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For the past decade or more, we have documented widespread iatrogenic underfeeding in intensive care unit (ICU) patients and that underfeeding was associated with worse clinical outcoms. Systematic barriers to adequately delivery of nutrition exist, many of which related to the initiation of feeds and use of a feeding protocol. Consequently, we developed a novel enteral feeding protocol designed to overcome the main barriers to adequate delivery of enteral nutrition, the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP protocol). The key components of this feeding protocol include: 1) Starting feeds at the target rate based on increasing evidence that some patients tolerate starting nutrition at a higher rate of delivery and that slow start ups are not necessary. For patients who are hemodynamically stable, we propose to shift from an hourly rate target goal to a 24 hour volume goal and give nurses guidance on how to make up this volume if there was an interruption for non-gastrointestinal reasons. 2) For patients who are deemed unsuitable for high volume intragastric feeds, we provide an option to initiate ‘trophic feeds.’ Trophic feeds represent an idea to provide a low volume of a concentrated feeding solution for 24 hours or longer, designed to maintain gastrointestinal structure and function rather than meet their protein and caloric goals. This option should reduce the numbers of patients ordered to be kept NPO. Thus, PEP up patients may gain some of the benefit of early EN. 3) To optimize tolerance in the early phase of critical illness, we propose to use a semi elemental feeding solution instead of a standard polymeric solution. There is some evidence that these semi elemental solutions are better assimilated than polymeric solutions in the critical care setting. These solutions can be changed to a more traditional polymeric solution once the patient is tolerating adequate amounts of nutrition. 4) Rather than wait for a protein debt to accumulate because of inadequate delivery of EN, protein supplements are prescribed at initiation of EN and can be discontinued if EN is well tolerated and they are receiving all their protein requirements through their standard EN. This strategy guarantees that the patient will most likely receive all their protein requirements in the early phase of their critical illness. 5) Rather than wait for a problem with gastrointestinal tolerance to develop, we propose to start motility agents at the same time EN is started with a re-evaluation in the days following to see if it is necessary. By preventing delayed gastric emptying, which frequently occurs in this patient population, we can improve nutritional adequacy. 6) Based on emerging evidence that a higher gastric residual volume (the volume of feeds remaining in the stomach when the bedside nurse aspirates the feeding tube) is safe and perhaps results in greater nutritional adequacy, we will include a higher gastric residual volume of 300ml (Or more, up to 500ml) in our protocol. Since the bedside nurses initiate and utilize feeding protocols to achieve target goals, we need to couple this newer generational feeding protocol with a comprehensive nurse-directed nutritional educational intervention that will focus on its safe and effective implementation. When combined with a nursing educational intervention and compared to a standard feeding protocol, the PEP uP protocol resulted in 12-15% increase in the amount of protein and calories received by patients in the context of a cluster randomized multicenter trial. Over the past decade, we have worked with scores of ICUs around the world to implement the PEP uP protocol in the real world setting. Below, we have created a number of tools and strategies that will be helpful to sites trying to implement PEP uP protocol in their ICUs.  We hope you will take the time to also learn about the initiative from PEP uP sites and read PEP uP publications.

PEP uP Discussion Group

The PEP uP google group is for you to discuss any of your experiences using the tools/education materials provided below. We also encourage you to share any new or adapted tools you come up with along the way.


Bedside Tools

Enteral Feeding Orders

This form is a paper based template that your site can adapt to use as the initial order form for enteral nutrition. The protocols differ in the initial order for voume based feeds due to the differences in kcal/ml of the formulas. If the use of a Peptamen or semi-elemental product is a barrier to your site implementing the PEP uP protocol, you may use a different formula.


Gastric Feeding Flowchart

This flow diagram illustrates the procedure for management of gastric residual volumes.


Volume Based Feeding Schedule

This table is a quick reference for determining goal rates of enteral feeding based on the volume of feed that needs to be delivered and the number of hours left in a 24 hr period. An example calculation is provided at the bottom.


Volume Based Feeding Calculations

This one-page document will help you quickly determine the volume-based goals and feeding rate when using an enteral formula that is 1.0 kcal/ml, 1.2 kcal/ml or 1.5 kcal/ml


Nurses' Guideline for the Management of Diarrhea

Reference sheet providing a guideline for potential causes of diarrhea and factors to consider in its management.


EN Guidelines for Surgical Procedures

Guideline to assist with the management of enteral feeding in critically ill patients that are going the operating room.


PEP uP Pocket Guide

Intended to be a quick overview of the PEP uP Protocol, and to direct nurses at the bedside to appropriate tools should they require further information


Bedside Nutrition Monitoring Tool

Web-based application used to monitor the progress of enteral nutrition in real time..


Information Sheets

PEP uP Summary



A small brochure summarizing PEP uP and use of Peptamen (specifically Peptamen 1.5) and Beneprotein.


Information Sheet for Nurses

Provides general information about the protocol rationale and guidelines for implementation of the protocol.



Also known as Nutrition Information Bytes, NIBBLES provide quick information about a popular nutrition topic. Issue 7 discusses trophic feeds, Issue 8 introduces the PEP uP protocol.


Implementation Tools

Educational Video

This MUST SEE 11 minute video made in collaboration with Nestle Health Sciences features the nurse and dietitian from the Credit Valley ICU, Mississauga, a PEP UP Canadian site that received a Best of the Best Award in the International Nutrition Survey 2013. Use this video for educating those working on implementing the PEP uP Protocol.


Webinar May 2014

You can follow along with the recorded webinar audio using the two PowerPoints: #1 was presented by Dr. Heyland and introduces the PEP uP Collaborative, reviews the Canadian PEP uP Collaborative results and discusses barriers to protocol implementation. PowerPoint #2 was presented by Rupinder Dhaliwal and reviews the PEP uP tools and INS 2014.



Hang posters on bulletin boards in the ICU, staff room, research boards, or any other medium for communication.



The long version, a lecture style inservice, is designed for educational sessions of 30-40 minutes, with cases. The short version, a bedside style inservices, is designed for short 10 – 15 min sessions with a few nurses at the bedside.


Grand Rounds Presentation

This is the PowerPoint Dr. Heyland has presented internationally at conferences and at site visits.


Slideshow of PEP uP pointers

This format of reminder messages is used to maintain awareness about the protocol. Play the slideshow on a large screen in a central area of the ICU or display these messages on bedside terminals.


Self Learning Module

This Word file provides an opportunity for staff to work through several cases after reading some basic information about the PEP uP protocol.



This FAQ document has been designed to address some common questions about the PEP uP Protocol, and to offer solutions to issues that might be encountered.
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