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1、 Page 1 of 3 Portland Continuous Intravenous Insulin Protocol ICU TARGET BLOOD GLUCOSE 70 to 110mg/dl Version 2008.1: ICU PHASE 4 1. Start “Portland Protocol” on all ICU patients as indicated below (place these orders on all ICU admission and postoperative order sets): Initial BG check on admission
2、to ICU then check BG every 2 hours X 6; then AC, 2 hours PC, and HS X 24 hours; if all BG 125 resume Protocol. Non-Diabetic Patients If continuing need for insulin exists on transfer after POD #3, and admission HgbA1c is greater than 6, ask physician to consult endocrinologist for DM workup and furt
3、her follow-up orders. 5. ICU Transfer: Transition to Floor (ward) version of Portland Protocol on transfer out of ICU in: All hyperglycemic patients: within 3 days of operation or ICU admission, or those eating less than 50% of a regular diet. Non-Diabetic Patients If continuing need for insulin exi
4、sts on transfer after POD #3, and admission HgbA1c is greater than 6, ask physician to consult endocrinologist for DM workup and further follow-up orders. 6. Protocol Cessation permissible ONLY on transfer in: Diabetic patients if more than 3 days since last operation or ICU admission and eating mor
5、e than 50% of a regular diet then: i. If admission HgbA1c is LESS than 6.5: Restart pre-admission gylcemic control meds at 7 AM on day of transfer and stop intravenous insulin infusion at 9AM prior to transfer (OR ) ii. If admission HgbA1c is GREATER than 6.5: Consider additional Basal-Pranial SQ in
6、sulin therapy Initiate Portland Basal-Prandial SQ Insulin Transition Protocol iii. Continue to monitor BG AC; 2 hours PC; and HS throughout rest of hospital stay Non-Diabetic Euglycemic Patients may stop protocol If meet criteria outlined in #4 “Duration” Non- Diabetic patients who remain hyperglyce
7、mic beyond the 3rd postoperative day - no need to continue Protocol on transfer. However Endocrinology consultation should be requested by physician (see #5 above) 7. Test Blood Glucose (BG) by finger stick, arterial, or venous line drop samples. Frequency of BG testing is as follows: Check BG every
8、 30 minutes when: BG greater than 150mg/dl; or BG less than 70 mg/dl; or after insulin drip is stopped; or after insulin drip is decreased more than 50%; or after Bolus IV Insulin dose is given; or when rapidly titrating Vasopressors (e.g. epinephrine, norepinephrine). Check BG every Hour when BG is
9、 70 150 mg/dl Check BG every 2 Hours when BG is 70 - 110, with less than 15mg/dl BG variation over 4 hours and Insulin Rate remains unchanged for 4 hours “Stable Infusion Rate”. Note If any change in BG more than 15mg/dl, or any change in Insulin Rate more than 0.5 units: Return to checking BG every
10、 Hour. During initiation of, rate change of, or cessation of any nutritional support or renal correction therapy Check BG every 30 minutes X 4 i. Nutritional support (enteral or parenteral) includes Tube Feedings, TPN, PPN ii. Renal correction therapy = Renal Dialysis, CVVH, CVVHD, Peritoneal dialys
11、is, etc. 8. See Page 2 For Intravenous Insulin Titration Guidelines 9. See Page 3 For Meal Orders and adjunctive Periprandial SQ dosing schedules Physician Signature_Date:_Time:_ Page 2 of 3 Portland Continuous Intravenous Insulin Protocol ICU TARGET BLOOD GLUCOSE 70 to 110mg/dl Version 2008.1: ICU
12、PHASE 4 ICU: May titrate Insulin Infusion between 0-30 units /hour using the following as GUIDELINES to rapidly (within 3 hrs) achieve and maintain BG in target range (70-110). Round insulin Infusion to the nearest tenth of a unit (0.1) when necessary. Blood Glucose (BG) Note: If ANY BG is less than
13、 40mg/dl or greater than 450mg/dl, obtain confirmatory laboratory BG Action: Less Than 50Stop Insulin: If not alert or if NPO: give 15 ml of D50W IV; If 40 give 25 ml of D50W IV If alert and taking PO give 8 ounces of juice PO OR 6 glucose tablets PO Recheck BG every 30 minutes until greater than 80
14、mg/dl If next BG is 50mg/dl: Double amount of previous treatment; If next BG is 50 65 mg/dl repeat treatment When BG greater than 80mg/dl: Restart Insulin rate at 50% of previous rate IF taking PO: give 4-6 ounces of juice OR 3 glucose tablets PO. Recheck BG every 30 minutes until greater than 80mg/
15、dl If next BG is 50-63 mg/dl: Repeat previous treatment When BG greater than 80mg/dl: Restart Insulin rate at 50% of previous rate & recheck BG in 30 minutes 64 to 72 If greater than last test: Decrease rate by 0.2 units / Hour If lower than last BG by more than 30 mg/dl: Stop drip & recheck BG in 3
16、0 minutes (see bold * order) If lower than last BG by 15 30 mg/dl: Decrease rate by HALF (50%) & recheck BG in 30 minutes If lower than last BG by 7 14 mg/dl: Decrease rate by 0.5 Units / Hour If equal to last BG or lower than last BG by less than 7 mg/dl: Decrease rate by 0.3 Units / Hour *If infus
17、ion turned off, recheck BG in 30 min, when BG greater than 80mg/dl restart at 50% of previous rate & recheck BG in 30 minutes Recheck BG every 30 minutes until greater than 80mg/dl 73 to 110 Target Range EXCELLENT! May titrate drip in ICU to maintain this range. See Suggestions: If higher than last
18、BG by more than 10mg/dl: Increase rate by 0.5 Units / Hour If lower than last BG by more than 40 mg/dl: Stop drip & recheck BG in 30 minutes (see bold * order) If lower than last BG by 2140 mg/dl: Decrease rate by HALF (50%) & recheck BG in 30 minutes If lower than last BG by 10-20mg/dl: Decrease ra
19、te by 0.5 Units / Hour * If infusion turned off, recheck BG 30 min, if / when BG greater than 110mg/dl restart at 50% of previous rate If within 10mg/dl of last BG same rate unless the following applies: FOR ANY BG in this range (even if within 10 mg/dl of last test) the following ALWAYS applies: BG
20、 has consistently decreased each of last 4 measurements: Decrease rate by an additional 0.3 Units / Hour BG has consistently increased each of last 4 measurements: Increase rate by an additional 0.2 Units / Hour 111 to 130 If higher than last BG by more than 50mg/dl: Increase rate by 2 Units/Hour If
21、 higher than last BG by 20 - 50mg/dl: Increase rate by 1 Unit / Hour If higher than last BG by 0 - 20mg/dl: Increase rate by 0.5 Units / Hour If lower than last BG by 1 - 20 mg/dl: Same rate If lower than last BG by 21 - 40mg/dl: Decrease rate by 1 Unit / Hour If lower than last BG by 41 60 mg/dl: D
22、ecrease rate by HALF (50%) and recheck BG in 30 minutes If lower than last BG by more than 60 mg/dl: Stop drip & recheck BG in 30 minutes (see bold * order below) *If infusion turned off, recheck BG 30 min, if /when BG greater than 120mg/dl restart at 50% of previous rate 131 to 150 If higher than l
23、ast BG by more than 30mg/dl: Increase rate by 2 Units/Hour & bolus with 3 units IV If higher than last BG by 0 - 30mg/dl: Increase rate by 1 Unit / Hour & bolus with 2 units IV If lower than last BG by 1 20: Increase rate by 1 Unit / Hour & bolus with 2 units IV If lower than last BG by 21 to 50mg/d
24、l: Same rate If lower than last BG by 51 80mg/dl: Decrease rate by HALF (50%) and recheck BG in 30 minutes If lower than last BG by more than 80mg/dl: Stop drip & recheck BG in 30 minutes (see bold * order below) *If infusion turned off, recheck BG 30 min, if /when BG greater than 120mg/dl restart a
25、t 50% of previous rate 151 to 180 If lower than last BG by more than 80mg/dl: Decrease rate by HALF (50%) If lower than last BG by 30 80mg/dl: Continue same rate If lower than last BG by 0 30: Increase Insulin rate by 1 Unit / Hour & bolus with 2 units IV If higher than last BG by 1- 20mg/dl: Increa
26、se Insulin rate by 2 Units / Hour & bolus with 4 units IV If higher than last BG by more than 20mg/dl: Increase Insulin rate by 3 Units/Hour & bolus 6 units IV Recheck BG in 30 minutes. Repeat BG every 30 minutes until less than 150mg/dl 181 to 240 If lower than last BG by more than 100 mg/dl: Decre
27、ase rate by HALF (50%) If lower than last BG by 50 100 mg/dl: Continue same rate If lower than last BG by less than 50mg/dl OR higher than last BG: BOLUS with 6 units Regular Insulin IV AND Increase Insulin rate by 2 Units / Hour If BG remains 181 - 240 mg/dl and has not decreased after 3 consecutiv
28、e increases in Insulin: a. Give DOUBLE previous IV BOLUS dose up to a maximum of 24 units AND b. DOUBLE Insulin drip rate - up to a maximum of 20 units / hour c. If on 20 units/hour and no response after 4 maximum boluses CALL MD for further orders Recheck BG in 30 minutes. Repeat BG every 30 minute
29、s until less than 150mg/dl Greater than 240 If lower than last BG by more than 150 mg/dl: Decrease rate by HALF (50%) If lower than last BG by 101-150mg/dl : Same rate If lower than last BG by 0- 100mg/dl OR if higher than last BG: BOLUS with 10 Units Regular Insulin IV AND DOUBLE Insulin rate up to
30、 a maximum of 30 units / hour If BG remains greater than 240 mg/dl and has not decreased after 3 consecutive increases in Insulin: d. Give DOUBLE previous IV BOLUS dose up to a maximum of 40 units AND e. DOUBLE Insulin drip rate - up to a maximum of 30 units / hour f. If on 30 units/hour and no resp
31、onse after 4 maximum boluses CALL MD for further orders Recheck BG in 30 minutes. Repeat BG every 30 minutes until less than 150mg/dl IF BG GREATER THAN 300 for 4 CONSECUTIVE READINGS: CALL MD FOR ADDITIONAL IV BOLUS ORDERS Physician Signature_Date:_Time:_ Page 3 of 3 Portland Continuous Intravenous
32、 Insulin Protocol ICU TARGET BLOOD GLUCOSE 70 to 110mg/dl Version 2008.1: ICU PHASE 4 10. Diet: 1800 ADA Diabetic Diet starts with any PO intake. When need to advance diet exists, may begin with FULL liquids or SUGAR- FREE clear liquids and advance as tolerated. Patient may take oral or enternal nut
33、rition at any time in conjunction with this protocol. 11. Prandial Subcutaneous Rapid-Acting Insulin Analogue (Humalog/Novolog/Apidra) Supplement in ADDITION to Insulin Infusion at MEALTIMES: a. For the patients FIRST meal give S.Q. Humalog/Novolog/Apidra immediately post-meal according to the follo
34、wing dosing schedule: Insulin Infusion Drip Rate at First Meal Eats Greater Than 50% of Meal Eats 25% to 50% of Meal Snacks or less than 25% of meal ROW # 0 to 1.9 Units / Hour4 Units2 Units1 Unit1 2 to 3.9 Units / Hour6 Units3 Units2 Units2 4 to 5.9 Units / Hour8 Units4 Units3 Units3 6 to 7.9 Units
35、 / Hour10 Units5 Units4 Units4 8 to 10 Units / Hour12 Units6 Units5 Units5 Over 10 Units / Hour14 Units7 Units6 Units6 b. Chart the ROW # used from the above dosing schedule from the initial meal = “Initial Row #”. c. Continue Protocol BG frequency monitoring and treatment as noted in the IV portion
36、 of this protocol. d. For all subsequent meals & periprandial S.Q. Insulin Analogue doses and titration use the table below. Note: Ignore the insulin IV insulin infusion rate after the first periprandial dose calculation and adjust all further doses using row # references. If consistently eating ent
37、ire meal tray, give S.Q. Humalog/Novolog/Apidra when tray arrives at bedside. If uncertain of oral intake, then give S.Q. Humalog/Novolog/Apidra immediately post-meal e. Based upon a postprandial BG reading obtained approximately 2 hours After Subcutaneous Analogue insulin was given, and using the “
38、Initial Row #” as THE FIRST baseline row, titrate (adjust) the S.Q. dosing schedule Row # for the NEXT meal as follows: If the 2 hour postprandial BG is greater than 175mg/dl, increase insulin schedule for next meal by TWO ROWS If the 2 hour postprandial BG is 125 - 175mg/dl, increase insulin schedu
39、le for next meal by ONE ROW If the 2 hour postprandial BG is 81 124mg/dl, then repeat this dosing schedule with next meal If the 2 hour postprandial BG is 60 - 80mg/dl, then DECREASE insulin schedule for next meal by ONE ROW If the 2 hour postprandial BG is less than 60mg/dl, then DECREASE insulin s
40、chedule for next meal by TWO ROWS ROW #Eats Greater Than 50% of Meal Eats 25% to 50% of Meal Snacks or less than 25% of meal 14 Units2 Units1 Unit 26 Units3 Units2 Units 38 Units4 Units2 Units 410 Units5 Units3 Units 512 Units6 Units3 Units 614 Units7 Units4 Units 716 Units8 Units4 Units 818 Units9
41、Units5 Units 920 Units10 Units5 Units 1022 Units11 Units6 Units 1124 Units12 Units6 Units 1226 Units13 Units7 Units f. With each meal chart the ACTUAL ROW # used for S.Q. periprandial dosing. g. This previous meal ROW# becomes the new Baseline row # from which the NEXT meal-related periprandial dose
42、 of S.Q Analogue will again be adjusted according to the titration schedule in 8.e as read from the table above. h. Continue to titrate each subsequent meal-related S.Q. dose of Humalog/Novolog/Apidra according to the titration schedule in 8.e using the Row # actually used from the previous (Immediately preceding) meal as the baseline Row #. i. May use PORTLAND PROTOCOL PRANDIAL TITRATION WORKSHEET, or chart in computer record Physician Signature_Date:_Time:_