376 trose concentration (0% and 10%) ad- ministered simultaneously into a single IV line. Variations in dextrose delivery are achieved through differential pro- portions of the 2 bags contributing to the total rate, which is determined by the patient’s degree of dehydration (Figure, A). A typical clinical course with the two bag system is exemplified in the Figure, B and C. As evident in the Figure, IV glucose administration is adjusted to control the rate of blood glucose decline and to prevent hypo- glycemia from developing despite the continued insulin requirement. By titrating the differential proportions of the 2 bags, the amount of glucose ad- ministration and the total fluid rate can be manipulated independently, as can the insulin infusion dose. Patient Characteristics Since the two bag system was intro- duced at our institution in 1994, DKA admissions from 1993 to 1995 were re- viewed. Ten patients treated by the two bag system and 10 by the one bag system were chosen by initial venous pH (<7.2) and length of intensive care unit stay (10 to 36 hours) and were subsequently matched for age, weight, and duration of IV therapy (Table). Selection of the IV system was made by the treating medical team, consist- ing of 4 attendings, 1 fellow, and rotat- ing housestaff, based temporally on our institutional switch in IV systems. Frequent modifications in intravenous therapy are required during the treat- ment of patients with diabetic ketoaci- dosis to adapt to fluctuations in the fluid, electrolyte, and dextrose needs of the patient. 1-3 Traditionally, on initia- tion of IV insulin therapy, one bag of IV electrolyte and dextrose solution, determined by the patient’s presenting clinical requirements, is prepared and T The “two bag system” for variable intravenous dextrose and fluid administration: Benefits in diabetic ketoacidosis management Adda Grimberg, MD, Ruben W. Cerri, MD, Marta Satin-Smith, MD, and Pinchas Cohen, MD hung; as blood glucose levels fall as a result of the ongoing insulin action, a new bag with the appropriately altered glucose content must be ordered from the pharmacy and then when ready, re- place the previous bag even if it was not completely consumed. Multiple se- quential fluid bag changes may follow the course of therapy. Several limita- tions of the traditional approach, here- after referred to as the “one bag sys- tem,” are easily apparent: restricted variations, slow response time, and in- creased cost. In 1994 a new method of IV fluid therapy called the “two bag system” was introduced at the Chil- dren’s Hospital of Philadelphia to ad- dress the aforementioned problems. This study reviews the design of the two bag system and in a case-controlled retrospective manner evaluates its effi- cacy at surmounting the shortcomings of the traditional one bag system. METHODS The Two Bag System Design The two bag system, an adaptation of euglycemic clamp experiment tech- niques, 4,5 consists of 2 bags of identical electrolyte content but different dex- From the Division of Pediatric Endocrinology and Dia- betes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, and the Division of Pedi- atric Endocrinology, Children’s Hospital of The King’s Daughters, Norfolk, Virginia. Supported by a Lawson Wilkins Pediatric Endocrine Society award to Dr Grimberg and fellowship grants from Eli Lilly and Pharmacia-Upjohn. Presented in part at The Eightieth Annual Meeting of The Endocrine Society, New Or- leans, Louisiana, June 24-27, 1998. Submitted for publication July 21, 1998; re- vision received Nov 4, 1998; accepted Dec 2, 1998. Reprint requests: Pinchas Cohen, MD, Asso- ciate Professor and Program Director, Divi- sion of Pediatric Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. Copyright © 1999 by Mosby, Inc. 0022-3476/99/$8.00 + 0 9/22/96283 DKA Diabetic ketoacidosis IV Intravenous A case-controlled retrospective analysis compared the “two bag system,” based on the euglycemic clamp technique, versus the traditional “one bag” method for intravenous diabetic ketoacidosis management. The two bag system can provide more cost-effective intravenous dextrose and fluid deliv- ery and enhance quality of care by improving the efficiency, timeliness, and flexibility of overall control. (J Pediatr 1999;134:376-8)