u P PROTOCOL All patients will receive a semielemental 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 ID: 706506
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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 dailySlide3
GET PEPPED UP!
OPTION 1: Begin Volume-Based feeds24 hour period begins at XX:XX h daily Patients receive a semi-elemental formula initially Day 1: start feeding at 25 mL/hrDay 2: Feeding rate determined by 24hr target volumeConsult 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 ScheduleSlide4
GET PEPED UP!
OPTION 2: Trophic feedsBegin a semi-elemental formula at 10 mL/h after initial tube placement confirmedDo not monitor gastric residual volumesReassess ability to transition to Volume-Based feeds next day
2
tsp
per hourSlide5
GET PEPPED UP!
OPTION 2: Trophic feedsIntended for patient who is: On vasopressors (regardless of dose)as long as they are adequately resuscitatedNot suitable for high volume enteral feeding: Ruptured AAASurgically placed jejunostomy
Upper intestinal anastomosis
Impending
intubation
Risk of re-feeding syndromeSlide6
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!Slide7
GASTRIC FEEDING FLOWCHARTSlide8
CASE STUDY
73 year old male is admittedto ICU at 2100 hours with a three day history of shortness of breath and weakness. Slide9
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/minCASE STUDY:Slide10
His past medical history is significant for COPDand alcohol dependence
He is admitted to ICU with a diagnosis of community acquired pneumoniaHe does not have bowel sounds and is NPOHis weight is 75kg and height is 1.8mCASE STUDY:Slide11
What do you anticipate will be ordered for feedingon admission?
NPO because no Bowel SoundsVolume based feeding because he is not receiving any vasopressorsStart trophic feeds at rate per PEP uP protocolStart metoclopramide and wait for bowel soundsCASE STUDY: ADMISSIONSlide12
What do you anticipate will be ordered for feedingon admission?
NPO because no Bowel SoundsVolume based feeding because he is not receiving any vasopressorsStart trophic feeds at rate per PEP uP protocolStart metoclopramide and wait for bowel soundsCASE STUDY: ADMISSIONSlide13
Does he require protein supplements?Yes. He requires protein supplements
because we want to avoid a nutrition deficit.No. Protein supplements are not requiredbecause he is a new admission.CASE STUDY: PEP uPInitial Orders: Protein SupplementsSlide14
Does he require protein supplements?Yes. He requires protein supplements
because we want to avoid a nutrition deficit.No. Protein supplements are not requiredbecause he is a new admission.CASE STUDY: PEP uPInitial Orders: Protein SupplementsSlide15
CASE STUDY: Admission OrdersThe resident orders volume-based feeds for him because he is adequately volume
resuscitatedand is not receiving vasopressorsIt is now 2200 hoursSlide16
For day 1 only, feeds will start at 25 mL/hDay 1 is only 9 hours long, and ends when the flow sheet for that day ends
On day 2, volume-based feeds beginCASE STUDY:Volume-based feeds: Getting StartedSlide17
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 rateWhat will the new rate be based on a 1.5kcal/ml formula?46 mL/hr62 mL/hr67 mL/
hr
70 mL/
hrSlide18
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 rateWhat will the new rate be based on a 1.5kcal/ml formula?46 mL/hr62 mL/hr67 mL/hr70 mL/
hrSlide19
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 feedsStop the metoclopramideImplement the diarrhea management guidelines
Increasing the tube feeding
rate
CASE STUDY:
Admission Day 2Slide20
He continues to receive volume based feedsper 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 feedsStop the metoclopramideImplement the diarrhea management guidelinesIncreasing the tube feeding rateCASE STUDY:
Admission Day 2Slide21
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?62 mL/hr75 mL/hr80 mL/hr
115 mL/
hr
CASE STUDY:
Admission
Day
3Slide22
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?62 mL/hr75 mL/hr80 mL/hr115 mL/hrCASE STUDY:
Admission
Day
3Slide23