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The PEP uP protocol was created in 2009 to enhance the delivery of enteral nutrition in critically ill patients. A pilot study was completed to test the feasibility, acceptability and safety of this new novel feeding protocol (1). It was found to be safe and acceptable to nurses but further studies were warranted to determine its effect on the delivery of enteral nutrition. In a cluster randomized controlled trial in 2010, the PEP uP protocol was demonstrated to be safe and resulted in a 12-15% increase in the amount of protein and calories received from enteral nutrition (2).

The PEP uP Collaborative was formed in 2012 and assisted sites in implementing the protocol in their ICU. Initially, we focused on Canadian ICUs and have recently observed the effect of the protocol in a 'real-life' setting among these sites (3). Twenty-four Canadian ICUs participated in the International Nutrition Survey 2013, 8 were PEP uP Collaborative sites who were actively implementing the protocol and 16 served as controls. The protocol was shown to improve the delivery of enteral nutrition in the critically ill, with enterally fed patients at PEP uP sites receiving more calories, protein and protein supplements than at control sites. 

The educational strategies and tools created for the PEP uP Collaborative were evaluated at 9 North American sites implementing the PEP uP protocol (4). Responses from the nurses surveyed showed that the teaching formats (eg. PowerPoint presentations, self-learning module) met the learning needs of most nurses and the majority of study tools were considered easy to use.


(1) Heyland DK, Cahill NE, Dhaliwal R, Wang M, Day AG, Alenzi A, Aris F, Muscedere J, Drover JW, McClave SA. Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care. 2010;14(2):R78. PubMed ID: 20429886.

(2) Heyland DK, Murch L, Cahill N, McCall M, Muscedere J, Stelfox HT, Bray T, Tanguay T, Jiang X, Day AG. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013 Dec;41(12):2743-53. PubMed ID: 23982032.

(3) McCall M, Cahill N, Murch L, Sinuff T, Bray T, Tanguay T, Heyland DK. Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies. Nutr Clin Pract. 2014;29(4):510:517. PubMed ID: 24757062.

(4) Heyland DK, Dhaliwal R, Lemieux M, Wang M, Day AG. Implementing the PEP uP Protocol in Critical Care Units in Canada: Results of a Multicenter, Quality Improvement Study. 2015;39(6):698-706. PubMed ID: 24748597.

(5) Heyland DK, Lemieux M, Shu L, Quisenburry K, Day, AG. What is "Best Achievable" practice in implementing the Enhanced Protein-energy provision via the enteral route feeding protocol in intensive care units in the United States? Results of a multicenter, quality improvement collaborative. JPEN J Parenter Enteral Nutr. 2018 Feb;42(2):308-317. PubMed ID: 27875285

(5) Yeh DD, Ortiz LA, Lee JM, Chan J, McKenzie K, Young B, Chetelat L, Collier B, Benson A, Heyland DK. PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial. JPEN. 2019. [Epub ahead of print]. PubMed ID: 30741439. 

Additional PEP uP Publications

Lee ZY, Barakatun-Nisak MY, Airini IN, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP uP Protocol): A Review of Evidence. Nutr Clin Pract. 2015. [Epub ahead of print]. PubMed ID: 26385874

Declercq B, Deane AM, Wang M, Chapman MJ, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation. Anaesth Intensive Care. 2016 Jan;44(1):93-8.  PubMed ID: 26673594

Roberts S, Brody R, Rawal S, Byham-Gray L. Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control. JPEN. 2018 [Epub ahead of print]. PubMed ID: 30229952


Nutrition Information Byte (NIBBLE): Enhanced Protein-Energy-Provision via the Enteral Route Feeding Protocol in Critically Ill Patients: The PEP uP Protocol

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