Potential Clinical Benefits of a Two-bag System for Fluid Management in Pediatric Intensive Care Unit Patients with Diabetic Ketoacidosis

Velasco, Jacqueline P; Fogel, Joshua; Levine, Robert L.; Ciminera, Peter; Fagan, D. G.; Bargman, Renee

doi:10.18544/pedm-23.01.0068

Cited by 5 publications

(8 citation statements)

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“…Furthermore, the length of the PICU stay and hospital length of stay were also not different between the groups. This is in contradiction to the study of Velasco et al 14 that demonstrated that the two bag system was associated with fewer hours of PICU stay compared to the one bag system. It is possible that the conflicting results may be related to the variations in the definitions of LOS and the variations in the transfer policies of patients with DKA from the PICU to a pediatric ward.…”

Section: Discussioncontrasting

confidence: 96%

The Two-bag System for Intravenous Fluid Management of Children with Diabetic Ketoacidosis: Experience from a Community-Based Hospital

Hasan

Hamid

Dubre

et al. 2021

Global Pediatric Health

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Objectives: Intravenous fluid (IVF) administration using the two-bag system compared with the one-bag system in children with diabetic ketoacidosis (DKA) admitted between January 1, 2015 and December 31, 2016. Design: Retrospective cohort study. Setting: Community-based hospital. Results: A total of 109 patients were enrolled with a mean age of 13.24 years. The 2 groups had comparable demographics. Initial laboratory results were similar except for initial PH and Sodium. The two bag system had significantly less number of calls compared to one bag system (25.2 vs 5.2 P = .0001). One bag system had fewer hypoglycemia <60 mg/dl (4 vs 12 P = .049). No statistically significant observations noted in regards to glucose drop rate, number of intravenous fluid bags used, amount of fluid boluses given, hospital stay and Pediatric ICU stay. Conclusions: The two-bag system has less resource utilization and slower blood glucose drop rate, but higher hypoglycemic events

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Section: Discussioncontrasting

confidence: 96%

The Two-bag System for Intravenous Fluid Management of Children with Diabetic Ketoacidosis: Experience from a Community-Based Hospital

Hasan

Hamid

Dubre

et al. 2021

Global Pediatric Health

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“…This accomplishment occurred through use of standardized DKA guidelines built on a two-bag fluid system, standardization of hand-offs, inclusion and education of all stakeholders, and explicit EMR orders to support clinical practice. While previous retrospective studies evaluating use of standardized management of DKA with or without two bag fluid system indicate the potential for decreased cost, 4,13,14 more rapid DKA resolution, 5,15 and/or decreased rates of hypoglycemia 5,7,8 ; to our knowledge, our study is the first to demonstrate how various tenets of quality improvement science can be prospectively paired with the implementation of standardized DKA guidelines based on a two-bag fluid system with the primary objective to decrease the rate of low BGs in pediatric patients with DKA.…”

Section: Discussionmentioning

confidence: 99%

“…Retrospective studies have concluded two bag-fluid systems, as compared to traditional single IV bag treatment methods, allow for quicker resolution of acidosis 5,6 and decreased rates of hypoglycemia. 5,7,8 However, no previous studies have prospectively implemented standardized DKA guidelines built on a two-bag system with the primary objective to reduce the occurrence of low blood glucoses (i.e., BG < 80 mg/dl).…”

Section: Piloting Of 6 Th Guidelines and Increased Incident Reportsmentioning

confidence: 99%

“…At standardized BG thresholds, the rate that each fluid bag is infused into the patient's IV's can be adjusted, this flexibility allows for immediate bedside customization of the overall dextrose concentration infused into the patient. Retrospective studies have concluded two bag‐fluid systems, as compared to traditional single IV bag treatment methods, allow for quicker resolution of acidosis 5,6 and decreased rates of hypoglycemia 5,7,8 . However, no previous studies have prospectively implemented standardized DKA guidelines built on a two‐bag system with the primary objective to reduce the occurrence of low blood glucoses (i.e., BG < 80 mg/dl).…”

Section: Introductionmentioning

confidence: 99%

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Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes

et al. 2021

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Objective In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. Research Design and Methods Plan‐do‐study‐act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two‐bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3) <15 mEq/L. Primary outcome: the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. Results From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. Conclusions Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.

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“…After the initial fluid, all the patients received isotonic fluid (0.9% saline) solution for a duration of 4 hours followed by a fluid solution consisting of 0.45% saline, with an aim to correct the dehydration over 48 hours. We use the two-bag system for fluid management in DKA patients in our unit [30]. Insulin infusion was started after 1 hour, upon the completion of initial fluid therapy.…”

Section: Treatment Protocol-mentioning

confidence: 99%

Initial Fluid Therapy in Pediatric Diabetic Ketoacidosis: A comparison of Hypertonic Saline Solution and Normal Saline Solution

Shafi¹,

Kumar²

2018

Pediatr Endocrino Diabetes Metab

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Introduction. The optimal fluid therapy in children with DKA is a matter of debate, especially if we take into account its association with cerebral edema, the most important complication. Hypertonic Saline Solution is used in the treatment of cerebral edema, and also has been used for volume resuscitation in children with shock. Aim of study. To compare the effects of 3% saline and 0.9% saline solutions on changes in vital parameters, sodium and chloride levels, lactate and pH; time needed for the correction of hyperglycemia; time needed for the control of ketoacidosis and incidence of cerebral edema. Methods. Open-label prospective RCT in which 40 children with moderate to severe DKA were randomized to receive either 3% saline or 0.9% saline as initial fluid therapy. Results. There was no significant difference between the two groups in the clinical vital parameters, time for the correction of hyperglycemia and the resolution of acidosis. Patients in the 3% saline group had a higher increase in sodium and chloride from baseline compared to the 0.9% saline group. The acidemia was noted to worsen in both groups after the initiation of fluid therapy, which was not associated with clinical deterioration. The frequency of cerebral edema was similar in both groups. Conclusions. Both 0.9% saline and 3% saline were equally effective as initial fluid in children with DKA with respect to hemodynamic improvement, the resolution of acidosis and the correction of hyperglycemia, but the use of 3% saline solution did not preclude the development of cerebral edema and has the potential to cause hypernatremia, hyperchloremia and hyperchloremic metabolic acidosis. Key words. diabetic ketoacidosis, diabetes mellitus, type 1, cerebral edema, hypertonic saline solution Streszczenie Wstęp. Wybór optymalnej metody terapii płynowej cukrzycowej kwasicy ketonowej (DKA) u dzieci pozostaje kwestią dyskusyjną, szczególnie w związku z ryzykiem obrzęku mózgu, najważniejszego powikłania. Hypertoniczny roztwór soli fizjologicznej jest używany w leczeniu obrzęku mózgu oraz był używany w leczeniu wstrząsu u dzieci. Cel badania. Porównanie wpływu leczenia 3% i 0,9% roztworem soli fizjologicznej na stan kliniczny oraz zmiany stężenia sodu, mleczanu i ph krwi, czasu korekty hiperglikemii oraz leczenia kwasicy i występowania obrzęku mózgu u dzieci. Metody. Przeprowadzono randomizowane badanie prospektywne, typu open-label, w grupie 40 dzieci z umiarkowaną do ciężkiej cukrzycową kwasicą ketonową. Dzieci losowano do grupy otrzymującej jako początkową terapię płynową 3% lub 0,9% roztwór soli fizjologicznej. Wyniki. Pomiędzy obiema grupami nie było istotnych różnic w stanie klinicznym, czasie korekty hiperglikemii oraz czasie wyrównania kwasicy. W grupie pacjentów, którzy otrzymali 3% roztwór soli stwierdzono większy wzrost stężenia sodu oraz chloru w porównaniu z grupą, która otrzymywała 0,9% roztwór soli. Obserwowano przejściowe pogorszenie pH po rozpoczęciu terapii płynowej w obu grupach, co jednak nie było związane z pogorszeniem stanu klinicznego. ...

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Potential Clinical Benefits of a Two-bag System for Fluid Management in Pediatric Intensive Care Unit Patients with Diabetic Ketoacidosis

Abstract: The two-bag system is associated with lower incidence of hypoglycemia and faster discharge from the PICU. We recommend that clinicians consider using the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis.

Cited by 5 publications

References 0 publications

The Two-bag System for Intravenous Fluid Management of Children with Diabetic Ketoacidosis: Experience from a Community-Based Hospital

The Two-bag System for Intravenous Fluid Management of Children with Diabetic Ketoacidosis: Experience from a Community-Based Hospital

Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes

Initial Fluid Therapy in Pediatric Diabetic Ketoacidosis: A comparison of Hypertonic Saline Solution and Normal Saline Solution

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