Comparison of a ‘two-bag system’ versus conventional treatment protocol (‘one-bag system’) in the management of diabetic ketoacidosis

Abstract

ObjectiveWe compared the conventional ‘one-bag protocol’ of management of diabetic ketoacidosis (DKA) with the ‘two-bag protocol’ which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose.Research design and methodsA retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system.ResultsThe baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO3 level >18 mg/dL nor the hospital length of stay differed between the two groups.ConclusionsOur study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

“…Another strategy that has recently emerged is use of a “two bag method” for fluid replacement 6869. This method consists of two bags of 0.45% sodium chloride, one with and one without 10% dextrose, that are adjusted on the basis of hourly blood glucose monitoring to maintain an intravenous fluid rate of 250 mL/h.…”

“…This method consists of two bags of 0.45% sodium chloride, one with and one without 10% dextrose, that are adjusted on the basis of hourly blood glucose monitoring to maintain an intravenous fluid rate of 250 mL/h. Two retrospective studies involving more than 500 patients found that the two bag method was associated with earlier correction of acidosis and shorter duration of intravenous insulin compared with conventional delivery of intravenous fluids 6869. When used in the emergency department, this method may reduce the need for hospital admission, and it may be associated with less hypoglycemia compared with conventional treatment.…”

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

“…This is consistent with findings of infrequent hypoglycaemia with the 'two-bag method', which is similar to the British protocol aside from doubling the dextrose rate to 25 g/h when glucose falls below 150 mg/dl. [19,20] We did not observe differences in markers of DKA resolution. Previous studies in paediatrics comparing insulin rates of 0.1-0.05 unit/kg/h throughout treatment similarly showed no difference in time to resolution.…”

“…The goal to maintain glucose above 150 mg/dl in American guidelines appeared to provide an adequate trigger for intervention with both the fixed‐rate and rate‐reduction approaches for the 40 hypoglycaemic patients in our study. This is consistent with findings of infrequent hypoglycaemia with the ‘two‐bag method’, which is similar to the British protocol aside from doubling the dextrose rate to 25 g/h when glucose falls below 150 mg/dl …”

Guidelines and controversies in the management of diabetic ketoacidosis – A mini-review

“…Closure of anion gap was noted to be earlier (10 h) with “two bag protocol” compared to “one bag protocol” (14 h). Hyperglycemia was also noted to improve faster in “two bag protocol” (7 h) compared to “one bag protocol” (9 h)[17]. Whether or not this affects length of hospital stay in the long term is difficulty to assess but should be explored in future prospective studies.…”