PICU Clinical Pathway for Known or Suspected
Central Diabetes Insipidus (DI)

PICU Patient with Known or Suspected
Central Diabetes Insipidus (DI)
  • Diagnostic Criteria for Central DI:
    • Both of the following criteria are required to diagnose Central DI
      • Urine Output (UOP)
        • > 4 mL/kg/hr if weight < 60 kg or
        • > 250 mL/hr if weight ≥ 60 kg for 2 consecutive hours and
      • Serum Na
        • > 145 mEq/L
  • Exclude other causes of polyuria e.g., hyperglycemia, diuretic use, acute or chronic kidney injury
  • Pre-existing Central DI Without
  • Hypovolemia or Hypernatremia And
  • Able to tolerate home DI regimen
  • Continue home DI regimen
  • Endocrinology Consult
  • Routine monitoring
  • Continued Treatment
  • FLOC/RN Assessment
    • History and Physical
    • Assess volume status
    • Labs: BMP, CBC, ABG or VBG, UA Serum osmolality,
      urine osmolality
New Onset Central DI or Pre-existing Central DI with Hypovolemia and/or Hypernatremia
Therapeutic Goals
  • Euvolemia
    • Normal vital signs
    • Adequate perfusion
  • Serum Na
    • 140-150 mEq/L
  • Urine Output
    • Weight < 60 kg: 1-2 mL/kg/hr
    • Weight ≥ 60 kg: 60-120 mL/hr
Concurrent Therapeutic Interventions
Monitoring, Fluid Management, Vasopressin Titration
Intravascular Volume Status, UOP Every 30 mins
Serum Na Every 1 hr*
Fluid Resuscitation
  • Restore intravascular volume with NSS or LR boluses
  • Do not replace UOP with additional fluids
  • Replace non-urinary losses with isotonic fluids or blood products as indicated
    • (e.g. surgical drain output)
Vasopressin Management
  • Start vasopressin
  • Initial Dose: 0.5 milli-units/kg/hr
  • Titration: Double dose every 30 mins until UOP within goal range
  • Usual Max Dose: 10 milli-units/kg/hr
Recurrent hypovolemia
and polyuria
Euvolemia and UOP within
goal range
Recurrent hypovolemia
UOP above
goal range
UOP within goal range
Intravascular Volume Status, UOP Every 1 hr
Serum Na Every 2-4 hrs*
*Obtain BMP every 6 hours
Ongoing Fluid Management
NPO or
Impaired Thirst
Cleared for PO with Intact Thirst
D5NSS or D5LR at 2/3 maintenance Allow to drink to thirst
Maintenance IV fluids not needed
If Na > 150, consider free water replacement
Be aware of a potential triple phase response
Titrate Vasopressin
Every 30-60 mins to maintain
UOP within goal range
Current Dose Titration Rate
> 2 milli-units/kg/hr 1-2 mill-units/kg/hr
≤ 2 milli-units/kg/hr 0.1-0.5 milli-units/kg/hr
  • If Na remains low, pursue workup for hyponatremia.
    • Consider other causes e.g. cerebral salt wasting and CSF losses
Euvolemia; Serum NA and UOP within goal range
Posted: March 2021
Authors: M. Kirschen, MD; M. Vajravelu, MD; K. Lord, MD; V. Srinivasan, MD; K. Resendiz Trujano, PharmD; R. Hunter, MD; A. Grachen, PharmD