The PEP uP Protocol
I’M
HUNGRY!!
Adequate Nutrition
 Provides fuel for cellular metabolism
 Prevents protein/muscle wasting
 Decreases ventilator time
 Helps prevent infection/VAP
 Decreases ICU length of stay
 Promotes healthy wound healing
 Reduces mortality
GUT disuse causes loss of functional and structural integrity of the GI
tract and is associated with increased complications
These changes are time dependent; the longer they are left NPO, the
greater the complications.
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 metaclopromide 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.
The 24 hour period begins at XXXXh daily.
Patient is to receive Peptamen 1.5 initially.
The total target volume for Day 1 of EN is based on the patient’s
weight in kilograms.
Consult dietitian to reassess 24 hr target volume as soon as
possible
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.
Intended for patient who is:
On vasopressors (regardless of dose) as long as they are
adequately resuscitated
Not suitable for high volume enteral feeding (ruptured
AAA, surgically place jejunostomy, upper intestinal
anastomosis, or impending intubation)
Get PEPPED UP!
Option 3: NPO
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 VolumeBased 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.
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.
No
Yes
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
No
Was the residual volume
greater than 300 mL the
last time it was
measured?
Case Study
 73
year old male is admitted to ICU at 2100 hours with a three
day history of shortness of breath and weakness.
 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 ?
a.
NPO because no Bowel Sounds
b.
Volume based feeding because he is not receiving
any vasopressors
c.
Start trophic feeds at rate per PEPuP protocol
d.
Start metoclopramide and wait for bowel sounds
Case Study
PEP uP Initial Orders:
Protein Supplements
Does he require protein supplements?

a.
Yes. He requires protein supplements because we want to
avoid a nutrition deficit.
b.
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 and you need to calculate his volume
based feeding for the remainder of the 24 hours.
*Remember: The 24 hours begin and end with the flow sheet
which in this example is 0700hrs.
Case Study
Volume Based Feeds:
Getting Started
 Based on his weight, what should his
adjusted target volume for the first day of
feeding be?
a. 413 ml
b. 1100 ml
c. 321 ml
d. 92 ml
Case Study
Calculating the adjusted rate

Based on the amount of time that remains in
the 24 hour period, what will your hourly rate
be ?
a.
46 ml/hr
b.
64 ml/hr
c.
50 ml/hr
d.
45 ml/hr
Case Study
Setting the 24 hour rate
 At
0700 hours 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?
• 46 ml/hr
• 62ml/hr
• 67 ml/hr
• 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?
• Stop the tube feeds
• Stop the metoclopramide
• Implement the diarrhea management guidelines
• 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?
• 62 ml/hr
• 75 ml/hr
• 80 ml/hr
• 115 ml/hr
Questions?