PICU Clinical Pathway for Known or Suspected
Central Diabetes Insipidus (DI)
PICU Patient with Known or Suspected
Central Diabetes Insipidus (DI)
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
- Urine Output (UOP)
- Both of the following criteria are required to diagnose Central DI
- 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
- Establish IV Access
- Consider Foley catheter placement
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
and polyuria
Euvolemia and UOP within
goal range
goal range
Recurrent hypovolemia
Euvolemia
UOP above
goal range
goal range
UOP within goal range
Intravascular Volume Status, UOP | Every 1 hr |
---|---|
Serum Na | Every 2-4 hrs* |
*Obtain BMP every 6 hours |
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 |
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 |
|
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
Authors: M. Kirschen, MD; M. Vajravelu, MD; K. Lord, MD; V. Srinivasan, MD; K. Resendiz Trujano, PharmD; R. Hunter, MD; A. Grachen, PharmD
Evidence
- Neurohypophyseal Peptide Function During Early Postoperative Diabetes Insipidus
- Incidence, Predictors and Early Post-Operative Course of Diabetes Insipidus in Paediatric Craniopharyngioma: a Comparison with Adults
- Central Diabetes Insipidus in Pediatric Severe Traumatic Brain Injury
- Perioperative Management of Diabetes Insipidus in Children
- Prevalence, Predictors and Patterns of Postoperative Polyuria and Hyponatraemia in the Immediate Course After Transsphenoidal Surgery for Pituitary Adenomas