2. MAIN FEATURES OF THE PEP uP PROTOCOL All patients will receive Peptamen ® Bariatric 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 ® Bariatric 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 ® Bariatric 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

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 –Risk of re-feeding syndrome

6. 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!

7. GASTRIC FEEDING FLOWCHART

8. CASE STUDY 73 year old male is admitted to ICU at 2100 hours with a three day history of shortness of breath and weakness.

9. 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:

10. 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:

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

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

13. 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 uP Initial Orders: Protein Supplements

14. 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 uP Initial Orders: Protein Supplements

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

16. 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

17. 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. CASE STUDY: Setting the 24 hour rate What will the new rate be? A.46 mL/hr B.62 mL/hr C.67 mL/hr D.70 mL/hr

18. 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. CASE STUDY: Setting the 24 hour rate What will the new rate be? A.46 mL/hr B.62 mL/hr C.67 mL/hr D.70 mL/hr

19. 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.Stop the tube feeds B.Stop the metoclopramide C.Implement the diarrhea management guidelines D.Increasing the tube feeding rate CASE STUDY: Admission Day 2

20. 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.Stop the tube feeds B.Stop the metoclopramide C.Implement the diarrhea management guidelines D.Increasing the tube feeding rate CASE STUDY: Admission Day 2

21. 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/hr B.75 mL/hr C.80 mL/hr D.115 mL/hr CASE STUDY: Admission Day 3

22. 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/hr B.75 mL/hr C.80 mL/hr D.115 mL/hr CASE STUDY: Admission Day 3