The PEP uP Protocol Self-learning Module Your ICU is one of 20 sites across North America participating in the PEP uP Protocol. The main objective of this study is to evaluate the effect of an innovative enteral feeding protocol and nursing education program on the adequacy of enteral feeding delivery. Each ICU will recruit 30 patients at baseline prior to implementing the protocol and another 30 patients after implementation of the protocol to evaluate your success with it. We will also document safety incidents related to enteral nutrition (EN), evaluate the protocol from the perspective of the nurses who use it, and capture 60 day hospital outcomes i.e. length of stay, mortality, etc. Why is this important? Adequate nutrition is very important to support the optimal recovery of critically ill patients. Sufficient nutrition helps to: Provide fuel for cellular metabolism Prevent protein loss and muscle wasting Decrease ventilator time Help prevent infection including ventilator associated pneumonia Promote healthy wound healing Decrease ICU length of stay Reduce mortality Did you know? International audits of nutrition practices have found that ICU patients only receive 40-50% of their nutritional requirements. This means that ICU patients worldwide are iatrogenically malnourished – in other words, we made them that way! 1 What’s New? There a few things about the PEP uP Protocol that may be quite different from how you are providing EN currently. These include: All patients will initially receive an enteral formula called Peptamen 1.5 All patients will start on the protein supplement Beneprotein®: o 2 packets (14 g) mixed in 120 ml water administered bid via OG/NG All patients will be given metoclopramide on Day 1 of enteral feeding - 10 mg IV q 6h The gastric residual volume threshold is 300 ml The enteral feeding initiation orders shown in Appendix 1 is the form that the admitting physician or resident will use to order the appropriate feeding option for your patient. You will notice that NPO is rarely an option; this should be chosen only when there is an absolute contraindication to enteral feeding. You will see some examples of contraindications given in the pre-printed orders. Even the sickest patient should be started on a low level of feeding, trophic feeds, to help maintain gut health. Gut disuse (aka NPO) causes loss of functional and structural integrity of the GI tract and is associated with increased complications. The other big difference you will see is that your patients’ feeds will now be based on a 24 hour target volume rather than the traditional hourly rate you are likely used to. This means that you may be changing hourly rates throughout the day to make up for times when the feeds are off. The case studies that follow will help you to work through these changes and become familiar with the PEP uP protocol. As you work through the case studies, we will ask you questions to test your knowledge. For the first case study, the answers are provided immediately after the questions. For the second case study, answers are found in the Appendix and there is an answer key at the end. If you are completing the electronic version of the learning module, when you come to red text, place your mouse over the text, then control/click and this will link directly to the highlighted area of the learning module. If you are completing the paper based version of the learning module, refer to the appropriate section of the Appendix. If you have any questions, please contact your Protocol Implementation Team (PIT) Crew: { Add contact details} 2 Case Studies Case Study Number 1 A 35 year old male was admitted at 0400h following a gunshot wound to chest. His injuries include massive trauma to right arm, left chest and left shoulder. He experienced 3 intra-operative cardiac arrests. On arrival to the ICU he is in pulmonary edema, right heart failure , vasopressin at 0.04 units/hr and his levophed continues to be titrated up to maintain a MAP of 60 mmHg; the current rate is 25 mcg/min. His weighs 70Kg and he is 1.74m tall. Questions: 1. On admission you inform the medical team that the patient is NPO. Which of the following interventions do you anticipate? a. Continue NPO b. Volume based enteral feeds c. Enteral feeds at 25/hr d. Trophic feeds If you chose trophic feeds you are correct. Because he is still requires vasopressors to maintain a MAP of 60 mmHg he may not be ready to start on volume based feeds. Starting on trophic feeds at 10 ml/hr will help protect his gut until he is stable. 2. He is oliguric, and his creatinine and urea continue to rise. What dose of metoclopramide will you administer ? a. Metoclopramide 10 mg q6h b. Metoclopramide 5 mg q6h c. Metoclopramide 10 mg q8h d. Metoclopramide not indicated Did you find the correct answer in the ENTERAL FEEDING INITIATION ORDERS? 3 On day 2 his levophed and vasopressin are discontinued. His enteral feeds are at 10 ml/hr. Questions: 3. On morning rounds you inform the medical team that the patient no longer requires vasopressor support and is receiving trophic feeds. What intervention do you anticipate? a. Increase trophic rate from 10 to 20 ml/hr b. Start enteral feeds at 25ml/hr and increase to target of 70ml/hr c. Start volume feeds at a target goal rate determined by dietitian d. Start volume feeds at 1100 ml/hr over 24 hours Starting volume feeds at a rate determined by a dietitian is the best choice. The PEP uP Protocol is meant for initial nutrition orders and reassessment by the dietitian is always the next step to make sure each patient’s individual nutrition requirements are met. If this patient was admitted on a weekend however, he could be moved over the volume feeding of 1100ml per 24 hrs (based on his weight of 70Kg) until Monday when he is stable. Make sure to bring this up at morning rounds. 4. At 0800 you measured the gastric residual volume and it is 350mls. You replace the aspirate and continue feeding at target goal rate. At 1200 his gastric residuals are measured again and it remains at 350 ml. What will you do? a. Replace 300 ml of aspirate and decrease rate by 50 ml/hr b. Replace all the aspirate and maintain current feeding rate c. Replace 300ml of aspirate and decrease rate by 25ml/hr d. Do not replace aspirate and hold tube feeds Use the GASTRIC FEEDING FLOWCHART in the Appendix to find the answer. The correct answer is c. As the previous residual volume measurement was greater than 300ml, replace 300ml of aspirate, discard the remainder and reduce rate by 25 ml/hr 4 He has remained stable throughout Day 3. On Day 4 of his admission the surgical team informs you at 1000h that they will be taking him back to the OR; they request that he be kept NPO after 2400 hours. Questions: 5. The dietitian has determined that his daily volume goal is 1200ml in 24 hours (starts at 0700h daily) which is a rate of 50ml/hr. What will be his new rate to reach his goal volume by midnight? a. 64 ml/hr b. 75 ml/hr c. 82 ml/hr d. 96 ml/hr Did you calculate 75 ml/hr? Since he needs to be NPO at midnight all of his feed volume needs to be infused by midnight, or in 17 hours total. He has received 150 ml since 0700: 50 ml/hr x 3 hours. 1200 – 150 = 1050 ml remaining. 1050ml/14 hours remaining = 75 ml/hr 6. What is the maximum hourly rate that you should infuse on volume based feeding? a. 125 ml/hr b. 135 ml/hr c. 150 ml/hr d. 160 ml/hr Refer to the VOLUME BASED FEEDING SCHEDULE to find the answer to this question. The maximum rate is 150ml/hr. 7. Your 24- hour intake indicates that he received 1100 ml in the last 24 hours. Based on the daily goal of 1200 ml in 24 hours, what will you report as his nutritional adequacy during morning rounds? a. 92% b. 94% 5 c. 96% d. 98% Part of your daily report in rounds should now include nutritional adequacy. This reports how much of the feed your patient received in the previous 24 hour period compared to what he/she should have received. This is reported as a percentage. Calculate nutritional adequacy by dividing the actual amount given by the target volume and multiplying x 100. Actual volume/target volume x100 = % of target delivered In this question the calculation would be 1100/1200 x 100 = 92% 8. He continues to receive 5mg metoclopromide as per the enteral feeding initiation orders. But his gastric residuals have been > 300 ml for 2 consecutive checks. What intervention do you anticipate? a. Consider Erythromycin 200 mg Q12h b. Increase Metoclopramide to 10 mg q4h c. Increase rate of feeds d. Hold feeds for 4 hours Refer to the GASTRIC FEEDING FLOWCHART in Appendix 3 to find the answer to this question. The correct answer is a. consider erythromycin. 6 One week following his admission he is scheduled for an MRI at 1400h. The enteral feeds are stopped from 1400h to 1700h. (N.B. In this example the flow sheet start time is 0700h). Questions: 9. You know that he is to receive 1200 ml in 24 hours which is a rate of 50ml/hr. Upon returning to the ICU at 1700h, what will be his new rate based on the 24 hour volume protocol ? a. 60 ml/hr b. 65 ml/hr c. 70 ml/hr d. 75 ml/hr Did you calculate the correct rate of 60 ml/hr? If not, here is how you would calculate the rate: 50 ml/hr x 7 hours = 350 ml delivered by 1400h. 1200 ml/24 hours – 350 ml = 850 ml remaining 850 ml/14 hours remaining = 60 ml/hr Now that you have worked through the first set of questions there is a second case study below. To encourage you to test your new knowledge of the PEP uP protocol, the answers to this study are found at the end rather than along with each question. See how you do! 7 Case Study # 2 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. 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. N.B. In this example the flow sheet start time is 0700h Questions: 1. 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 10 ml/hr d. Start metoclopramide and wait for bowel sounds 2. 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. The resident orders volume based feeds for him because he is adequately volume resuscitated and is not receiving vasopressors. It is now 2200h and you need to calculate his volume based feeding for the remainder of the 24 hours, his weight is 75 kilograms. (Remember, the 24 hours begin and end at 0700h daily.) Questions: 3. Based on his weight, what should his adjusted target volume for the first day of feeding be? a. 413ml b. 1100 ml c. 321 ml d. 92 ml 8 4. 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 5. 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 this rate be? a. 46 ml/hr b. 62ml/hr c. 67 ml/hr d. 70 ml/hr Admission day 2: He continues to receive volume based feeds per PEP uP protocol. He has developed diarrhea and is having 6-7 loose stools per day. Question: 6. Which of the following would be an appropriate action? a. Stopping the tube feeds b. Stopping the metoclopramide c. Implement the diarrhea management guidelines d. Increasing the tube feeding rate The dietitian reassesses the patient and recommends that he receives 1500 ml over 24 hours. The feeds were stopped while going for a test and were not started upon return to the unit. At 1700 hours the feeds have been off for 4 hours. Question: 7. What rate will you run the feeds for the remainder of the time? a. 62 ml/hr b. 75 ml/hr 9 c. 80 ml/hr d. 115 ml/hr Congratulations, you have completed the Learning Module! Thank you for helping us implement the PEP uP Protocol. If you still have questions about how to implement the PEP uP Protocol please ask the Protocol Implementation Team (PIT) Crew: {add contact details} 10 Answers: Case study 2 1. What do you anticipate will be ordered for feeding on admission? Answer: Volume based feeding because he is hemodynamically stable 2. Does he require protein supplements? Answer: Yes. He requires protein supplements because we want to avoid a protein deficit. 3. Based on his weight of 75Kg, what should his 24 hour volume based feeding would be? Answer: (1100 ml target volume x 9 hours left in Day 1) 24 = 413 ml target volume for day 1 4. Based on the amount of time that remains in the 24 hour period, what will your hourly rate be? Answer: 413ml target volume for Day 1 9 hrs remaining in Day 1 = 46 ml/hr 5. What will the new rate be? Answer: 1100 ml 24 hr target volume 24 hrs = 46 ml/hr 6. Which of the following would be an appropriate action? Answer: Implement the diarrhea management protocol 7. At 1700 hours the feeds have been off for 4 hours. What rate will you run the feeds for the remainder of the time? Answer: 80 ml/hr 1500ml/24 hr = 63 ml/hr. 63 x 6 hr = 378 ml infused. 1500 – 378 = 1122 ml remaining to be infused. 1122 ml/14 hr = 80 ml/hr 11 Appendix 1 Weight (kg) Allergies Addressograph ENTERAL FEEDING INITIATION ORDERS To Be Completed by Nursing, the Dietitian or MD and signed by an MD Page 1 of 1 Use this order in all patients meeting the following criteria: Include if: - Adult patients (≥18 years) - Mechanically ventilated at or within 6 hours of ICU admission in whom you would normally initiate enteral nutrition 1. OR Exclude if: - Enteral or parenteral nutrition initiated before ICU admission - Patients on mask ventilation CXR to confirm initial tube placement. ______________ tube placement confirmed ________________________. (gastric, intestinal) (e.g. radiographically, endoscopically) 2. Begin Volume-Based Feeding. (24 hour period as per flow sheet - Xam to Xam). a) Start enteral feeding with Peptamen 1.5 b) Calculate 24 hr target volume based on patient’s actual admission weight: < 50 kg 700 ml/24 hrs 50.1 – 65 kg 900 ml/24 hrs 65.1- 80kg 1100 ml/24 hrs 80.1 – 95 kg 1300 ml/24 hrs > 95.1 kg 1600 ml/24 hr c) For the first day of enteral feeding ONLY, adjust 24 hour volume goal to account for # of hrs left until X am (or the start of the next 24 period). To calculate adjusted target volume for first day of feeding: [24 hr target volume x # of hrs left to feed in Day 1] ÷ 24 = ml is your target volume for Day 1 of EN d) For both day 1 volume goal and subsequent 24 hour volume goals, calcluate the hourly rate of infusion using the Volume Based Feeding Schedule. e) Consult dietitian to reassess 24 hr target volume (continue weight based 24 hr target volume calculating hourly rate as per Volume Based Feeding Schedule until dietitian review) Monitor gastric residual volumes as per Gastric Feeding Flow Chart OR Begin Trophic Feeds Start Peptamen 1.5 at 10 mL/h. Do not monitor gastric residual volumes. Reassess ability to transition to VolumeBased Feeding the next day. [For patients on vasopressors (regardless of dose) as long as they are adequately resuscitated OR patients not suitable for Volume Based Feeding (e.g. ruptured AAA, upper intestinal anastomosis, surgically place jejunostomy, or impending intubation)]. OR NPO. Please write in reason: _________________ ______.(For contraindications to EN only: bowel perforation, bowel obstruction, proximal high output fistula). Note: recent OR and high NG output are not contraindications to EN. Reassess and switch to Volume-Based Feeding the next day. Do not start metoclopramide or protein supplements in patients who are NPO. 3. Unless NPO: Start metoclopramide: 4. Unless NPO: Protein supplement Beneprotein® - 2 packets mixed in 120 ml sterile water bid via NG (consider holding in renal failure if not on dialysis or if pt. has hepatic encephalopathy). 5. Monitor nutritional adequacy daily: (volume of EN rec’d in last 24 hour period/prescribed 24 hour target volume) and report this percentage intake on daily rounds. 6. Monitor lytes and Ca, Mg, Phos q12h x 72 hours then as per ICU admission orders. 10 mg IV q 6 hr, or 5 mg q6h IV if renal dysfunction. Reassess daily. 12 TRANSCRIPTION 7. Flush tube with at least 10 mL sterile water q4 h during feedings, if feedings are held, after aspiration for residuals, and before and after medication and Beneprotein administration. 8. For declogging tubes, give pancrelipase 8,000 units mixed with crushed Na bicarbonate 500 mg in 25 mL warm water prn. 9. You may override Total Fluid Intake (TFI) order if needed; Do not increase IV rate to make up for held feedings because this volume will be made up later with increased rates of EN. Signature & Designation: Printed Name: Date (YYYY/MM/DD) & Time (HHMM): * The examples included in the learning module refer to a ICU flow sheet starting at 700h* 13 Appendix 2 Volume Based Feeding Schedule Hours remaining in the day to feed 24h volume Goal total mL formula per 24h 2400 2350 2300 2250 2200 2150 2100 2050 2000 1950 1900 1850 1800 1750 1700 1650 1600 1550 1500 1450 1400 1350 1300 1250 1200 1150 1100 1050 1000 950 900 850 800 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 100 104 109 114 120 126 133 141 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 98 102 107 112 118 124 131 138 147 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 96 100 105 110 115 121 128 135 144 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 94 98 102 107 113 118 125 132 141 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 92 96 100 105 110 116 122 129 138 147 150 150 150 150 150 150 150 150 150 150 150 150 150 150 90 93 98 102 108 113 119 126 134 143 150 150 150 150 150 150 150 150 150 150 150 150 150 150 88 91 95 100 105 111 117 124 131 140 150 150 150 150 150 150 150 150 150 150 150 150 150 150 85 89 93 98 103 108 114 121 128 137 146 150 150 150 150 150 150 150 150 150 150 150 150 150 83 87 91 95 100 105 111 118 125 133 143 150 150 150 150 150 150 150 150 150 150 150 150 150 81 85 89 93 98 103 108 115 122 130 139 150 150 150 150 150 150 150 150 150 150 150 150 150 79 83 86 90 95 100 106 112 119 127 136 146 150 150 150 150 150 150 150 150 150 150 150 150 77 80 84 88 93 97 103 109 116 123 132 142 150 150 150 150 150 150 150 150 150 150 150 150 75 78 82 86 90 95 100 106 113 120 129 138 150 150 150 150 150 150 150 150 150 150 150 150 73 76 80 83 88 92 97 103 109 117 125 135 146 150 150 150 150 150 150 150 150 150 150 150 71 74 77 81 85 89 94 100 106 113 121 131 142 150 150 150 150 150 150 150 150 150 150 150 69 72 75 79 83 87 92 97 103 110 118 127 138 150 150 150 150 150 150 150 150 150 150 150 67 70 73 76 80 84 89 94 100 107 114 123 133 145 150 150 150 150 150 150 150 150 150 150 65 67 70 74 78 82 86 91 97 103 111 119 129 141 150 150 150 150 150 150 150 150 150 150 63 65 68 71 75 79 83 88 94 100 107 115 125 136 150 150 150 150 150 150 150 150 150 150 60 63 66 69 73 76 81 85 91 97 104 112 121 132 145 150 150 150 150 150 150 150 150 150 58 61 64 67 70 74 78 82 88 93 100 108 117 127 140 150 150 150 150 150 150 150 150 150 56 54 59 57 61 59 64 62 68 65 71 68 75 72 79 76 84 81 90 87 96 93 104 100 113 108 123 118 135 130 150 144 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 52 54 57 60 63 66 69 74 78 83 89 96 104 114 125 139 150 150 150 150 150 150 150 150 50 52 55 57 60 63 67 71 75 80 86 92 100 109 120 133 150 150 150 150 150 150 150 150 48 50 52 55 58 61 64 68 72 77 82 88 96 105 115 128 144 150 150 150 150 150 150 150 46 48 50 52 55 58 61 65 69 73 79 85 92 100 110 122 138 150 150 150 150 150 150 150 44 46 48 50 53 55 58 62 66 70 75 81 88 95 105 117 131 150 150 150 150 150 150 150 42 43 45 48 50 53 56 59 63 67 71 77 83 91 100 111 125 143 150 150 150 150 150 150 40 41 43 45 48 50 53 56 59 63 68 73 79 86 95 106 119 136 150 150 150 150 150 150 38 39 41 43 45 47 50 53 56 60 64 69 75 82 90 100 113 129 150 150 150 150 150 150 35 37 39 40 43 45 47 50 53 57 61 65 71 77 85 94 106 121 142 150 150 150 150 150 33 35 36 38 40 42 44 47 50 53 57 62 67 73 80 89 100 114 133 150 150 150 150 150 14 Hours remaining in the day to feed 24h volume Goal total mL formula per 24h 750 700 650 600 550 500 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 31 33 34 36 38 39 42 44 47 50 54 58 63 68 75 83 94 107 125 150 150 150 150 150 29 30 32 33 35 37 39 41 44 47 50 54 58 64 70 78 88 100 117 140 150 150 150 150 27 28 30 31 33 34 36 38 41 43 46 50 54 59 65 72 81 93 108 130 150 150 150 150 25 26 27 29 30 32 33 35 38 40 43 46 50 55 60 67 75 86 100 120 150 150 150 150 23 24 25 26 28 29 31 32 34 37 39 42 46 50 55 61 69 79 92 110 138 150 150 150 21 22 23 24 25 26 28 29 31 33 36 38 42 45 50 56 63 71 83 100 125 150 150 150 Nursing Instructions for Physician Ordered 24 hour Volume-Based Enteral Feeding Example: Order for volume based enteral feeding will be the total volume goal for 24 hours. The 24 hour period corresponds to the flow sheet (i.e X am to X am each day). If the total volume ordered is 1800 mL, the hourly rate is 75 mL/hour. If the patient was fed 450 mL of feeding (6 hours) and the tube feeding is on “hold” for 5 hours, then subtract from the goal volume the amount of feeding the patient has already received. Volume Ordered per 24 hours 1800 mL – Tube feeding in (current day) 450 = Volume of feeding remaining in day to feed 1800 – 450 = 1350 mL Patient now has 13 hours left in the day to receive 1350 mL of tube feeding. Check the chart for the new goal rate based on the number of hours remaining in the current 24 hr period. Select the goal rate closest to volume needed. In this example it would be 1350. Next go to column 13 (the number of hours remaining to feed) and the amount of feeding to provide will be 104 mL/hour. In this example the patient will receive a total volume of 1352 mL for the remaining hours in the day. Please contact your ICU dietitian or PIT Crew if you have any questions Important Nursing Assessment Volume based feeding should be used with caution. Nurses should always assess for feeding intolerance. Examples of intolerance include: abdominal distention, abdominal cramping, nausea & vomiting, diarrhea defined as 5 stools or 750 mL per 24h period, and gastric residuals greater than 300 mL. 15 Appendix 3 Gastric Feeding Flow Sheet 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 Was the residual volume greater than 300 mL the last time it was measured? No 16