Central Diabetes Insipidus (DI)/Arginine Vasopressin Deficiency (AVP-D) Clinical Pathway – PICU

PICU Clinical Pathway for Known or Suspected Central Diabetes Insipidus (DI),
also Known as Arginine Vasopressin Deficiency (AVP-D)

Goals and Metrics
Patient Education
Provider Resources
Child in the PICU with Known or Suspected
Central Diabetes Insipidus (DI), also
Known as Arginine Vasopressin Deficiency (AVP-D)
  • Pre-existing Central DI/AVP-D without
  • Hypovolemia or hypernatremia and
  • Able to tolerate home Central DI/AVP-D regimen
  • Continue home Central DI/AVP-D regimen
  • Endocrinology Consult
  • Routine monitoring
  • Continued treatment
  • Team Assessment
New Onset Central DI/AVP-D
or Pre-existing Central DI/AVP-D
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
Monitor
Intravascular Volume Status, UOP Every 15-30 mins
Serum Na Every 1-2 hrs*
Fluid Resuscitation
  • Restore intravascular volume with NS or
    LR boluses
  • Do not routinely order urine output replacement fluids
  • Replace non-urinary losses with isotonic fluids or blood products as indicated
    • (e.g., surgical drain output)
Acute Vasopressin Management
Start Vasopressin
Initial Dose 0.5 milli-units/kg/hr
Titration Double dose every 30 mins until UOP w/in goal range
Usual Max Dose 10 milli-units/kg/hr
Recurrent hypovolemia
and polyuria
Euvolemia and UOP within
goal range
Recurrent hypovolemia
Euvolemia
UOP above
goal range
UOP within goal range
Monitor
Intravascular Volume Status, UOP Every 1 hr
Serum Na Every 2-4 hrs*
*Obtain BMP every 6 hrs
Ongoing Fluid Management
NPO or
Impaired Thirst		 Cleared for PO with Intact Thirst
D5NS 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
Criteria for Floor Care
Posted: March 2021
Revised: June 2024
Editors: Clinical Pathways Team