Effective Tuesday, Jan. 30 at Cadillac and Grayling hospitals, Munson Healthcare will replace the existing PowerPlan to be used in the emergency department and within the hospital to guide the treatment of adults 18+ with diabetic ketoacidosis utilizing a two-bag infusion method and electrolyte replacement protocol. This protocol went live at Kalkaska Memorial Health Center, Munson Medical Center, and Paul Oliver Memorial Hospital on Feb. 22, 2023.
The DKA protocol is initiated at diagnosis, usually in the Emergency Department, and continues through admission to resolution.
For individuals 18-21 years of age, providers can select EITHER the pediatric or the adult DKA PowerPlan. Please continue to utilize the pediatric DKA PowerPlan unless the patient needs ICU level care (high severity of illness and patient to be managed by critical care service).
This is a two-phase PowerPlan.
- Phase 1: Includes the key lab, patient care, and medication orders for DKA management.
- Ordered after initial diagnostic labs are complete. Insulin drip, maintenance bag 1 (saline +/- potassium), and bag 2 (dextrose + saline) should all be ordered at this time.
- Potassium level should be verified prior to starting insulin and replaced if < 3.3 mmol/L.
- There is a DKA-specific electrolyte replacement protocol that should be ordered for all patients (prechecked within the plan). Patients with acute or chronic renal impairment do not qualify for electrolyte replacement under protocol, but nursing will be prompted to obtain an order for replacement from provider based on lab results.
- Phase 2: Initiated once DKA is resolved.
NOTE: Do NOT immediately discontinue PowerPlan upon DKA resolution.- Order subcutaneous insulin via appropriate PowerPlan using STAT priority for first basal dose if transitioning to insulin glargine.
- Reminder: All patients with type 1 diabetes not on an insulin pump and ordered a regular diet should have orders for basal, nutritional, and correctional insulins. Per standard insulin orders, nutritional insulin will be withheld if patient is not eating or eating less than 50% of meals.
- Transition phase includes an order to nursing to discontinue insulin drip, dextrose fluids, and electrolyte protocol 2 hours after administration of basal insulin. Timing may vary if patient is initiated on a non-glargine based regimen (i.e. insulin pump, U500 regular insulin). Consult Pharmacy for additional guidance.
- Transition phase also includes diet advancement and initial post-resolution lab monitoring.
- Once patient is fully transitioned to maintenance insulin regimen, the PowerPlan can be discontinued (later the same day or next day, or upon transfer out of ICU).
Resources
- Adult DKA Cerner PowerPlan (2-page print-and-post flyer)
- Adult DKA Reference Text
- On-Demand CME | Diabetic Ketoacidosis: 2 Bags are Better than 1; Courtney Van Houzen, PharmD; MMC Pharmacy Resident