The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients

J Intensive Care Med. 2023 Jul;38(7):668-674. doi: 10.1177/08850666231175387. Epub 2023 May 11.


Purpose: To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method.

Materials and methods: This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables.

Results: We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16.

Conclusions: For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.

Keywords: DKA; Two-Bag Method; critical care; diabetic ketoacidosis.

MeSH terms

  • Adult
  • Bicarbonates
  • Diabetes Mellitus*
  • Diabetic Ketoacidosis* / complications
  • Diabetic Ketoacidosis* / therapy
  • Humans
  • Hypoglycemia*
  • Hypokalemia*
  • Insulin
  • Retrospective Studies


  • Bicarbonates
  • Insulin