Calculator Training & Frequently Asked Questions

How to use Saferinsulin.org

This video is an aid for practice educators and those working with the Saferinsulin calculator. It is not a substitiute for in person training on the safe use of IV insulin in critical care and the calculator should only be used in units where permission is given by the medical team and formal training has taken place.

Frequently Asked Questions

Below are some examples of questions that users have asked when using the saferinsulin calculator. This advice is published to improve safety. Insulin is a high-risk medication and infusions should only be administered by staff who are trained to do so. Decisions about prescribing and administering are the responsibility of the clinicians.

Calculator not available

The calculator doesn't appear to be functioning or I cannot access it on my computer! We have built a number of mechanisms that make the Saferinsulin calculator as resilient as possible and whilst downtimes are rare please ensure you have a back up plan, this would include your trusts own static/paper variable rate insulin infusion (VRII). Please report any issues with calculator functioning. The calculator can be accessed on any web based device including your mobile phone.

Calculator not increasing rate above 15 units/hr

The current insulin rate is high and the calculator will not give a recommended rate higher than 15units/hr, what should I do?

We have set the maximum rate advised by the calculator to 15 units/hr for obvious safety reasons. It is very rare for a patient to require 15units/hr of IV insulin to control blood glucose and this should prompt urgent and regular medical and diabetes specialist review. It is essential to:

• Check lines for leaks or misplacement
• Check the cannula is not tissued
• Check the infusion is correct and not expired. Consider changing the syringe.

If rates higher than 15units/hr are considered necessary then consider adjuncts such as long acting insulins and use an alternative VRII or FRII.

No feed or IV glucose - won't give calculation without it

My patient hasn’t got a nasogastric feeding tube and their blood glucose is e.g 16.4mmol/l (elevated above 10mmol/l). We wish to start IV insulin, but the calculator won’t give an output as there is no enteral feed, glucose or TPN running. Should we start IV glucose just because we are starting IV insulin? This conundrum comes up every now and again. There are rarely any situations where starting maintenance fluids with 5% glucose is absolutely contraindicated until some form of feed is established. The main danger here is unopposed IV insulin which can rapidly drop blood glucose in a few short hours. This risk can be reduced by having a steady infusion of glucose until enteral feed is running and can be absorbed.

The calculator asks for confirmation of feed or IV glucose running as we have found that this reduces hypoglycaemic episodes caused by unopposed insulin (No Feed No Need).

What if the patient is hyperglycaemic and has fluid overload or there is a risk from administering hypotonic fluid? There are situations where the risk of a small rate of background IV fluids may be considered to exceed the risk of using unopposed IV insulin (an example would be cardiogenic shock with fluid overload) or where hypotonic fluids might worsen the risk of hyponatraemia or tissue oedema (for example, traumatic brain injury).

In these situations it may be practical to override the slider and use the calculator as you would if there was feed running. The calculator will still work the same and as the blood glucose values fall the insulin rate will be reduced to reflect the patient coming into target range (6-10mmol). As there is unopposed IV insulin there should be strict adherence to the hourly blood glucose checks and introduction of some form of nutrition or IV glucose is recommended at the earliest opportunity.

Governance Code

What is this for, where should it be recorded and what if I can’t access the prescription chart to do this? The Governance Code allows users to review the advice given by the calculator at a later time by displaying the values of glucose and insulin rate inputted and the advice given at a specific time. Should an error occur it is helpful to be able to exclude a problem with the algorithm. This code should ideally be copied and pasted into the Electronic Patient Record (ideally against the insulin infusion prescription). If computer access makes this difficult or impossible, it can be manually recorded on a paper prescription. The most important safety measure is to ensure 1-2 hourly glucose checks and insulin rate adjustment. If computer or EPR access is a problem, mobile phones or tablets can be used to access the calculator. Governance Code recording can be resumed when IT problems are addressed. It is essential that all glucose values and insulin rates should be recorded on the patient’s ICU chart.

Training

How do I get trained on the use of the calculator? There is a training video on the Resources tab which covers the use of the calculator. It is not advised that this calculator is used on ICU’s without the express permission of the medical team and education team who are responsible for ensuring staff are competent in its use.