MAIN FEATURES
OF THE PEP uP PROTOCOL
• All patients will receive a semi-elemental formula
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 XX:XX h daily
• Patients receive a semi-elemental formula 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 PEPED UP!
OPTION 2: Trophic feeds
•
•
•
Begin a semi-elemental formula 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:
– Ruptured AAA
– Surgically placed jejunostomy
– Upper intestinal anastomosis
– Impending intubation
– Risk of re-feeding syndrome
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)
Replace 300 mL of aspirate, discard
remainder. Reduce rate by 25 mL/h
to no less than 10 mL/h.
Step 1: Start metoclopramide 10 mg
IV q 6 hr. If already prescribed, go to
Step 2.
Elevate head of bed to 45° (or as much
as possible) unless contraindicated.
Start feed at initial rate or volume ordered.
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.
Measure gastric residual volumes q4h.
Is the residual volume > 300 ml?
NOTE: Do not aspirate small bowel tubes.
NO
YES
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
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.
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?
A.
B.
C.
D.
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any vasopressors
Start trophic feeds at rate per PEP uP protocol
Start metoclopramide and wait for bowel sounds
CASE STUDY: ADMISSION
What do you anticipate will be ordered for feeding
on admission?
A.
B.
C.
D.
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any vasopressors
Start trophic feeds at rate per PEP uP protocol
Start metoclopramide and wait for bowel sounds
CASE STUDY: PEP uP
Initial Orders: Protein Supplements
Does he require protein supplements?
A.
B.
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?
A.
B.
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 25 mL/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 based on a 1.5kcal/ml formula?
A.
B.
C.
D.
46 mL/hr
62 mL/hr
67 mL/hr
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 based on a 1.5kcal/ml formula?
A.
B.
C.
D.
46 mL/hr
62 mL/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?
A.
B.
C.
D.
Stop the tube feeds
Stop the metoclopramide
Implement the diarrhea management guidelines
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?
A.
B.
C.
D.
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
based on a 1.5 kcal/ml formula?
A.
B.
C.
D.
62 mL/hr
75 mL/hr
80 mL/hr
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
based on a 1.5 kcal/ml formula?
A.
B.
C.
D.
62 mL/hr
75 mL/hr
80 mL/hr
115 mL/hr