MAIN FEATURES OF THE PEP u P PROTOCOL

MAIN FEATURES OF 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 XX:XX h 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 PEPED 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:

– Ruptured AAA– Surgically placed jejunostomy– Upper intestinal anastomosis– Impending intubation

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.

GET PEPPED UP!

GASTRIC FEEDING FLOWCHART

CASE STUDY73 year old male is admittedto 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 improvedand his respiratory rate is 14/min

CASE STUDY:

• His past medical history is significant for COPDand 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:

What do you anticipate will be ordered for feedingon admission?

A. NPO because no Bowel SoundsB. Volume based feeding because he is not receiving any vasopressorsC. Start trophic feeds at rate per PEP uP protocolD. Start metoclopramide and wait for bowel sounds

CASE STUDY: ADMISSION

What do you anticipate will be ordered for feedingon admission?

A. NPO because no Bowel SoundsB. Volume based feeding because he is not receiving any vasopressorsC. Start trophic feeds at rate per PEP uP protocolD. Start metoclopramide and wait for bowel sounds

CASE STUDY: ADMISSION

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: PEP uPInitial 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: PEP uPInitial Orders: Protein Supplements

CASE STUDY: Admission Orders• The resident orders volume-based feeds for him

because he is adequately volume resuscitatedand is not receiving vasopressors

• It is now 2200 hours

• 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:Volume-based feeds: Getting Started

At 0700 hours, a dietitian still has not yet assessed the patient. You will recalculate the hourly enteral feeding ratefor the next 24 hours, or until he is reassessed at rounds.

CASE STUDY:Setting the 24 hour rate

What will the new rate be?A. 46 mL/hrB. 62 mL/hrC. 67 mL/hr D. 70 mL/hr

At 0700 hours, a dietitian still has not yet assessed the patient. You will recalculate the hourly enteral feeding ratefor the next 24 hours, or until he is reassessed at rounds.

CASE STUDY:Setting the 24 hour rate

What will the new rate be?A. 46 mL/hrB. 62 mL/hrC. 67 mL/hrD. 70 mL/hr

He continues to receive volume based feedsper PEP uP protocol.

He has developed diarrhea and is having4 to 5 loose stools per day.

Which of the following would be an appropriate action?A. Stop the tube feedsB. Stop the metoclopramideC. Implement the diarrhea management guidelinesD. Increasing the tube feeding rate

CASE STUDY: Admission Day 2

He continues to receive volume based feedsper PEP uP protocol.

He has developed diarrhea and is having4 to 5 loose stools per day.

Which of the following would be an appropriate action?A. Stop the tube feedsB. Stop the metoclopramideC. Implement the diarrhea management guidelinesD. Increasing the tube feeding rate

CASE STUDY: Admission Day 2

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?A. 62 mL/hrB. 75 mL/hrC. 80 mL/hrD. 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?A. 62 mL/hrB. 75 mL/hrC. 80 mL/hrD. 115 mL/hr

CASE STUDY: Admission Day 3