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

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Child in the PICU with Known or Suspected
Central Diabetes Insipidus (DI), also
Known as Arginine Vasopressin Deficiency (AVP-D)

Diagnostic Criteria for Central DI/AVP-D:
- Polyuria for 2 consecutive hrs
  - Defined as:
    - > 4 mL/kg/hr if weight < 60 kg
    - > 250 mL/hr if weight ≥ 60 kg
    - and
    - Blood sodium level (Serum Na) > 145 mEq/L
Review differential diagnosis for other causes of polyuria and hypernatremia

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
- History and Physical Exam
- Assess volume status
- Labs:
  - BMP, CBC, ABG or VBG, UA
    Serum osmolality, urine osmolality

Review

New Onset Central DI/AVP-D
or Pre-existing Central DI/AVP-D
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

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

Authors:

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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

Evidence

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