What are the meal orders and adjunctive preprandial subcutaneous dosing scheduled according to the Portland IV insulin therapy protocol?

Updated: Nov 06, 2018
  • Author: Guy W Soo Hoo, MD, MPH; Chief Editor: George T Griffing, MD  more...
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Answer

Answer

The Portland Meal Orders and Adjunctive Periprandial Subcutaneous Dosing Schedules are listed below. The ICU target blood glucose level is 125-175 mg/dL. The 1800 American Diabetes Association Diabetic Diet starts with any oral intake. When the diet is advanced, begin with full liquids or sugar-free clear liquids and advance as tolerated. Patient may take oral or enternal nutrition at any time in conjunction with this protocol. Prandial subcutaneous rapid-acting insulin analogue (Humalog/Novolog/Apidra) is administered in addition to insulin infusion at meal times. For the patient’s first meal, administer subcutaneous rapid-acting insulin analogue immediately after the meal, according to the dosing schedule in the table below.

Table 1. Subcutaneous Rapid-acting Insulin Analogue Dosing. (Open Table in a new window)

Insulin Infusion Drip Rate at First Meal

Eats >50% of Meal

Eats 25-50% of Meal

Snacks or Eats < 25% of meal

Row

0-1.9 U/h

4 U

2 U

1 U

1

2-3.9 U/h

6 U

3 U

2 U

2

4-5.9 U/h

8 U

4 U

3 U

3

6-7.9 U/h

10 U

5 U

4 U

4

8-10 U/h

12 U

6 U

5 U

5

More than 10 U/h

14 U

7 U

6 U

 

Chart the row number used from the above dosing schedule from the initial meal. Continue protocol blood glucose level frequency monitoring and treatment as noted in the intravenous portion of this protocol. For all subsequent meals and periprandial subcutaneous rapid-acting insulin analogue doses and titration, use the table below. Note: Ignore the insulin intravenous insulin infusion rate after the first periprandial dose calculation and adjust all further doses using row number references. If the patient is consistently eating entire meal tray, administer subcutaneous rapid-acting insulin analogue when the tray arrives at bedside. If uncertain of oral intake, then administer subcutaneous rapid-acting insulin analogue immediately after the meal.

Based on a postprandial blood glucose level reading obtained approximately 2 hours after subcutaneous rapid-acting insulin analogue was given, and using the initial row number as the first baseline row, titrate (adjust) the subcutaneous dosing schedule row number for the next meal as follows:

  • If the 2 hour postprandial blood glucose level is more than 200 mg/dL, increase insulin schedule for the next meal by 2 rows.

  • If the 2 hour postprandial blood glucose level is 176-200 mg/dl, increase insulin schedule for the next meal by one row.

  • If the 2 hour postprandial blood glucose level is 125-175 mg/dl, then repeat this dosing schedule with the next meal .

  • If the 2 hour postprandial blood glucose level is 100-124 mg/dL, then decrease the insulin schedule for the next meal by one row.

  • If the 2 hour postprandial blood glucose level is less than 100 mg/dl, then decrease the insulin schedule for the next meal by two rows.

Table 2. Subsequent Meals and Periprandial Subcutaneous Rapid-Acting Insulin Analogue Doses and Titration. (Open Table in a new window)

Row

Eats >50% of Meal

Eats 25-50% of Meal

Snacks or Eats < 25% of meal

1

4 U

2 U

1 U

2

6 U

3 U

2 U

3

8 U

4 U

2 U

4

10 U

5 U

3 U

5

12 U

6 U

3 U

6

14 U

7 U

4 U

7

16 U

8 U

4 U

8

18 U

9 U

5 U

9

20 U

10 U

5 U

10

22 U

11 U

6 U

11

24 U

12 U

6 U

12

26 U

13 U

7 U

With each meal chart, the actual row number is used for subcutaneous periprandial dosing. This previous meal row number becomes the new baseline row number from which the next meal-related periprandial dose of subcutaneous analogue will again be adjusted according to the titration schedule. Continue to titrate each subsequent meal-related subcutaneous dose of insulin analogue according to the titration schedule, using the row number actually used from the previous (immediately preceding) meal as the baseline row number.


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