STUDY OBJECTIVE: We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of the two-bag versus one-bag method in diabetic ketoacidosis (DKA) management in adult and pediatric populations.
METHODS: The study was registered with the Prospective Register of Systematic Reviews, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was conducted across MEDLINE, EMBASE, and CENTRAL databases up to March 2025, with no restrictions on study design. Two reviewers independently assessed studies for bias using Cochrane Risk of Bias 2 (RoB2) tool and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I), extracted data, and synthesized findings using RevMan software. The Grading of Recommendations, Assessment, Development, and Evaluations tool was used to assess certainty of evidence. Main outcomes of interest were incidence of hypoglycemia and time to DKA resolution.
RESULTS: Of 4,190 studies screened, 21 met inclusion criteria. These included 9 adult studies with 3,329 patient visits and 12 pediatric studies with 1,385 visits. Of these, one study was at critical risk of bias and was removed from meta-analysis. In both adult and pediatric populations, the two-bag method was associated with reduced incidence of hypoglycemia (risk ratio: 0.50, 95% confidence interval [CI] 0.41 to 0.59; I2=51.8%) and time to DKA resolution (MD: -1.76 hours; 95% CI -2.80 to -0.71; I2=61%). In adults only, the two-bag method was associated with a shortened duration of insulin infusion (MD: -3.74 hours, 95% CI -4.96 to -2.52; I2=0%) and reduced incidence of hypokalemia (risk ratio: 0.84, 95% CI 0.76 to 0.93; I2=47%).
CONCLUSION: The two-bag method is associated with reduced incidence of hypoglycemia and time to DKA resolution in both adult and pediatric populations.
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Hospital Doctor/Hospitalists | |
| Internal Medicine | |
| Pediatric Emergency Medicine |  |
| Endocrine | |
The 2-bag method seems superior to the 1-bag method in terms of outcomes related to hypogylcemia, hypokalemia, and reduction in time of DKA. Although most studies were retrospective in nature (and used different primary outcomes), the data are very suggestive of benefit, especially in adults. Most of the studies had some biases, which creates a need for a large formal study looking at this question for both adults and pediatrics.
Well done meta-analysis that demonstrates that current management strategy remains safer.
