The “two bag system” for variable intravenous dextrose and fluid administration: Benefits in diabetic ketoacidosis management

Grimberg, Adda; Cerri, Ruben W.; Satin-Smith, Marta; Cohen, Pinchas

doi:10.1016/s0022-3476(99)70469-5

Cited by 47 publications

(42 citation statements)

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“…This is consistent with the median time of 49 and 42 minutes to administration of IV fluids in the protocol and non-protocol groups, respectively. The initial order for the 2-bag system at our hospital provides nursing staff with the ability to adjust rates as determined by the patient's blood glucose results and therefore should happen at the time the results are available, similar to the response time of 1 minute reported by Poirier et al 6 and 7.4 minutes found by Grimberg et al 5 with a 2-bag system. Limitations of this study include the possibility that the improvements seen may have resulted from standardizing practice rather than the protocol itself.…”

Section: Discussionsupporting

confidence: 54%

“…4 Studies have shown time and cost benefits associated with implementing a protocol for management of pediatric DKA, using a 2-bag IV fluid system. [5][6][7] A 2-bag system consists of 2 fluid bags with identical electrolyte concentrations but different dextrose concentrations (0% and 10%) administered intravenously and simultaneously via a Y-site. This enables insulin and electrolyte therapy to be maintained while titrating the dextrose concentration to meet the patient's requirements without having to order, prepare, and administer additional fluid bags when a change in dextrose concentration is needed.…”

Section: Introductionmentioning

confidence: 99%

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

Veverka

Marsh

Norman

et al. 2016

The Journal of Pediatric Pharmacology and Therapeutics

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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.

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Section: Discussionsupporting

confidence: 54%

Section: Introductionmentioning

confidence: 99%

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

Veverka

Marsh

Norman

et al. 2016

The Journal of Pediatric Pharmacology and Therapeutics

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“…Young children with DKA, older children with established diabetes and those with non ketotic hyperosmolar states tend to demonstrate marked sensitivity to insulin [40]. Some suggest the use of two bag infusion system, wherein identical electrolyte solutions differing only in the concentration of dextrose (one at 0%, another at 10%) are simultaneously run through different cannulae, with the rates of administration titrated as per results of blood glucose testing [39,41].…”

Section: Rate Of Fluid Administrationmentioning

confidence: 99%

“…Continuous noninvasive capnography to measure endtidal CO 2 is suggested to correlate well with the degree of acidosis in DKA; the resolution of ketoacidosis is evident in form of steady increment of ETCO 2 towards normal range (35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) [56].…”

Section: Monitoringmentioning

confidence: 99%

Management of Diabetic Ketoacidosis

et al. 2010

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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.

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“…O principal objetivo é proporcionar à equipe médica uma maneira mais rápida e prática de fazer o controle glicêmi-co 4 .…”

Section: O Sistema De Duas Soluçõesunclassified

Diabetic ketoacidosis in children: review of pathophysiology and treatment with the use of the

Collett‐Solberg¹

2001

J Pediatr (Rio J)

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Objectives: To review diabetic ketoacidosis, including the two bags system, a method of administering liquids in order to provide a smoother correction of the hyperglycemic and ketotic states.Methods: Review of recent publications (last 7 years) from a Medline search and chapters published in pediatric textbooks that discuss the etiology, therapy, and complications of diabetic ketoacidosis. The management approach incorporates the findings of these publications as well as the clinical experience at the Childrens Hospital of Philadelphia and Duke University Medical Center. Results:The pathology of the type 1 Diabetes Mellitus involves the progressive destruction of the ß cells of the pancreas, causing insulin deficiency. Insulin is essential in the metabolism of carbohydrates, protein and fat. Insulin deficiency may lead to diabetic ketoacidosis which has three components: 1) hyperglycemia, which causes glycosuria and consequently dehydration; 2) lipolysis which, causes ketonemia/ketonuria; and 3) acidosis, that is caused by the dehydration and the high serum levels of ketones. Diabetic ketoacidosis is a serious condition and, if not treated appropriately, can cause coma and death. In children cerebral edema is the major complication of the therapy for diabetic ketoacidosis. Careful replacement of insulin, fluids, glucose and electrolytes is essential. Conclusions:The literature presents different ways to manage DKA in pediatrics, without a consensus on the cause of the most important complication (cerebral edema), and consequently without a consensus on the best approach.The use of the two saline bags in patients in DKA allows fast adjustments in the dextrose concentration of the infusion fluids, simplifying and reducing the costs of the treatment of diabetic ketoacidosis.J Pediatr (Rio J) 2001; 77(1): 9-16: diabetes mellitus, cerebral edema, diabetic ketoacidosis, fluid therapy. ResumoObjetivo: Rever vários aspectos da cetoacidose diabética, incluindo o sistema de duas soluções, um método de administrar líquidos que proporciona correção mais suave do estado de hiperglicemia e de cetose.Métodos: Revisão de publicações recentes (dos últimos 7 anos) referidas na base de dados da Medline e capítulos de livros de pediatria que abordam a etiologia, o tratamento e as complicações da cetoacidose diabética. O tratamento aqui apresentado utiliza a informação encontrada nestes artigos e a experiência clínica adquirida no Childrens Hospital of Philadelphia e no Duke University Medical Center.Resultados: A patologia do diabetes mellitus tipo 1 envolve a destruição das células ß do pâncreas, causando uma deficiência de insulina. A insulina é essencial para o metabolismo de carboidratos, proteínas e gorduras. A deficiência de insulina pode levar a um quadro de cetoacidose diabética que apresenta três componentes: 1) a hiperglicemia, que causa glicosúria e conseqüentemente desidratação; 2) a lipólise em excesso, que causa aumento nos níveis séricos e urinários de corpos cetônicos; e 3) a acidose metabólica, que é causa...

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The “two bag system” for variable intravenous dextrose and fluid administration: Benefits in diabetic ketoacidosis management

Cited by 47 publications

References 3 publications

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

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

Management of Diabetic Ketoacidosis

Diabetic ketoacidosis in children: review of pathophysiology and treatment with the use of the

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