1. PEP uP Powerpoint - Long Version
The
Protocol

2. Main Features the PEP uP Protocol
PEP uP Powerpoint - Long Version
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*
Teaching points:
Peptamen is the initial formula for all study patients. This will be reassessed by unit dietitians and the formula may be changed.
What does not change is volume based feeding.
Metoclopramide is started immediately and reassessed daily. If the patient is tolerating feeds motility agent should be stopped after 24 hours tolerating feeds.
All patients are started on protein and motility agents whether they start on volume based or trophic feeds. THE NEED FOR THESE IS TO BE REASSESED DAILY.

3. PEP uP Powerpoint - Long Version
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
Teaching point:
All patients are started on volume based feeds unless they meet criteria to be unable to start. Those are discussed on the next 2 slides, and found in the pre-printed orders.

4. PEP uP Powerpoint - Long Version
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
Teaching point:
These feeds are started in patients who would traditionally have been left NPO. The small volume helps protect the gut until the patient is ready for volume based feeding.
Daily reassessment is essential.
~2 tsp
per hour

5. PEP uP Powerpoint - Long Version
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
Teaching point:
These feeds are started in patients who would traditionally have been left NPO. The small volume helps protect the gut until the patient is ready for volume based feeding.
Daily reassessment is essential.

6. PEP uP Powerpoint - Long Version
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.
Teaching point:
Must have a contraindication to enteral nutrition.
Reassessment essential.

7. Gastric Feeding Flowchart
PEP uP Powerpoint - Long Version No
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 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.
Was the residual volume greater than 300 mL the last time it was measured?
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.
Yes
All participants will have a copy of the flowchart to refer to as well. Remind that they will be using this flowchart during the case study to follow.
Key points:
Tube placement confirmed
HOB 45 – contraindications could include spinal precautions, subarachnoid hemorrhage. Consider reverse trendelenburg when appropriate.
Monitor gastric residuals q4h, acceptable residuals 300 ml and less. 7

8. Case Study
73 year old male is admitted to ICU at hours with a three day history of shortness of breath and weakness.

9. 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

10. 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

11. Case Study: Admission
What do you anticipate will be ordered for feeding on admission?
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any vasopressors
Start trophic feeds at rate per PEPuP protocol
Start metoclopramide and wait for bowel sounds
Correct answer:
Volume based feeding because he is not receiving any vasopressors
Teaching points:
Lack of bowel sounds is not a reason to keep him NPO
Stable, so does not require trophic feeds, used to maintain gut health in patients not ready for volume based feeding
Metoclopramide is to be started on all patients 11

12. Case Study: Admission
What do you anticipate will be ordered for feeding on admission?
NPO because no Bowel Sounds
Volume based feeding because he is not receiving any vasopressors
Start trophic feeds at rate per PEPuP protocol
Start metoclopramide and wait for bowel sounds
Correct answer:
Volume based feeding because he is not receiving any vasopressors
Teaching points:
Lack of bowel sounds is not a reason to keep him NPO
Stable, so does not require trophic feeds, used to maintain gut health in patients not ready for volume based feeding
Metoclopramide is to be started on all patients 12

13. Case Study: PEP uP Initial Orders: Protein Supplements
Does he require protein supplements?
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.
Correct answer: Yes he requires protein supplements because we want to avoid a nutrition deficit.
Teaching point:
All patients in the protocol are started on protein supplements immediately. 13

14. Case Study: PEP uP Initial Orders: Protein Supplements
Does he require protein supplements?
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.
Correct answer: Yes he requires protein supplements because we want to avoid a nutrition deficit.
Teaching point:
All patients in the protocol are started on protein supplements immediately. 14

15. 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
Teaching point:
How many hours remain in the feeding day? Answer – 9 hours (2200h-0700h)
For day 1, he will receive 25mL/hr, but on subsequent days, refer to preprinted orders – According to his weight what volume should he receive?

16. 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
Key teaching point:
Make sure on day 2 patient begins volume based feeds where rate is adjusted to compensate for interruptions. Patients should not be left at 25mL/h after day 1. 16

17. 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?
46 ml/hr
62ml/hr
67 ml/hr
70 ml/hr
Correct answer:
46 ml/hr (1100/24)
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 75Kg) until Monday. Make sure to bring this up at morning rounds.
The rate needs to be set at 0700, but remind that this could be changed once he is assessed by the dietitian. The important point to remember that it remains volume based feeding so it should be a volume target, not a ml/hr order. 17

18. 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?
46 ml/hr
62ml/hr
67 ml/hr
70 ml/hr
Correct answer:
46 ml/hr (1100/24)
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 75Kg) until Monday. Make sure to bring this up at morning rounds.
The rate needs to be set at 0700, but remind that this could be changed once he is assessed by the dietitian. The important point to remember that it remains volume based feeding so it should be a volume target, not a ml/hr order. 18

19. 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
Correct answer:
Implement the diarrhea management guidelines.
Emphasize that the feeds are not to be stopped.
Metoclopramide is for gastric motility only, it does not cause diarrhea
Increasing the TF will not likely help 19

20. 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
Correct answer:
Implement the diarrhea management guidelines.
Emphasize that the feeds are not to be stopped.
Metoclopramide is for gastric motility only, it does not cause diarrhea
Increasing the TF will not likely help 20

21. 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
Correct answer:
80 ml/hr
Feeds were off at 1300h so the patient received 6 hours of volume. This means there are 18 hours of volume remaining to be delivered in 14 hours (1700h – 0700h).
1500 – 378 = 1122/14= 80 ml/hr
1500/24=63 ml/hr original rate 21

22. 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
Correct answer:
80 ml/hr
Feeds were off at 1300h so the patient received 6 hours of volume. This means there are 18 hours of volume remaining to be delivered in 14 hours (1700h – 0700h).
1500 – 378 = 1122/14= 80 ml/hr
1500/24=63 ml/hr original rate 22

23. Questions?