Two-bag Versus One-bag Method for Adult and Pediatric Diabetic Ketoacidosis Management

Arjuna Srikrishnaraj; Allison Ruth Souter; Nicolas Woods; Kristine Van Aarsen; Alla Iansavitchene; Nathan L Haas; Justin W Yan

doi:10.1016/j.annemergmed.2025.07.032

Two-bag Versus One-bag Method for Adult and Pediatric Diabetic Ketoacidosis Management

Ann Emerg Med. 2026 Mar;87(3):346-364. doi: 10.1016/j.annemergmed.2025.07.032. Epub 2025 Sep 6.

Authors

Arjuna Srikrishnaraj¹, Allison Ruth Souter², Nicolas Woods³, Kristine Van Aarsen³, Alla Iansavitchene⁴, Nathan L Haas⁵, Justin W Yan⁶

Affiliations

¹ Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Electronic address: asrikris@uwo.ca.
² Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
³ Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada.
⁴ Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada; Corporate Academics, Library Services, London Health Sciences Centre, London, ON, Canada.
⁵ Department of Emergency Medicine, University of Michigan, Ann Arbor, MI.
⁶ Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada.

PMID: 40913602
DOI: 10.1016/j.annemergmed.2025.07.032

Abstract

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.

Keywords: Diabetic ketoacidosis; Hypoglycemia; One-bag method; Two-bag method.

Publication types

Systematic Review
Meta-Analysis

MeSH terms

Adult
Child
Diabetic Ketoacidosis* / therapy
Humans
Hypoglycemia / epidemiology
Hypoglycemic Agents / administration & dosage
Insulin* / administration & dosage

Substances

Insulin
Hypoglycemic Agents