The "two bag system" for variable intravenous dextrose and fluid administration: benefits in diabetic ketoacidosis management

Revised one-bag IV fluid protocol for pediatric DKA: a feasible approach and retrospective comparative study

BACKGROUND

This study compared the effectiveness of the traditional and revised one-bag protocols for pediatric diabetic ketoacidosis (DKA) management.

METHODS

This single-center retrospective cohort study included children diagnosed with DKA upon admission between 2012 and 2019. Our institution reevaluated and streamlined the traditional one-bag protocol (revised one-bag protocol). The revised one-bag protocol rehydrated all pediatric DKA patients with dextrose (5 g/100 ml) containing 0.45% NaCl at a rate of 3500 ml/m2 per 24 h after the first 1 h bolus of normal saline, regardless of age or degree of dehydration. This study examined acidosis recovery times and the frequency of healthcare provider interventions to maintain stable blood glucose levels.

RESULTS

The revised one-bag protocol demonstrated a significantly shorter time to acidosis recovery than the traditional protocol (12.67 and 18.20 h, respectively; p < 0.001). The revised protocol group required fewer interventions for blood glucose control, with an average of 0.25 dextrose concentration change orders per patient, compared to 1.42 in the traditional protocol group (p < 0.001). Insulin rate adjustments were fewer in the revised protocol group, averaging 0.52 changes per patient, vs. 2.32 changes in the traditional protocol group (p < 0.001).

CONCLUSION

The revised one-bag protocol for pediatric DKA is both practical and effective. This modified DKA management achieved acidosis recovery more quickly and reduced blood glucose fluctuations compared with the traditional one-bag protocol. Future studies, including randomized controlled trials, should assess the safety and effectiveness of the revised protocol in a broad range of pediatric patients with DKA.

Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set

BACKGROUND

Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care.

OBJECTIVE

To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy.

METHODS

Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events.

RESULTS

One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen.

CONCLUSION AND RELEVANCE

Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.

Les recommandations en vigueur pour la prise en charge de l'acidocétose diabétique pédiatrique

Pour traiter l'acidocétose diabétique pédiatrique, il faut porter une attention particulière aux liquides et aux électrolytes pour limiter le risque de complications, telles qu'une lésion cérébrale, associée à une morbidité et une mortalité élevées. L'incidence d'œdème cérébral en cas d'acidocétose diabétique n'a pas diminué malgré les protocoles visant la limitation des liquides qui s'appuient sur la restriction de la réanimation liquidienne initiale. Selon de nouvelles données probantes, l'administration précoce de liquides isotoniques n'entraîne pas de risque supplémentaire et peut améliorer les résultats cliniques chez certains patients. Les protocoles et les directives cliniques sont adaptés et axés particulièrement sur la surveillance et le remplacement initiaux et continus des liquides et des électrolytes. Il est maintenant recommandé de commencer par une réanimation à l'aide de liquides isotoniques chez tous les patients dans les 20 à 30 minutes suivant leur arrivée à l'hôpital, suivie par la réplétion du déficit volumique sur une période de 36 heures, en association avec une perfusion d'insuline et des suppléments d'électrolytes, ainsi qu'avec la surveillance et la prise en charge attentives d'une éventuelle lésion cérébrale.

Current recommendations for management of paediatric diabetic ketoacidosis

Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.

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

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.

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

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

Implementation of an Intravenous Fluid Titration Algorithm to Treat Pediatric Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a common cause of admission to the pediatric intensive care unit and many centers utilize the "two-bag system" to treat DKA. We developed an intravenous fluid (IVF) titration algorithm to standardize adjustments of the two bags. A retrospective cohort study was performed comparing 155 patients treated before and 175 patients treated after implementation of the IVF titration algorithm. Postimplementation patients reached the blood glucose target zone faster and had a higher probability of remaining at goal while on insulin infusion. There was no significant difference in incidence of cerebral edema or hypoglycemia between study groups. Overall IVF titration algorithm compliance was 95%. Implementation of an IVF titration algorithm is safe and effective when treating DKA in children.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

Evaluation of the Two-Bag System in Adult Diabetic Ketoacidosis Patients

PURPOSE

Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus (DM). This study was designed to assess if the two-bag (TB) system, which utilizes 2 intravenous (IV) fluid bags, one containing sodium chloride and the other containing sodium chloride and dextrose, is an effective and safe alternative to the traditional one-bag (OB) system in adults with DKA.

METHODS

A retrospective review was performed at an academic medical center. Adults with DKA were included if treated with the OB or TB system. The primary outcome was time to anion gap closure. Secondary outcomes included duration of insulin infusion, time to serum bicarbonate correction, number of continuous IV fluid orders, intensive care unit (ICU) and hospital length of stay (LOS), and rates of hypoglycemia and hypokalemia.

RESULTS

One hundred twenty-two patients were included. Sixty-eight were treated with the OB system and 54 with the TB system. There were no differences in time to anion gap closure, duration of insulin infusion, ICU LOS, or hospital LOS. Time to bicarbonate correction was shorter in the OB group (13.5 [IQR: 7-29] vs 25 [IQR: 11-50] hours; P = .03). There were no differences in rates of hypoglycemia or hypokalemia between groups.

CONCLUSION

The TB system had similar efficacy and safety when compared to the OB system. Both approaches can be considered in adults with DKA.

Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis

Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

The Two-Bag Method for Treatment of Diabetic Ketoacidosis in Adults

BACKGROUND

The "two-bag method" of management of diabetic ketoacidosis (DKA) allows for titration of dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations while keeping fluid, electrolyte, and insulin infusion rates constant.

OBJECTIVE

We aimed to evaluate the feasibility and potential benefits of this strategy in adult emergency department (ED) patients with DKA.

METHODS

This is a before-and-after comparison of a protocol using the two-bag method operationalized in our adult ED in 2015. A retrospective electronic medical record search identified adult ED patients presenting with DKA from January 1, 2013 to June 30, 2016. Clinical and laboratory data, timing of medical therapies, and safety outcomes were collected and analyzed.

RESULTS

Sixty-eight patients managed with the two-bag method (2B) and 107 patients managed with the one-bag method (1B) were identified. The 2B and 1B groups were similar in demographics and baseline metabolic derangements, though significantly more patients in the 2B group received care in a hybrid ED and intensive care unit setting (94.1% vs. 51.4%; p < 0.01). 2B patients experienced a shorter interval to first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p < 0.05), shorter duration of insulin infusion (14.1 vs. 21.8 h; p < 0.05), and fewer fluid bags were charged to the patient (5.2 vs. 29.7; p < 0.01). Frequency of any measured hypoglycemia or hypokalemia trended in favor of the 2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively), though did not reach significance.

CONCLUSIONS

The 2B method appears feasible for management of adult ED patients with DKA, and use was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while no safety concerns were observed.

A randomized controlled trial of one bag vs. two bag system of fluid delivery in children with diabetic ketoacidosis: Experience from a developing country

PURPOSE

To compare one vs. two bag system with respect to blood glucose variability (BGV), time for resolution of acidosis and incidence of hypoglycemia, hypokalemia, and cerebral edema in children with diabetic ketoacidosis (DKA).

MATERIAL AND METHODS

In an open labelled randomized controlled trial, thirty consecutive patients ≤12years with DKA were randomized to either one (n=15) or two bag (n=15) system of intravenous fluid delivery. The two bags had similar electrolyte but differing dextrose concentration (none vs. 12.5%) and changing the rate of fluid, delivered different dextrose concentrations. BGV was primary outcome while hypoglycemia (blood glucose, BG<50mg/dL), hypokalemia (serum potassium<3.5mEq/L), time to resolution of acidosis and cerebral edema were secondary outcomes.

RESULTS

The one and two bag systems had similar BGV parameters; median hourly absolute BG change (mg/dL) [44 (30-74.5) vs. 36 (31-49); p=0.54], mean of standard deviation of BG measurements [65.1 (25.1) vs. 65.5 (26.8); p=0.96] and median number of undesirable events (hourly blood sugar change ≥50mg/dL) [4.5 (1.75-6.0) vs. 5.0 (3.0-8.0); p=0.31]. The incidence of hypoglycemia [42.9% (n=6) vs. 26.7% (n=4); p=0.45] and hypokalemia [64% (n=9) vs. 67% (n=10); p=0.23], and mean (SD) time to resolution of acidosis [20.3 (14.8) and 20.3 (7.0); p=0.59] were similar in both the groups. None had cerebral edema.

CONCLUSIONS

The one and two bag systems were similar to each other with respect to BGV, incidence of complications and time to resolution of acidosis.

Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids

BACKGROUND

Pediatric diabetic ketoacidosis (DKA) is a disease associated with several complications that can be severe. One complication includes cerebral edema (CE), and patients may experience significant morbidity with this disease.

OBJECTIVE

This review evaluates the myths concerning CE in pediatric DKA including mechanism, presentation of edema, clinical assessment of dehydration, and association with intravenous (i.v.) fluids.

DISCUSSION

Multiple complications may occur in pediatric DKA. CE occurs in < 1% of pediatric DKA cases, though morbidity and mortality are severe without treatment. Several myths surround this disease. Subclinical CE is likely present in many patients with pediatric DKA, though severe disease is rare. A multitude of mechanisms likely account for development of CE, including vasogenic and cytotoxic causes. Clinical dehydration is difficult to assess. Literature has evaluated the association of fluid infusion with the development of CE, but most studies are retrospective, with no comparator groups. The few studies with comparisons suggest fluid infusion is not associated with DKA. Rather, the severity of DKA with higher blood urea nitrogen and greater acidosis contribute to CE. Multiple strategies for fluid replacement exist. A bolus of 10 mL/kg of i.v. fluid is likely safe, which can be repeated if hemodynamic status does not improve.

CONCLUSIONS

Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe.

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

OBJECTIVE

We 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 METHODS

A 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.

RESULTS

The 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.

CONCLUSIONS

Our 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.

A Pediatric Diabetic Ketoacidosis Management Protocol Incorporating a Two-Bag Intravenous Fluid System Decreases Duration of Intravenous Insulin Therapy

OBJECTIVES: Diabetic ketoacidosis (DKA) is a leading cause of morbidity and mortality in children with type 1 diabetes. We implemented a standardized DKA management protocol by using a 2-bag intravenous (IV) fluid system. The purpose of the study was to examine if the protocol improved clinical outcomes and process efficiency. METHODS: This was a retrospective study of patients who did and did not undergo the protocol. Patients were included if they were 18 years of age or younger, were diagnosed with DKA, admitted to an intensive care unit or stepdown unit, and received continuous IV insulin. RESULTS: Of 119 encounters evaluated, 46 (38.7%) received treatment with the protocol and 73 (61.3%) did not. The median time to normalization of ketoacidosis was 9 hours (IQR 5-12) and 9 hours (IQR 6.5-13) for protocol and non-protocol groups, respectively (p = 0.14). The median duration of IV insulin therapy was 16.9 hours (IQR 13.7-21.5) vs. 21 hours (IQR 15.3-26) for protocol and non-protocol groups (p = 0.03). The median number of adjustments to insulin drip rate was 0 (IQR 0-1) and 2 (IQR 0-3) for protocol and non-protocol groups (p = 0.0001). There was no difference in the incidence of hypokalemia, hypoglycemia, or cerebral edema. CONCLUSIONS: The protocol did not change time to normalization of ketoacidosis but did decrease the duration of insulin therapy, number of adjustments to insulin drip rate, and number of wasted IV fluid bags without increasing the incidence of adverse events.

A Pediatric Diabetic Ketoacidosis Management Protocol Incorporating a Two-Bag Intravenous Fluid System Decreases Duration of Intravenous Insulin Therapy

OBJECTIVES: Diabetic ketoacidosis (DKA) is a leading cause of morbidity and mortality in children with type 1 diabetes. We implemented a standardized DKA management protocol by using a 2-bag intravenous (IV) fluid system. The purpose of the study was to examine if the protocol improved clinical outcomes and process efficiency. METHODS: This was a retrospective study of patients who did and did not undergo the protocol. Patients were included if they were 18 years of age or younger, were diagnosed with DKA, admitted to an intensive care unit or stepdown unit, and received continuous IV insulin. RESULTS: Of 119 encounters evaluated, 46 (38.7%) received treatment with the protocol and 73 (61.3%) did not. The median time to normalization of ketoacidosis was 9 hours (IQR 5-12) and 9 hours (IQR 6.5-13) for protocol and non-protocol groups, respectively (p = 0.14). The median duration of IV insulin therapy was 16.9 hours (IQR 13.7-21.5) vs. 21 hours (IQR 15.3-26) for protocol and non-protocol groups (p = 0.03). The median number of adjustments to insulin drip rate was 0 (IQR 0-1) and 2 (IQR 0-3) for protocol and non-protocol groups (p = 0.0001). There was no difference in the incidence of hypokalemia, hypoglycemia, or cerebral edema. CONCLUSIONS: The protocol did not change time to normalization of ketoacidosis but did decrease the duration of insulin therapy, number of adjustments to insulin drip rate, and number of wasted IV fluid bags without increasing the incidence of adverse events.

Diabetic ketoacidosis in the pediatric emergency department

Despite many advances, the incidence of pediatric-onset diabetes and diabetic ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic pediatric illnesses and, along with DKA, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves fluid resuscitation with insulin and electrolyte replacement under constant monitoring for cerebral edema. When DKA is recognized and treated immediately, the prognosis is excellent. However, when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.

Evaluation of the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis

OBJECTIVES

A one-bag and a two-bag system have both been used to manage intravenous fluid administration in pediatric patients with diabetic ketoacidosis (DKA). The one-bag system, however, has been noted to have limitations, such as slow response time. This study evaluates whether the two-bag system provides any clinical benefit in pediatric DKA patients as compared to the one-bag system.

METHODS

This was a retrospective, non-blinded chart review. Inclusion criteria were patients ≤ 18 years old and whose admission had the code of DKA as the diagnosis. Baseline clinical and demographic data were collected. Descriptive statistics were used in the data analysis.

RESULTS

A total of 31 patients were included, 9 (29%) in the one-bag group and 22 (71%) in the two-bag group. Baseline characteristics were similar between the two groups. Mean (SD) rate of complete blood glucose (CBG) correction was 31.04 mg/dL/hr (20.61) in the two-bag group and 21.04 mg/dL/hr (16.26) in the one-bag group (p = 0.297). The rate of bicarbonate correction, however, was faster with the two-bag system than the one-bag system (0.949 ± 0.553 mEq/L/hr and 0.606 ± 0.297 mEq/L/hr, respectively) (p = 0.047). The two-bag system also had a faster time to ketone (p = 0.04), but not pH (p = 0.172), correction.

CONCLUSIONS

The two-bag system provided a faster rate of bicarbonate and ketone correction compared to the one-bag system. The two-bag system also provided a trend towards a faster rate of blood glucose and pH correction.

Pediatric diabetic ketoacidosis management in the era of standardization

Up to 70% of children with new-onset Type 1 diabetes mellitus (T1DM) present with diabetic ketoacidosis (DKA), with most cases initially assessed by their primary care provider. DKA is the most common cause of death in children with T1DM, mainly related to cerebral edema that occurs at a frequency of 0.15-4.6%. Early recognition of DKA can be improved by increasing the awareness of early clinical symptoms such as enuresis, polyuria and polydipsia. Clinical acumen paired with early assessment of patients with suspected T1DM and known T1DM, particularly if risk factors for DKA are present, can prevent serious complications and fatal outcomes. Urgent referral to specialist centers for suspected new-onset T1DM/DKA is required. A standardized approach is recommended to be followed to ensure successful initial management of DKA, both in the nonspecialist setting before transfer and in the more specialized hospital setting. This article outlines such a management approach.

Management of diabetic ketoacidosis

Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.

Sodium concentration in rehydration fluids for children with ketoacidotic diabetes: effect on serum sodium concentration

OBJECTIVES

To analyze in a retrospective cohort if sodium concentration in the rehydration fluids influence natremia in children with diabetic ketoacidosis (DKA).

STUDY DESIGN

Consecutive episodes of diabetic ketoacidosis admitted in a tertiary care referral center from 2000 to 2005. Rehydration was programmed for 48 hours with a 2-bag system. Initial rehydration was performed with isotonic fluids and thereafter with variable tonicity. Analysis of the influence of the different factors on natremia was performed with a multivariate linear regression analysis.

RESULTS

Forty-two episodes of DKA were reviewed. Increased sodium content in rehydration fluids behaved as an independent variable, causing a positive tendency of natremia (P < .008).

CONCLUSIONS

Sodium concentration in the rehydration fluids behaves as an independent factor that influences positively the trend of the serum concentration of sodium during DKA rehydration. We propose the use of isotonic solutions for rehydration in diabetic ketoacidosis.

Evaluation of the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis

OBJECTIVES

A one-bag and a two-bag system have both been used to manage intravenous fluid administration in pediatric patients with diabetic ketoacidosis (DKA). The one-bag system, however, has been noted to have limitations, such as slow response time. This study evaluates whether the two-bag system provides any clinical benefit in pediatric DKA patients as compared to the one-bag system.

METHODS

This was a retrospective, non-blinded chart review. Inclusion criteria were patients ≤ 18 years old and whose admission had the code of DKA as the diagnosis. Baseline clinical and demographic data were collected. Descriptive statistics were used in the data analysis.

RESULTS

A total of 31 patients were included, 9 (29%) in the one-bag group and 22 (71%) in the two-bag group. Baseline characteristics were similar between the two groups. Mean (SD) rate of complete blood glucose (CBG) correction was 31.04 mg/dL/hr (20.61) in the two-bag group and 21.04 mg/dL/hr (16.26) in the one-bag group (p = 0.297). The rate of bicarbonate correction, however, was faster with the two-bag system than the one-bag system (0.949 ± 0.553 mEq/L/hr and 0.606 ± 0.297 mEq/L/hr, respectively) (p = 0.047). The two-bag system also had a faster time to ketone (p = 0.04), but not pH (p = 0.172), correction.

CONCLUSIONS

The two-bag system provided a faster rate of bicarbonate and ketone correction compared to the one-bag system. The two-bag system also provided a trend towards a faster rate of blood glucose and pH correction.

Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children

OBJECTIVE

To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA).

STUDY DESIGN

Retrospective cohort study.

SETTING

Pediatric intensive care unit of a university-based children's hospital.

PATIENTS

Children with moderate to severe DKA admitted between March 2001 and February 2003.

RESULTS

The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n=12) were compared with those of children who received standard treatment alone (n=59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH>or=7.3) in the insulin glargine group was shorter than the standard therapy group (12.4+/-2.9 h and 17.1+/-6.2 h respectively, p<0.001). The insulin infusion time was shorter in the insulin glargine group (14.8+/-6.0 h vs 24.4+/-9.0 h, p<0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2+/-1.0 days vs 3.72+/-1.06 days).

CONCLUSIONS

In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.

Pediatric diabetic ketoacidosis and hyperglycemic hyperosmolar state

Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, ketosis and acidosis. The pathophysiology of DKA is reviewed and diagnostic and therapeutic modalities are discussed in the context of the currently available evidence. Complications associated with DKA are often a result of the treatment itself, and these issues are also discussed.

A prospective study of the "two-bag system'' in diabetic ketoacidosis management

The "two-bag'' system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional "one-bag'' system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The "two-bag'' system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.

Improving management of diabetic ketoacidosis in children

OBJECTIVE

The optimal fluid management for diabetic ketoacidosis (DKA) is uncertain. In an effort to simplify DKA therapy, we revised the treatment protocol in our institution to use a simpler method of calculating fluid needs, use fluids with higher sodium concentration, and allow glucose concentration to be adjusted easily. We performed a retrospective study to determine the effects of these revisions.

DESIGN

We compared patients treated with traditional and revised protocols (~220 and ~300 patients, respectively, over consecutive 2.75-year intervals). Sixty patient records were randomly selected from the first group (30 treated with each of 2 protocol versions) and 30 from the second group. Biochemical and clinical parameters were analyzed.

RESULTS

Patients selected for detailed analysis were similar in demographics and initial laboratory measurements. Patients treated under the revised fluid protocol received less total fluid, needed fewer intravenous fluid changes, were treated at less cost, and resolved acidosis more rapidly than patients treated under the original protocols. The rate of cerebral edema (0.3%-0.5%) was unchanged.

CONCLUSION

A DKA protocol that necessitates less fluid delivery and fewer calculations simplifies therapy and is associated with more rapid correction of acidosis.

Management of decompensated diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome

DKA and HHS represent two extremes in the spectrum of decompensated diabetes mellitus. Their pathogenesis is related to absolute or relative deficiency in insulin levels and elevations in insulin counterregulatory hormones that lead to altered metabolism of carbohydrate, protein, and fat and varying degrees of osmotic diuresis and dehydration, ketosis, and acidosis. In DKA, insulin deficiency and ketoacidosis are the prominent features of the clinical presentation, and insulin therapy is the cornerstone of therapy. In HHS, hyperglycemia, osmotic diuresis, and dehydration are the prominent features, and fluid replacement is the cornerstone of therapy. As many as one-third of patients may have mixed features of both DKA and HHS. Because the three-pronged approach to therapy for either DKA or HHS consists of fluid administration, intravenous insulin infusion, and electrolyte replacement, mixed cases are managed using the same approach. The therapeutic regimen is tailored according to the prominent clinical features present. In adult patients with mixed features, fluids may be administered more rapidly than they would be in younger patients, or in patients with DKA alone, because the risk for fatal cerebral edema in adults is low and the consequences of undertreatment include vascular occlusion and increased mortality. In younger patients with mixed features, rapid correction of metabolic abnormalities and, consequently, of hyperosmolarity by administration of hypotonic fluids and insulin should be avoided to decrease the risk for precipitating cerebral edema. In addition, if ketoacidosis has been a prominent feature in a mixed case, the patient may have type 1 diabetes with no residual pancreatic islet beta cell secretion and may subsequently need ongoing, life-long insulin therapy after resolution of the acute episode of decompensated diabetes. ICU admission is indicated in the management of DKA, HHS, and mixed cases in the presence of cardiovascular instability, inability to protect the airway, obtundation, the presence of acute abdominal signs or symptoms suggestive of acute gastric dilatation, or if there is not adequate capacity on the floor unit to administer the intravenous insulin infusion and to provide the frequent and necessary monitoring that must accompany its use.