Two Bag System for Diabetic Ketoacidosis
Two Bag System for Diabetic Ketoacidosis
This is a study investigating the best way to treat diabetic ketoacidosis (DKA) with
 intravenous (IV) fluids in the hospital. The purpose of this study is to determine whether
 the "two bag" system of administering IV fluids for the treatment of adults with DKA leads to
 a shorter time requiring intravenous insulin (a shorter time to anion gap closure), when
 compared to usual care the traditional "one bag" system of IV fluids. Participants will be
 assigned randomly to either the usual care group or the "two bag" system group. Based on
 studies performed in the past, the investigators predict that patients treated with the two
 bag system of IV fluids for DKA will have a significantly shorter time requiring treatment
 with intravenous insulin when compared to the traditional one bag system.
The two bag system has been studied in the pediatric population and is used frequently in
 pediatric intensive care units. It involves two bags of identical fluids with electrolytes,
 except one bag has 0% dextrose and the other has 10% dextrose. The two fluid bags run
 simultaneously into a single IV. The rates of the two fluid bags are adjusted according to
 the patient's blood sugar. Since the hyperglycemia in DKA typically corrects before the
 ketosis, this provides a more efficient method of titrating the dextrose concentration based
 on the patient's needs, while continuing to infuse the insulin at a constant rate to prevent
 further ketogenesis. The benefits of the two bag system from the pediatric literature
 include: decreased response time to IV fluid changes, decreased time to correction of
 bicarbonate and ketones, and decreased total IV fluid volume administered. There was one
 retrospective study of the two bag system in adults, which showed decreased time to anion gap
 closure and decreased hypoglycemic events. To this date, there are no prospective randomized
 trials to evaluate the efficacy of the two bag system in adults.

 Patients admitted with DKA in the critical care pavilion will be randomized to either the
 "two bag system" or "usual care" group.

 Patients in both groups will be treated for DKA with IV fluid resuscitation for dehydration
 and an insulin infusion according to usual care, recommended at 0.1 U/kg/hr.

 The two bag system of IV fluids will be ordered as delineated below:

 If blood sugar is > 300, run D10 solution at 0 ml/hr and saline solution at 200 ml/hr.

 If blood sugar is 250-299, run D10 solution at 50 ml/hr and saline solution at 150 ml/hr.

 If blood sugar is 200-249, run D10 solution at 100 ml/hr and saline solution at 100 ml/hr.

 If blood sugar is 150-199, run D10 solution at 150 ml/hr and saline solution at 50 ml/hr.

 If blood sugar is < 150, run D10 solution at 200 ml/hr and saline solution at 0 ml/hr.

 The control group will be usual care of DKA based on the American Diabetes Association
 Guidelines using a "one bag system."

 In both groups, blood sugars will be checked every hour while on the insulin drip. A basic
 metabolic panel will be checked every 4 hours to monitor the anion gap. Once the anion gap is
 closed on two occasions and the subject is able to tolerate an enteral diet, the patient will
 be transitioned to subcutaneous insulin and insulin drip will be discontinued.
Inclusion Criteria:

 1. Diagnosis of diabetic ketoacidosis defined as:

 1. Blood sugar greater than 250 mg/dl

 2. Venous pH less than 7.25

 3. Bicarbonate less than 18

 4. Evidence of ketone formation with either positive urine ketones or elevated
 beta-hydroxybutyrate > 3

 5. Anion gap greater than 10 +/ - 2 (or higher than expected anion gap corrected for
 albumin)

 2. 18-85 years of age

 Exclusion Criteria:

 1. Pregnancy

 2. Hyperglycemic hyperosmolar state

 3. Ketosis from other etiology such as starvation or alcoholic ketosis

 4. Acute exacerbation of congestive heart failure

 5. Acute coronary syndrome or non-ST elevation MI

 6. Pulmonary edema from other cause such as decompensated liver failure or acute renal
 failure

 7. Renal failure requiring renal replacement therapy (hemodialysis)

 8. Septic shock