Pediatric Diabetic Ketoacidosis Management in the Era of Standardization

Ildiko H Koves; Catherine Pihoker


Expert Rev Endocrinol Metab. 2012;7(4):433-443. 

In This Article

The Two-bag System

The two-bag system system (Figure 2) is a cost-effective[50] management of frequent fluid type changes during DKA and allows for rapid glucose titration.[51] This system uses the simultaneous administration of two intravenous fluid bags with identical electrolyte and sodium content, but one of the bags, 'Bag 2', also containing 10% dextrose. In 'Bag 1,' the electrolyte composition may be normal or half normal saline with or without 40 mEq/l potassium. In the first 4–6 h of therapy, the authors recommend a normal saline composition. Variation in dextrose rate delivery is achieved through a differential proportion of the two bags contributing to the total rate. The rate is determined by the degree of dehydration and remains constant, to rehydrate over 48 h. The dextrose amount delivered depends on the glucose values and the rate of fall in glucose. The rate of total fluid administration during the use of the two-bag system includes the maintenance fluids required and distributed over 48 h and replacement of the 7–8% deficit fluid volume for the estimated degree of dehydration. When calculating the fluid infusion rate, all fluids administered, including those prior to arrival, need to be taken into account and included in the fluids to be replaced over the 48-h period.

Figure 2.

The 'two-bag system'. Trifuse is an intravenous line attachment that infuses the fluids from three lines into one.K: Potassium.

The insulin rate does not typically change during the use of the two-bag system. In unusual circumstances with hypoglycemia and maximized dextrose delivery, the insulin infusion rate may need to be decreased.


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