Electronic Glycemic Management Systems Versus Conventional Insulin Infusion Protocols in Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Non-Randomized Studies.

Background and Objectives: Electronic glycemic management systems (eGMSs) are increasingly used to guide intravenous insulin infusion for hospitalized patients with diabetic ketoacidosis (DKA), but available comparative evidence remains non-randomized and clinically heterogeneous and includes multiple algorithmically distinct platforms. Methods and Materials: We conducted a systematic review and meta-analysis in accordance with PRISMA guidance and a prospectively registered protocol (PROSPERO: 2025 CRD420251019614). Seven non-randomized studies comprising 3874 hospitalized patients were included; six studies contributed data to the primary meta-analysis of time to DKA resolution. The primary outcome was time to DKA resolution. Secondary outcomes included ICU length of stay (LOS), hospital LOS, duration of insulin infusion, and hypoglycemia (mild and severe). Random-effects models were applied. Results: Six studies contributed to the primary meta-analysis of time to DKA resolution; across the review, seven studies included 3874 patients. The pooled analysis showed no statistically significant difference between groups (SMD -0.04, 95% CI -0.22 to 0.14; I2 = 74.8%). Recorded hypoglycemia was lower among patients managed with eGMS; however, these estimates should be interpreted cautiously because of heterogeneity, serious-to-critical risk of bias, and potential differences in glucose-monitoring and documentation practices. ICU and hospital LOSs and duration of insulin infusion showed no statistically significant differences overall, with heterogeneity across studies. Conclusions: In available non-randomized evidence, eGMS-guided insulin infusion was not associated with a clear difference in time to DKA resolution, ICU length of stay, hospital length of stay, or insulin infusion duration compared with conventional protocols. Lower recorded hypoglycemia was observed with eGMSs, but this finding should be considered hypothesis-generating because of serious-to-critical risk of bias, residual confounding, substantial heterogeneity, and possible detection bias. High-quality randomized trials or target trial emulation studies are needed before recommending widespread adoption, as certainty of evidence was very low across all outcomes.