DKA Powerplans
Gentle reminder that we have both adult and pediatric powerplans to manage DKA. Please use them when required.
Pediatric DKA 2-Bag System — Go Live October 15
1. PowerPlan 1: ED PED DKA (2-Bag System)
- Call Pediatrician ASAP after DKA recognition
- Initiate 1 hour of fluid resuscitation — IVF Bolus NS 0.9% 10 mL/kg:
- No vascular decompensation: bolus over 60 minutes
- Vascular decompensation: rapid bolus over 15 minutes — repeat bolus PRN (use the "lightbulb" icon in orders to re-open PowerPlan and select PRN bolus)
- Complete the remainder of the hour with NS 0.9% at Total Fluid Intake (TFI) rate in Table 2.0
- Vitals and neuro assessments: q15 min × 1 hour
- Transfer from Queens Blvd to Midtown after initiating bolus, ASAP (unless requiring CritiCall)
2. Signs of Cerebral Injury
- Call CritiCall
- Use the "lightbulb" icon in orders to re-open PowerPlan to order this section if needed
- Decrease TFI to 75% (after initial fluid bolus)
- Repeat electrolytes
- Treat with hypertonic saline or mannitol
- Do NOT bolus insulin or give sodium bicarbonate (unless ECG changes or CPR)
3. PowerPlan 2: PED DKA Admission (2-Bag System, Phased)
- Ordered by Pediatrician after the 1st hour of fluid management
- Complete the Pediatric DKA Fluid Calculations PowerForm first (see video #2 below)
- View trends from PowerForms completed by nurses: Results Review → Assessments
- Two Bag Rates = TFI − Insulin Rate
- 2-Bag rate is changed based on hourly PoCT glucose (adjusted by nurses)
- 2-Bag solutions are changed based on potassium level q2 hours (adjusted by nurses)
- Nurses initiate potassium PHASES (only 1 initiated at a time)
- Nurses may insert a 2nd PIV site for q2h lab draws (lab orders need to be changed to "Nurse Collect")
- Vitals and neuro assessments: q30 min × 2 hours, then q1 hour
Resources
WRHN DKA 2-Bag System Algorithm — attached and posted in both EDs.
- Webinar: Diabetic Ketoacidosis Two-Bag System (Feb 2025) — Dr. J. Brar, LHSC
- ED Workflow Video
- Pediatric DKA Admission Workflow for Providers
Please reach out if you have any questions or would like to trial the PowerPlan. If you use the 2-Bag System, we would appreciate your feedback.
Oncology Screening
Gentle reminder that screening for malignancy should be an outpatient test in most cases.
Asthma Powerplans
Use them — and don't forget to order PRN inhalers as well. There have been some cases where a delay in consult time caused kids to deteriorate when they could have been receiving additional meds.
GI vs Hospitalist Admits
Hospitalists have agreed that:
All GI admissions are to be admitted to hospitalist except cases of confirmed IBD.
The following presentations should involve a GI consultation and opinion prior to admission under the hospitalist, as specialized input may guide initial management:
- New onset Pancreatitis
- New onset cirrhosis / liver failure
- Upper GI bleeds (to expedite scope, make treatment recommendation — e.g. octreotide infusion, etc.)
The rest of the cases may not need a review with GI, but at all times should be left at the discretion of the ER physician and Hospitalist on-call.