!
Option 2: Trophic feeds
•
Begin Peptamen 1.5 at 10 mL/h after initial
tube placement confirmed
•
Do not monitor gastric residual volumes
•
Reassess ability to transition to Volume-Based
feeds next day
~2 tsp
per hour
Get PEPPED UP!
Option 2: Trophic feeds
Intended for patient who is:
On vasopressors (regardless of dose) as long
as they are adequately resuscitated
 Not suitable for high volume enteral feeding:
o
Ruptured AAA
o
Surgically placed jejunostomy
o
Upper intestinal anastomosis
o
Impending intubation
Get PEPPED UP!
Option 3: NPO
 Only if contraindication to EN present: bowel
perforation, bowel obstruction, proximal high
output fistula.
× Recent operation and high NG output are not
a contraindication to EN.
 Reassess ability to transition to Volume-Based
feeds next day.
Gastric Feeding Flowchart
Place feeding tube or use existing
gastric drainage tube.
X-ray to confirm placement (as required)
Elevate head of bed to 45° (or as much
as possible) unless contraindicated.
Start feed at initial rate or volume ordered.
Measure gastric residual volumes q4h.
Is the residual volume > 300 ml?
NOTE: Do not aspirate small bowel tubes.
No
Replace up to 300mL
of aspirate, discard
remainder. Set rate of
EN based on
remaining volume and
time until X am (max
rate 150mL/hr).
Reassess motility
agents after feeds
tolerated at target rate
for 24 hours.
Replace 300 mL of aspirate, discard
remainder. Reduce rate by 25 mL/h to
no less than 10 mL/h.
Step 1: Start metoclopramide 10mg IV q
6 hr. If already prescribed, go to Step 2.
Step 2: Consider adding erythromycin
200 mg IV q12h (may prolong Qt
interval). If 4 doses of erythromycin are
ineffective, go to Step 3.
Step 3: Consider small bowel feeding
tube placement and discontinue motility
agents thereafter.
Yes
Yes
Was the residual volume greater than
300 mL the last time it was measured?
No
Case Study
73 year old male is admitted to ICU at
2100 hours with a three day history of
shortness of breath and weakness.
Case Study
•
He is in respiratory distress with oxygen saturations of
88% on 15 liters with a respiratory rate of 36/min
•
He is intubated and placed on FiO2 of 50%, PEEP 15
and PSV of 12
•
His saturations have improved and his respiratory rate is
14/min
Case Study
•
His past medical history is significant for COPD and alcohol
dependence
•
He is admitted to ICU with a diagnosis of community
acquired pneumonia
•
He does not have bowel sounds and is NPO
•
His weight is 75Kg and height is 1.8m
Case Study: Admission
• What do you anticipate will be ordered for
feeding on admission?
o
o
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any
vasopressors
o
Start trophic feeds at rate per PEPuP protocol
o
Start metoclopramide and wait for bowel sounds
Case Study: Admission
• What do you anticipate will be ordered for
feeding on admission?
o
o
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any
vasopressors
o
Start trophic feeds at rate per PEPuP protocol
o
Start metoclopramide and wait for bowel sounds
Case Study:
PEP uP Initial Orders:
Protein Supplements
•
Does he require protein supplements?
o
o
Yes. He requires protein supplements because we want to
avoid a nutrition deficit.
No. Protein supplements are not required because he is a
new admission.
Case Study:
PEP uP Initial Orders:
Protein Supplements
•
Does he require protein supplements?
o
o
Yes. He requires protein supplements because we want to
avoid a nutrition deficit.
No. Protein supplements are not required because he is a
new admission.
Case Study:
Admission Orders
• The resident orders volume-based feeds for him
because he is adequately volume resuscitated
and is not receiving vasopressors
• It is now 2200 hours
Case Study
Volume Based Feeds:
Getting Started
• For day 1 only, feeds will start at 25mL/h
• Day 1 is only 9 hours long, and ends when the
flow sheet for that day ends
• On day 2, volume-based feeds begin
Case Study:
Setting the 24 hour rate
• At 0700 hours, a dietitian still has not yet
assessed the patient. You will recalculate the
hourly enteral feeding rate for the next 24 hours,
or until he is reassessed at rounds
• What will the new rate be?
o
46 ml/hr
o
62ml/hr
o
67 ml/hr
o
70 ml/hr
Case Study:
Setting the 24 hour rate
• At 0700 hours, a dietitian still has not yet
assessed the patient. You will recalculate the
hourly enteral feeding rate for the next 24 hours,
or until he is reassessed at rounds
• What will the new rate be?
o
46 ml/hr
o
62ml/hr
o
67 ml/hr
o
70 ml/hr
Case Study
Admission Day 2
• He continues to receive volume based feeds per
PEP uP protocol
• He has developed diarrhea and is having 4 to 5
loose stools per day
• Which of the following would be an appropriate
action?
o
Stop the tube feeds
o
Stop the metoclopramide
o
Implement the diarrhea management guidelines
o
Increasing the tube feeding rate
Case Study
Admission Day 2
• He continues to receive volume based feeds per
PEP uP protocol
• He has developed diarrhea and is having 4 to 5
loose stools per day
• Which of the following would be an appropriate
action?
o
Stop the tube feeds
o
Stop the metoclopramide
o
Implement the diarrhea management guidelines
o
Increasing the tube feeding rate
Case Study
Admission day 3
• He is now receiving 1500 ml in 24 hours volume
based feeding after the dietitian reassessed
• The feeds were stopped while going for a test
and were not started upon return to the unit
• At 1700h the feeds have been off for 4 hours
• What rate will you run the feeds for the
remainder of the time?
o
62 ml/hr
o
75 ml/hr
o
80 ml/hr
o
115 ml/hr
Case Study
Admission day 3
• He is now receiving 1500 ml in 24 hours volume
based feeding after the dietitian reassessed
• The feeds were stopped while going for a test
and were not started upon return to the unit
• At 1700h the feeds have been off for 4 hours
• What rate will you run the feeds for the
remainder of the time?
o
62 ml/hr
o
75 ml/hr
o
80 ml/hr
o
115 ml/hr
Questions?