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Two-versus one-bag fluid delivery in pediatric and adolescent diabetic ketoacidosis: A systematic review and meta-analysis

Clin Exp Pediatr > Accepted Articles
DOI: https://doi.org/10.3345/cep.2023.01536    [Accepted]
Published online June 27, 2024.
Two-versus one-bag fluid delivery in pediatric and adolescent diabetic ketoacidosis: A systematic review and meta-analysis
Maya Leila Nasser1,2  , Joseph Nasr2, Reem Belal Zalloum3, Nathanael Yap1,2, Natalie Errika Bourdakos1,2, Shahid Miangul1,2, Tara Anne Betts4, Hayato Nakanishi1,2, Christian Aloysius Than1,5, Serge Jabbour6
1St. George's University of London, London, United Kingdom
2University of Nicosia Medical School, Nicosia, Cyprus
3College of Liberal Arts and Sciences, University of Illinois at Chicago, Chicago, United States
4Cardiff and Vale University Health Board, Heath Park, Cardiff, United Kingdom
5School of Biomedical Sciences, The University of Queensland, Brisbane, Australia
6Thomas Jefferson University Hospital, Philadelphia, United States
Maya Leila Nasser, Email: nasser.m@live.sgul.ac.cy
Received: 14 November 2023   • Revised: 8 March 2024   • Accepted: 13 April 2024
Two rehydration protocols currently exist to treat diabetic ketoacidosis (DKA) in pediatric patients aged <21 years: the traditional “one-bag” system and the more recent “two-bag” system. This study aimed to evaluate the safety and efficacy of the newer two-bag system versus the well-established one-bag system. The CiNAHL, Cochrane Library, Embase, PubMed, Scopus, and Web of Science databases were comprehensively searched from inception to June 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis framework. Eligible studies were those that reported participants <21 years of age who presented to the emergency room with a clinical diagnosis of DKA. This review was prospectively registered on PROSPERO (CRD42023427551). From the initial screening of 42 studies, 8 unique studies encompassing 583 patients met the eligibility criteria. The analysis yielded no significant intergroup differences in hypoglycemia (odds ratio, 0.61; 95% confidence interval [CI], 0.20–1.87; I2=3%) or mean glucose correction rate (mean difference [MD], 0.04 mg/dL/hr; 95% CI, -13.10 to 13.17; I2=64%). The incidence of cerebral edema was as low (0.17%) across groups, with only one case reported in the one-bag group. Notably, the mean time to DKA resolution (MD, -3.24 h; 95% CI, -5.57 to -0.91; I2=0%) and mean response time for intravenous fluid changes (MD, -32.75 min; 95% CI, -43.21 to -22.29; I2=59%) was lower for the two-bag system. This meta-analysis presents preliminary evidence suggesting that the two-bag system may confer advantages over the one-bag system for selected patients. However, further studies with greater patient stratification based on DKA severity, fluid composition, and protocol are needed to draw definitive conclusions and elucidate the extent of these advantages.
Key Words: Two-bag, Intravenous fluid, Diabetic ketoacidosis, Diabetic ketoacidosis, Pediatric, Meta-analysis

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