MAIN FEATURES OF THE PEP u P PROTOCOL

2. 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

3. 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

4. GET PEPED UP! OPTION 2: Trophic feeds • Begin Peptamen® 1.5at 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 tspper hour

5. 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

6. GET PEPPED UP! OPTION 3: NPO Onlyif 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.

7. GASTRIC FEEDING FLOWCHART

8. CASE STUDY 73 year old male is admittedto ICU at 2100 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 improvedand his respiratory rate is 14/min

10. 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

11. CASE STUDY: ADMISSION • What do you anticipate will be ordered for feedingon admission? • NPO because no Bowel Sounds • Volume based feeding because he is not receiving any vasopressors • Start trophic feeds at rate per PEP uPprotocol • Start metoclopramide and wait for bowel sounds

12. CASE STUDY: ADMISSION • What do you anticipate will be ordered for feedingon admission? • NPO because no Bowel Sounds • Volume based feeding because he is not receiving any vasopressors • Start trophic feeds at rate per PEP uPprotocol • Start metoclopramide and wait for bowel sounds

13. CASE STUDY: PEP uPInitial Orders: Protein Supplements • Does he require protein supplements? • Yes. He requires protein supplementsbecause we want to avoid a nutrition deficit. • No. Protein supplements are not requiredbecause he is a new admission.

14. CASE STUDY: PEP uPInitial Orders: Protein Supplements • Does he require protein supplements? • Yes. He requires protein supplementsbecause we want to avoid a nutrition deficit. • No. Protein supplements are not requiredbecause he is a new admission.

15. 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

16. 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

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 ratefor the next 24 hours, or until he is reassessed at rounds. • What will the new rate be? • 46 mL/hr • 62 mL/hr • 67 mL/hr • 70 mL/hr

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 ratefor the next 24 hours, or until he is reassessed at rounds. • What will the new rate be? • 46 mL/hr • 62 mL/hr • 67 mL/hr • 70 mL/hr

19. CASE STUDY: Admission Day 2 • He continues to receive volume based feedsper PEP uPprotocol. • He has developed diarrhea and is having4 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

20. 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? • Stop the tube feeds • Stop the metoclopramide • Implement the diarrhea management guidelines • Increasing the tube feeding rate

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

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