Portland Protocol – Review Runal Shah

2nd year ResidentMasters in Emergency Medicine

Kokilaben Dhirubhai Ambani HospitalMumbai

Objectives•Know your insulin

•Clinical applicability

•Portland protocol

Know your Insulin• Human Actrapid Insulin (HAI)

▫ 100% neutral human insulin

▫ Max concentration after subcutaneous administration 1.5-2.5 hours

▫ Short acting

▫ Injection should be followed by a meal or snack containing carbohydrates within 30 minutes

▫ Should be stored in a refrigerator 2°-8°C▫ 100IU/ml of 10ml vial

Clinical applicability• ICU application

• Hyperglycemia–Increased Morbidity, Mortality▫ Immune dysfunction▫ Increased systemic inflammation▫ Vascular insufficiency

• Improved glycemic control leads to decrease in mortality from 8.0 to 4.6% *

• *Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 Nov 8. 345(19):1359-67.

Portland Protocol• In 1992, the Providence Heart and Vascular

Institute developed the Portland Protocol© from data extrapolated from diabetic patients who underwent cardiac surgery.

• It has undergone multiple modifications since its inception and takes into account many of the nuances previously identified.

• Other protocols▫ Georgia Hospital Association Protocol (the Davidson or

Glucommander Protocol)

PORTLAND

PROTOCOL

Portland Protocol• Target blood sugar range : 100-150 mg/dl

▫ Initial blood glucose check upon admission and then every 2 hours

▫ HbA1c to check ▫ Portland protocol starts at Sugars > 125 mg/dl

• Mix 1 unit of Regular human insulin per 1 ml of 0.9% normal saline and start IV infusion via pump.

Portland Protocol• Frequency of testing is as follows:

▫ Check blood glucose every 30 minutes when blood glucose is more than 200mg/dL or less than 100 mg/dL

▫ Check blood glucose every hour when levels are 100-200 mg/dL.

▫ Check blood glucose every two hours when levels are 125-175 mg/dL and blood glucose varies less than 15 mg/dL over 4 hours and the insulin rate remains unchanged for 4 hours.

▫ Note: If any change in blood glucose more than 15mg/dL occurs or any change in insulin rate more than 0.5 units occurs, return to checking blood glucose every hour.

Portland Protocol• Pros

▫ Good control of sugars over intermittent SC Insulin▫ Known diabetics in whom sugar is not controlled

with subcutaneous Insulin

• Cons▫ Bedside calculation of insulin dose is cumbersome

work▫ Hypoglycemia – the most feared side effect▫ Warning signs of hypoglycemia are difficult to

appreciate in critically ill patients▫ Nurse driven with varying physician output▫ Capillary blood vs. Venous blood sugar diff !! (~70)

Thank You…

• Ref : Medscape

Tintinalli 7/ehttp://appsor.providence.org/portlandprotocol