Written by Millie Cossé
Spoon Feed
The two-bag method of treating DKA was superior for both adult and pediatric patients in this systematic review and meta-analysis.
On the count of two…
The “two-bag method” for treating DKA refers to having two fluid bags available to run in conjunction with an insulin drip. One contains dextrose, the other doesn’t. Potassium can be added depending on needs, and the rate of infusion of these bags of fluid depends on the patient’s blood sugar. This creates the potential for some confusion (especially in settings without regularly practiced protocols).
Authors of this systematic review and meta-analysis found that the two-bag method outperformed traditional fluid resuscitation in terms of reduced incidence of hypoglycemia (risk ratio 0.50, 95%CI 0.41 to 0.59), time to DKA resolution (MD -1.76 hours; 95%CI -2.8 to -0.7), shortened duration of insulin infusion (MD -3.74 hours, 95%CI -4.96 to -2.52), and reduced incidence of hypokalemia (risk ratio 0.84, 95%CI 0.76 to 0.93).
How will this change my practice?
I love the two-bag system and consider it an elegant way to avoid hypoglycemic episodes. It can fall apart if your department doesn’t have a standardized protocol and go-to fluids (isotonic fluids containing potassium and dextrose usually must be mixed). But it’s well worth establishing a protocol, in my opinion.
Source
Two-bag Versus One-bag Method for Adult and Pediatric Diabetic Ketoacidosis Management. Ann Emerg Med. 2025 Sep 6:S0196-0644(25)01095-9. doi: 10.1016/j.annemergmed.2025.07.032. Epub ahead of print. PMID: 40913602.
I use a 3 bag system:
1) LR Running Wide Open
2) D10 as needed
3) 50mEq KCl at 10 mEq/hr
4) SQuID Protocol to avoid insulin drips in most patients
Oh yeah, well I use FOUR bags! Just kidding…Love the SQuID!