implementing the portland protocol - continuous .../media/files/providence or migrated...

The Portland Diabetic Project

copyright©Furnary-2006

Implementing The Portland Protocol -Continuous Intravenous Insulin Infusion

in your institution

Anthony P. Furnary, MD

St Vincent Medical CenterProvidence Health Systems

Portland, OR



Phased Implementation of the Portland CII Protocol

Dates Location Target BG (mg/dl)

1987 - 1991 SQI > ICU / Tele 150 - 200

1992 - 1994 ICU only 150 - 200

1995 - 1998 OR / ICU / Tele 150 - 200

1999 - 2000 OR / ICU / Tele 125 - 175

2001 - 2004 OR / ICU / Tele 100 - 150

2005 - OR / ICU 70 - 110 Telemetry 80 - 120



Blood Glucose Assessment / Tabulation

GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG

BG-DOSBG-POD1

BG-POD2 BG-POD4

BG-POD3

DOS POD1 POD2 POD3 POD4

1. Arterial Line Drop2. Venous Line Drop3. Capillary (finger-stick)

q 0.5 - 2 hour}

3-BG = Avg 3-day Postoperative BG



3-BG vs. Operative Date

1986 1988 1990 19

100

150

200

250

300

Year of Surgery992 1994 1996 1998 2000 2002

SQI CII

Blo

od G

luco

se (m

g/dl

)



Hyperglycemia in the peri-operative

period can be safely and effectively

eliminated through the use of a

Continuous Intravenous Insulin Infusion

(CII = “The Portland Protocol”)

Hyperglycemia : CII Hypothesis



Safety = % of patients with BG measurements <40 / <50 / <60 / <70

SAFETY & EFFICACYof an insulin infusion protocol

Efficacy = Amount of time it takes to achieve 90% compliance with

target BG range



1. Define Duration

• Surgical Patients: Start “Portland Protocol”during surgery & continue throughout ICU stay

• Medical Patients: Continue Portland Protocolthroughout ICU stay.

For an ICU Protocol:



2. What about the “Non-Diabetic” Patient?• For patients who do not have a diagnosis of “diabetes”, but who present with hyperglycemia: start PDX protocol if blood glucose > 125 mg/dl x 3 consecutive readings OR >150mg/dl at any one time.

• If continuing need for insulin exists, consult endocrinologist on discharge from ICU for DM workup and follow-up orders.



3a. Initial Infusion Rate Portland CII Protocol: 80 - 120

BG Initial Infusion Rate (units / hour)

Non-DM & NIDDM IDDM

80 - 120 0.5 Units/hour 1 Unit / Hour

121 - 180 1 Unit / Hour 2 Units / Hour

181 - 240 2 Units / Hour 3.5 Units / Hour

241 - 300 3.5 Units / Hour 5 Units / Hour

301 - 360 5 Units / Hour 6.5 Units / Hour

>360 6.5 Units / Hour 8 Units / Hour



3b. IV Insulin Bolus dosing Portland CII Protocol: 80 - 120

BG IV Insulin Bolus (units)

80 - 120 0 Units

121 - 180 0 Units

181 - 240 4 Units

241 - 300 8 Units

301 - 360 12 Units

>360 16 Units



4. Frequency & Source of BG ’s

For an ICU Protocol:Test Blood glucose (BG) by finger stick, arterial, or venous

line drop sample. Frequency of BG testing is as follows:a. If BG ≥150 or < 80 : check BG every 30 minutesb. If BG 80 - 150: check BG every hour.c. When titrating epinephrine, check q. 30 minutesd. When BG 80 – 120, with <15 mg/dl change and

insulin rate remains unchanged x 4hr., then maytest q. 2 hrs.



4a. Insulin Titration

In the Intensive Care Unit:Nurses may titrate Insulin drip at **will** to

rapidly (within 3 hrs) achieve and hold BG in target range (80-120) using the following as guidelines.



Insulin Titration:Caveats

• Built-in hypoglycemic prevention / recovery• Fine titration within target BG range• Variable titration for any given BG level

– Dependent on rate of change– Does not make a continuous variable a categorical one

• IV insulin Boluses for high (>180) BG levels• Double boluses and drip rates if insulin resistant



4b. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

<60 STOP INSULIN!Give 25 cc D50Recheck BG in 30 minutes.When BG > 70:restart Insulin at 50% of previous rate.



4c. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

60 - 69 STOP INSULIN!IF Previous BG > 100:

Give 25 cc D50Recheck BG in 30 minutes.When BG > 70:restart Insulin at 50% of previous rate.



4d. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

70 - 79 If ≥ last test maintain same rate.If lower than last test by more than

20 mg/dl, decrease rate by 50%.If lower than last test by less than

20 mg/dl, decrease rate by 0.5 units/hr.Recheck BG in 30 minutes.



BG Action

80 - 120 Excellent! You are in the Target Range! Titrate drip at will to maintain this range!

Suggestions:If higher than last BG by more than 10 mg/dl

– increase rate by 0.5 unit/hrIf lower than last BG by more than 10 mg/dl

– decrease rate by 0.5 unit/hrIf within 10 mg/dl of last BG:If BG consistently decreasing

– decrease rate by 0.3 unit/hrIf BG consistently increasing

– increase rate by 0.2 unit/hr

4e. Insulin Titration Portland CII Protocol: 80 - 110




• Built-in hypoglycemic prevention / recovery• Fine titration within target BG range• Variable titration (several) for any given BG level





4f. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

121 - 150 If higher than last test By more than 20 mg/dl -- increase rate by 1 Unit/hrIf within 20 mg/dl of last test

-- increase rate by 0.5 Unit/hrIf 20 - 70 mg/dl lower than last test

-- SAME RATE If lower than last test by more than

70 mg/dl, decrease rate by 50%



4g. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

151 - 180 If lower than last test by more than30 mg/dl -- SAME RATE

If lower than last test by less than 30mg/dl …OR… If higher than last test:Increase rate by 1 Unit/hr

Recheck BG in 30 minutes.



4h. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

181 - 240 If lower than last test by more than50 mg/dl -- SAME RATE

If lower than last test by less than 50mg/dl …OR… If higher than last test:BOLUS with 4 units ANDIncrease rate by 2 Unit/hr

Recheck BG in 30 minutes.



4i. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

> 240 If lower than last test by more than100 mg/dl -- SAME RATE

If lower than last test by less than 100/dl …OR… If higher than last test:IV BOLUS per “IV Bolus Table” above

AND DOUBLE INSULIN RATERecheck BG in 30 minutes.



4j. Insulin Titration Portland CII Protocol: 80 - 120

BG Action

**NOTE** If BG 151 – 240 mg/dl and has not decreased after 3 consecutive increases in insulin, then bolus with 4 units and double insulin rate.

If BG > 300 for 4 consecutive readings: call MD for additional IV bolus orders.

MD: Continue Doubling Bolus and Doubling Drip to effect



5. Define Enteral Diet

1800 ADA Diabetic diet starts with any PO intake.

Begin FULL liquids and advance as tolerated.

Avoid clear liquid diet if possible.



6a. Prandial SQ Insulin Analogue Supplement

In addition to insulin infusion at mealtimes:

• If consistently eating a full meal, give S.Q. Humalog 15 min. pre-meal;

• If uncertain of oral intake, then give immediately post-meal.

• Test BG 2 hours after SQ Humalog



6b. Prandial SQ Humalog Supplement

7 Units14 Units>10

6 Units12 Units8 - 10

5 Units10 Units6 - 8

4 Units8 Units4 - 6

3 Units6 Units2 - 4

2 Units4 Units0 - 2

Eats <50% of meal

Eats >50% of meal

Drip Rate



6c. Prandial SQ Insulin Analogue Supplement

Test BG 2 hours after SQ Humalog:a. If BG >175 mg/dl, then increase next meal-related

dose by two “rows”b. If BG 125 - 175 mg/dl, then increase next meal-related

dose by one “row”.c. If BG 80 – 125, repeat this dose with next meald. If BG < 80 mg/dl decrease next meal-related dose by

one “row”.



DURATION OF INTENSIVE INSULIN THERAPY

MATTERS!!!

RATIONALE FOR EXTENDING PORTLAND PROTOCOL TO THE

FLOOR:



Independent association of Isolated BGMeasurements on Mortality

Odds Ratio0.5 1.0 1.5 2.0 2.5 3.0 3.5

BG-Preop

Hgb A-1C

BG-POD2

BG-POD1

BG-DOS

3-BG

BG-POD3



Independent association of Isolated BGMeasurements on DSWI

Odds Ratio1.0 1.5 2.0 2.5

Hgb A-1C

3-BG

BG-Preop

BG-DOS

BG-POD3

BG-POD2

BG-POD1



1. Define Duration

•Surgical Patients: Start “Portland Protocol” during surgery & continue throug 7 AM of the 3rd Post-operative Day. Patients who are not taking enteral nutrition on the 3rd POD should remain on this protocol until taking at least 50% of a soft ADA diet

•Medical Patients: should remain on Portland Protocoluntil taking a soft ADA diet.

For a Floor Protocol:



2. Frequency & Source of BG ’sFor a Floor Protocol:

Test (BG) by finger stick or venous line drop sample. Frequency of BG testing is as follows:a. If BG ≥180 or < 80 : check BG every 30 minutesb. If BG 80 - 180: check BG every hour.c. When BG 80 – 120, with <15 mg/dl change and

insulin rate remains unchanged x 4hr., then maytest q. 2 hrs.

d. May stop q. 2 hr testing on POD #3 in surgery patients or as noted in #1 (see items #1 & #8).

e. At night: Test q. 2 hr if BG 120 - 150; Test q4 hr if BS 80 - 120 and “stable infusion rate” exists.



3. Conversion to SQI

• CONVERSION TO Basal - Prandial Insulin• Basal -- 40% of 24 hour Insulin requirement

•MUST BE AT BASAL (non-stressed) RATE•This does not occur on 1st OR 2nd POD!•Glargine•NPH

• Periprandial Analogues

For a Floor Protocol:



↓Safe/Efficacy ↑Safe/Efficacy

FREQUENCY of BGIntermittent Continuous BG2 hr 1 hr 0.5 hr4hr

↓Complexity ↑ComplexityINSULIN TITRATIONLess Precise More Precise

Euglycemia HyperglycemiaTARGET RANGE70 - 80 - 90 - 100 - 110 - 120 - 130 - 140 - 150 - 160 - 170 - 200



↓Safe/Efficacy ↑Safe/Efficacy

Nursing EducationSeldom Ongoing

Inexperienced ExperiencedNursing Staff StabilityAgency Rns Staff RNs

Team MentorsAtmosphere/Culture



“Caveats For Success”• Start with a high Target Range = 150 - 200• Start with a PROOVEN patient population = ICU/CTS• USE AN ESTABLISHED PROTOCOL!

– Don’t “reinvent the wheel”• CHOOSE a protocol with known safety and efficacy• ENGAGE Champions from multiple disciplines• EMPOWER the RN’s with the data• ADVANCE from the ICU….. Move to the floor

implementing the portland protocol - continuous .../media/files/providence or migrated...

Documents