The document reviews the Portland Protocol for insulin therapy in critically ill patients, detailing the need for managing hyperglycemia to reduce morbidity and mortality. It outlines the protocol's development, clinical applicability, and specific blood glucose monitoring and insulin administration guidelines. The protocol aims for a target blood sugar range of 100-150 mg/dl and highlights both benefits and challenges in its implementation.

1. Portland Protocol – Review
Runal Shah
2nd year Resident
Masters in Emergency Medicine
Kokilaben Dhirubhai Ambani Hospital
Mumbai

2. Objectives
• Know your insulin
• Clinical applicability
• Portland protocol

3. 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

4. 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.

5. 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)

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7. 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.

8. 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.

9. 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)

10. Thank You…
• Ref :
Medscape
Tintinalli 7/e
http://appsor.providence.org/portlandprotocol