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

Hasan, Rashed A.; Hamid, Kewan; Dubre, Donald; Nolan, Brian; Sharman, Mahesh

doi:10.1177/2333794x21991532

Cited by 4 publications

(4 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The one‐bag system consists of an initial administration of a fluid with electrolytes and subsequent administration of dextrose to prevent hypoglycemia. This approach has been associated with slow response times and increased hospital costs 38,39 . Meanwhile, the two‐bag system consists of one bag with the fluid with electrolytes and another with a fixed dextrose concentration (e.g., 10% or 12.5%).…”

Section: Discussionmentioning

confidence: 99%

“…This approach has been associated with slow response times and increased hospital costs. 38,39 Meanwhile, the two-bag system consists of one bag with the fluid with electrolytes and another with a fixed dextrose concentration (e.g., 10% or 12.5%). By adjusting the administration rates of each bag individually, we provide different concentrations of glucose while keeping a constant final fluid delivery.…”

Section: Administration Systemmentioning

confidence: 99%

See 1 more Smart Citation

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

Patino‐Galarza,

Duque‐Lopez,

Cabra‐Bautista

et al. 2024

J Evidence Based Medicine

View full text Add to dashboard Cite

AimTo determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA).MethodsWe conducted a systematic review with an attempt to conduct network meta‐analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable.ResultsTwelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution‐PlasmaLyte®), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid‐base status (∼2 h less with low vs. high volume); time to receive subcutaneous insulin (∼1 h less with low vs. high fluid rate); length of stay (∼6 h less with RL vs. saline); and resolution of the DKA (∼3 h less with two‐bag vs. one‐bag scheme). However, available evidence is scarce and poor.ConclusionsThere is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Administration Systemmentioning

confidence: 99%

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

Patino‐Galarza,

Duque‐Lopez,

Cabra‐Bautista

et al. 2024

J Evidence Based Medicine

View full text Add to dashboard Cite

show abstract

“…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%

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

et al. 2021

View full text Add to dashboard Cite

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.

show abstract

“…When comparing two-bag to one-bag fluid management, retrospective studies have demonstrated a variety of potential benefits and harms [19][20][21][22]. Possible benefits include faster resolution of acidosis, lower resource utilization, and lower hypoglycaemia and hypokalaemia.…”

Section: Recent Evidencementioning

confidence: 99%

Fluid therapy in diabetic ketoacidosis

Ramanan,

Delaney,

Venkatesh

2023

Current Opinion in Clinical Nutrition &Amp; Metabolic Care

View full text Add to dashboard Cite

Purpose of review To evaluate recent evidence (2021–2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. Recent findings Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of “two-bag” compared to conventional “one-bag” fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. Summary Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.

show abstract

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

Cited by 4 publications

References 14 publications

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

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

Fluid therapy in diabetic ketoacidosis

Contact Info

Product

Resources

About