Implementing The Portland Protocol - Continuous Intravenous Insulin Infusion in your institution
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1 Implementing The Portland Protocol - Continuous Intravenous Insulin Infusion in your institution Anthony P. Furnary, MD St Vincent Medical Center Providence Health Systems Portland, OR
2 Phased Implementation of the Portland CII Protocol Dates Location Target BG (mg/dl) SQI > ICU / Tele ICU only OR / ICU / Tele OR / ICU / Tele OR / ICU / Tele OR / ICU Telemetry
3 Blood Glucose Assessment / Tabulation 1. Arterial Line Drop 2. Venous Line Drop 3. Capillary (finger-stick) GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG } q hour DOS POD1 POD2 POD3 POD4 BG-DOS BG-POD1 BG-POD2 BG-POD3 BG-POD4 3-BG = Avg 3-day Postoperative BG
4 Blood Glucose (mg/dl) The Portland Diabetic Project 3-BG vs. Operative Date SQI 300 CII Year of Surgery
5 Hyperglycemia : CII Hypothesis 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 )
6 SAFETY & EFFICACY of an insulin infusion protocol Safety = % of patients with BG measurements <40 / <50 / <60 / <70 Efficacy = Amount of time it takes to achieve 90% compliance with target BG range
7 1. Define Duration For an ICU Protocol: Surgical Patients: Start Portland Protocol during surgery & continue throughout ICU stay Medical Patients: Continue Portland Protocol throughout ICU stay.
8 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.
9 3a. Initial Infusion Rate Portland CII Protocol: BG Initial Infusion Rate (units / hour) Non-DM & NIDDM IDDM Units/hour 1 Unit / Hour Unit / Hour 2 Units / Hour Units / Hour 3.5 Units / Hour Units / Hour 5 Units / Hour Units / Hour 6.5 Units / Hour > Units / Hour 8 Units / Hour
10 3b. IV Insulin Bolus dosing Portland CII Protocol: BG IV Insulin Bolus (units) Units Units Units Units Units > Units
11 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 minutes b. If BG : check BG every hour. c. When titrating epinephrine, check q. 30 minutes d. When BG , with <15 mg/dl change and insulin rate remains unchanged x 4hr., then may test q. 2 hrs.
12 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.
13 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
14 BG The Portland Diabetic Project 4b. Insulin Titration Portland CII Protocol: Action <60 STOP INSULIN! Give 25 cc D50 Recheck BG in 30 minutes. When BG > 70: restart Insulin at 50% of previous rate.
15 BG The Portland Diabetic Project 4c. Insulin Titration Portland CII Protocol: Action STOP INSULIN! IF Previous BG > 100: Give 25 cc D50 Recheck BG in 30 minutes. When BG > 70: restart Insulin at 50% of previous rate.
16 BG The Portland Diabetic Project 4d. Insulin Titration Portland CII Protocol: Action 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.
17 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
18 BG Action The Portland Diabetic Project 4e. Insulin Titration Portland CII Protocol: 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/hr If lower than last BG by more than 10 mg/dl decrease rate by 0.5 unit/hr If within 10 mg/dl of last BG: If BG consistently decreasing decrease rate by 0.3 unit/hr If BG consistently increasing increase rate by 0.2 unit/hr
19 Insulin Titration:Caveats Built-in hypoglycemic prevention / recovery Fine titration within target BG range Variable titration (several) 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
20 BG The Portland Diabetic Project 4f. Insulin Titration Portland CII Protocol: Action If higher than last test By more than 20 mg/dl -- increase rate by 1 Unit/hr If within 20 mg/dl of last test -- increase rate by 0.5 Unit/hr If mg/dl lower than last test -- SAME RATE If lower than last test by more than 70 mg/dl, decrease rate by 50%
21 BG The Portland Diabetic Project 4g. Insulin Titration Portland CII Protocol: Action If lower than last test by more than 30 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.
22 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
23 BG The Portland Diabetic Project 4h. Insulin Titration Portland CII Protocol: Action If lower than last test by more than 50 mg/dl -- SAME RATE If lower than last test by less than 50mg/dl OR If higher than last test: BOLUS with 4 units AND Increase rate by 2 Unit/hr Recheck BG in 30 minutes.
24 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
25 BG The Portland Diabetic Project 4i. Insulin Titration Portland CII Protocol: Action > 240 If lower than last test by more than 100 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 RATE Recheck BG in 30 minutes.
26 BG The Portland Diabetic Project 4j. Insulin Titration Portland CII Protocol: Action **NOTE** If BG 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
27 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.
28 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 postmeal. Test BG 2 hours after SQ Humalog
29 6b. Prandial SQ Humalog Supplement Drip Rate >10 Eats >50% of meal 4 Units 6 Units 8 Units 10 Units 12 Units 14 Units Eats <50% of meal 2 Units 3 Units 4 Units 5 Units 6 Units 7 Units
30 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 mg/dl, then increase next meal-related dose by one row. c. If BG , repeat this dose with next meal d. If BG < 80 mg/dl decrease next meal-related dose by one row.
31 RATIONALE FOR EXTENDING PORTLAND PROTOCOL TO THE FLOOR: DURATION OF INTENSIVE INSULIN THERAPY MATTERS!!!
32 Independent association of Isolated BG Measurements on Mortality Hgb A-1C BG-Preop 3-BG BG-DOS BG-POD1 BG-POD2 BG-POD Odds Ratio
33 Independent association of Isolated BG Measurements on DSWI Hgb A-1C BG-Preop 3-BG BG-DOS BG-POD1 BG-POD2 BG-POD Odds Ratio
34 1. Define Duration For a Floor Protocol: 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 3 rd POD should remain on this protocol until taking at least 50% of a soft ADA diet Medical Patients: should remain on Portland Protocol until taking a soft ADA diet.
35 2. Frequency & Source of BG s For 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 minutes b. If BG : check BG every hour. c. When BG , with <15 mg/dl change and insulin rate remains unchanged x 4hr., then may test 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 ; Test q4 hr if BS and stable infusion rate exists.
36 3. Conversion to SQI For a Floor Protocol: 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
37 Safe/Efficacy The Portland Diabetic Project Safe/Efficacy Intermittent 4hr FREQUENCY of BG 2 hr 1 hr 0.5 hr Continuous BG Complexity Less Precise INSULIN TITRATION More Precise Complexity Euglycemia TARGET RANGE Hyperglycemia
38 Safe/Efficacy The Portland Diabetic Project Safe/Efficacy Seldom Nursing Education Ongoing Inexperienced Agency Rns Nursing Staff Stability Staff RNs Experienced Atmosphere/Culture Team Mentors
39 Caveats For Success Start with a high Target Range = 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
CARDIAC SURGERY INTRAVENOUS INSULIN PROTOCOL PHYSICIAN ORDERS INDICATIONS EXCLUSIONS. Insulin allergy
Page 1 of 5 INDICATIONS EXCLUSIONS 2 consecutive blood glucose measurements greater than 110 mg per dl AND NPO with a continuous caloric source AND Diagnosis of : Cardio-thoracic Surgery NOTE: This protocol
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