Diabetes Insipidus (DI) Post-operative Neurosurgical Management Clinical Pathway

Pathway Background and Objectives

Diabetes Insipidus (DI) refers to the passage of large volumes of dilute urine, and may result from the decreased secretion of antidiuretic hormone (ADH) by the posterior pituitary gland. Patients undergoing neurosurgical surgery in the sellar or parasellar region are at increased risk for post-operative DI, which may be transient, triphasic (DI → SIADH → DI), or permanent. Patients who do not have an intact thirst mechanism (adipisic central DI) are a particular challenge, as they may not drink enough to replace their urine losses, which can result in severe hypernatremia. Uncontrolled hypernatremia has adverse effects, including increased risk of neurological sequelae and venothromboembolism. In addition, provider variability and inconsistent care delivery can be significant barriers in establishing a timely diagnosis of DI. The objectives of this pathway are to:

Standardize the management of post-operative patients at risk for developing DI by standardizing:
- Initial PICU monitoring for the development of DI
- Initial PICU management if DI develops
- Medical readiness criteria for patients to transfer to the med/surg floors
Standardize the management of post-operative patients with confirmed DI in the PICU and on the floors by:
- Minimizing fluctuations in sodium levels and volume status
- Expediting the development of an outpatient plan in order to facilitate a safe discharge home

Algorithm Educational Module

Key References

Christ-Crain M, Biche DG, Fenske WK, et al. Diabetes insipidus. Nat Rev Dis Primers. 2019 Aug;5(1): 54.
Di lorgi N, Napoli F, Allegri AE, et al. Diabetes Insipidus – Diagnosis and Management. Horm Res Paediatr. 2012;77(2):69-84.
Melmed S, Koenig R, Rosen C, Auchus R, Goldfine A. Williams Textbook of Endocrinology. 14th ed. Elsevier; c2019. 1792 p.
Pratheesh R, Swallow DM, Rajaratnam S, et al. Incidence, predictors and early post-operative course of diabetes insipidus in paediatric craniopharygioma: a comparison with adults. Childs Nerv Syst. 2013 Jun;29(6):941–9.

Disclaimer

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.