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

Abstract

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.

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

“…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.…”

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

“…Alternatively, a two-bag (TB) system consists of 2 intravenous (IV) fluid bags with identical electrolyte content; however, one bag contains no dextrose, while the other contains dextrose (typically 5%-10%). 3 -8 These bags can be simultaneously infused and inversely titrated according to patients’ serum glucose values. 3 -8 For example, the bag without dextrose is infused alone if plasma glucose exceeds 300 mg/dL, but once plasma glucose approaches 250 to 300 mg/dL, both bags are infused simultaneously.…”