Two‑Bag Triumph? What the Evidence Really Shows in Diabetic Ketoacidosis Care

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Diabetic ketoacidosis is a familiar ED diagnosis, but the best fluid strategy is still up for debate. Many of us default to the traditional one‑bag system, even though it can be slow to adjust and prone to glucose swings. This new meta‑analysis compares one‑bag versus two‑bag DKA management across adults and children, examining hypoglycemia rates, time to resolution, and operational impact. Join Dr. Knudsen-Robbins as she breaks down what the evidence shows — and whether the two‑bag fluid system truly offers a clinical edge for treatment.

Srikrishnaraj A, Souter AR, Woods N, et al. Two-bag Versus One-bag Method for Adult and Pediatric Diabetic Ketoacidosis Management. Ann Emerg Med. 2026;87(3):346-364. doi:10.1016/j.annemergmed.2025.07.032.

General Background

  • Diabetic ketoacidosis (DKA) is a common emergency department diagnosis, and management strategies continue to evolve.

  • One area of ongoing debate is whether a two‑bag system (separate bags for dextrose-containing and non‑dextrose fluids) offers advantages over the traditional one‑bag system during DKA treatment.

Hypothesis / Study Question

  • Does the two‑bag system improve clinical outcomes compared with the one‑bag system in adults and children with DKA?

  • Primary outcomes of interest: time to DKA resolution and incidence of hypoglycemia.

Methodology

  • Study type: Systematic review and meta‑analysis.

  • Included studies: 21 total (4 randomized controlled trials, 16 retrospective cohort studies, 1 prospective quality improvement study).

  • Population:

    • Adults: 9 studies, 3,329 encounters

    • Pediatrics: 12 studies, 1,385 encounters

  • Intervention: Two‑bag fluid system

  • Comparator: One‑bag fluid system

  • Outcomes assessed: time to DKA resolution, incidence of hypoglycemia, incidence of hypokalemia, duration of insulin infusion, hospital length of stay.

Results

  • Hypoglycemia:

    • Adults: 54% reduction with the two‑bag system

    • Children: 38% reduction with the two‑bag system

  • Time to DKA resolution: shorter with the two‑bag system in both adults and children.

  • Hypokalemia: 16% reduction in adults using the two‑bag system.

  • Insulin infusion duration: decreased with the two‑bag system.

  • Hospital length of stay: decreased only in pediatric populations.

Limitations

  • Limited number of prospective studies; most included data are retrospective.

  • Heterogeneity in study design, institutional protocols, definitions of DKA resolution, and fluid/insulin management strategies.

  • Potential publication bias and variable reporting of adverse events.

  • Applicability may vary depending on local nursing workflows, pharmacy support, and staff familiarity with two‑bag protocols.

Clinical Implications / Conclusion

  • The two‑bag system appears to reduce hypoglycemia, shorten time to DKA resolution, and decrease insulin infusion duration, with additional benefits in hypokalemia reduction (adults) and hospital length of stay (children).

  • Institutions may consider piloting this approach if training and operational workflows allow.

  • More high‑quality prospective studies are needed to confirm these findings and guide standardized practice.

AUTHORSHIP

Written by: Chloe Knudsen-Robbins MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Writing, Editing, Posting, and Audio Editing by Anita Goel, MD; Associate Professor, APD of UC EM Residency Program, and Co-editor of Tamingthesru.com

Cite as: Knudsen-Robbins, C., Goel, A. Two‑Bag Triumph? What the Evidence Really Shows in Diabetic Ketoacidosis Care. TamingtheSRU.com. www.tamingthesru.com/blog/journal-club/two-bag-system-for-diabetic-ketoacidosis-meta-analysis. 5/25/26.