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DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse PICU Nurse Educator Educator Lucile Packard Lucile Packard Children’s Children’s Hospital Hospital

DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

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Page 1: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

DI AND SIADHDI AND SIADH

Pat Hock RNPat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’sLucile Packard Children’s HospitalHospital

Page 2: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

DI and SIADHDI and SIADH Disturbances of Water Disturbances of Water BalanceBalance• 60% to 80% of the human body is 60% to 80% of the human body is

composed of water.composed of water.• Water content varies with age, Water content varies with age,

gender, skeletal muscle mass and fat gender, skeletal muscle mass and fat content.content.

• Osmolality is one of several factors Osmolality is one of several factors regulating fluid balance between the regulating fluid balance between the intracellular and extracellular fluid intracellular and extracellular fluid compartments.compartments.

Page 3: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

ADH: AntiDiuretic HormoneADH: AntiDiuretic Hormone

• Formed in the supraoptic and Formed in the supraoptic and paraventricular nuclei of the paraventricular nuclei of the hypothalamus.hypothalamus.

• Transported to the posterior lobe of the Transported to the posterior lobe of the Pituitary Gland and stored.Pituitary Gland and stored.

• ADH is released: in response to an ADH is released: in response to an increase in intravascular osmotic pressure, increase in intravascular osmotic pressure, hypovolemia, decrease in pulse pressure. hypovolemia, decrease in pulse pressure. And in response to fear, pain, anxiety.And in response to fear, pain, anxiety.

Page 4: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital
Page 5: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital
Page 6: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Function of ADH Function of ADH

• ADH increases the permeability of ADH increases the permeability of the renal distal tubule and collecting the renal distal tubule and collecting ducts to water.ducts to water.

• Less free water is excreted in urineLess free water is excreted in urine

• Urine volume is decreasedUrine volume is decreased

• Concentration of urine is increasedConcentration of urine is increased

Page 7: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Diabetes InsipidusDiabetes Insipidus

• DI is a clinical condition due to a DI is a clinical condition due to a deficit of ADH or due to the kidney’s deficit of ADH or due to the kidney’s resistance to the effects of ADH. resistance to the effects of ADH.

• DI may be central (neurogenic) or DI may be central (neurogenic) or nephrogenic.nephrogenic.

• DI may be a transient or a DI may be a transient or a permanent condition.permanent condition.

Page 8: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Etiologies of DIEtiologies of DI

• CNS disorders that damage or create pressure in CNS disorders that damage or create pressure in the area of the hypothalamus, pituitary stalk, or the area of the hypothalamus, pituitary stalk, or posterior pituitary glandposterior pituitary gland

• Head InjuriesHead Injuries• CNS infectionsCNS infections• Intraventricular HemorrhageIntraventricular Hemorrhage• Neurosurgical Procedures: common postoperatively Neurosurgical Procedures: common postoperatively

with resection of craniopharyngiomas, pituitary with resection of craniopharyngiomas, pituitary gland tumors, or suprasellar tumors.gland tumors, or suprasellar tumors.

• Associated with certain drugs: Ethanol, phenytoin, Associated with certain drugs: Ethanol, phenytoin, halothane, opiate antagonists, lithiumhalothane, opiate antagonists, lithium

Page 9: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital
Page 10: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Signs and Symptoms of DISigns and Symptoms of DI

• POLYURIA- first sign POLYURIA- first sign • Low Urine osmolality (less than 100-200 mOsm/L)Low Urine osmolality (less than 100-200 mOsm/L)• Urine specific gravity <1.010Urine specific gravity <1.010• Hypernatremia (serum sodium greater than 145 Hypernatremia (serum sodium greater than 145

mEq/L)mEq/L)• Serum hyperosmolar (greater than 300 mOsm/L)Serum hyperosmolar (greater than 300 mOsm/L)• Thirst, polydipsiaThirst, polydipsia• Irritability or mental status changesIrritability or mental status changes• DehydrationDehydration• ShockShock

Page 11: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Clinical Management of DI Clinical Management of DI • Goal is to prevent circulatory failure Goal is to prevent circulatory failure

and hyperosmolar encephalopathy.and hyperosmolar encephalopathy.

• Replace volume deficit and ongoing Replace volume deficit and ongoing losseslosses

• Replace ADHReplace ADH

• Close monitoring of serum and urine Close monitoring of serum and urine lytes/osmolalitylytes/osmolality

Page 12: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Fluid ReplacementFluid Replacement

• Correct Hypernatremia slowlyCorrect Hypernatremia slowly

• Bolus with NS if hypotensiveBolus with NS if hypotensive

• Volume deficit replaced over 24 to 48 Volume deficit replaced over 24 to 48 hourshours

• Replace ongoing urine lossesReplace ongoing urine losses

Page 13: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

VasopressinVasopressin

• Available IV, subcutaneous, and Available IV, subcutaneous, and intranasal formsintranasal forms

• DDAVP given intranasallyDDAVP given intranasally

• Pitressin IVPitressin IV

• Therapeutic effect: increase in Therapeutic effect: increase in specific gravity and decrease in urine specific gravity and decrease in urine output within 1 hour of dose.output within 1 hour of dose.

Page 14: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Nursing Management Nursing Management

• Close monitoring of intake and Close monitoring of intake and outputoutput

• Frequent hemodynamic monitoringFrequent hemodynamic monitoring

• Frequent Neuro assessmentsFrequent Neuro assessments

• Serial labs: urine specific gravity and Serial labs: urine specific gravity and osmolality, Serum sodium and osmolality, Serum sodium and osmolalityosmolality

Page 15: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

ComplicationsComplications

• Cardiac collapseCardiac collapse

• ShockShock

• Cerebral EdemaCerebral Edema

• HerniationHerniation

• DeathDeath

• Electrolyte imbalancesElectrolyte imbalances

• Water intoxication and fluid overloadWater intoxication and fluid overload

Page 16: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Syndrome of Inappropriate Syndrome of Inappropriate AntiDiuretic Hormone AntiDiuretic Hormone

• SIADH is a clinical condition involving and SIADH is a clinical condition involving and excess of ADH secretion.excess of ADH secretion.

• The patient is hyponatremic with a low The patient is hyponatremic with a low serum osmolality, which normally would serum osmolality, which normally would inhibit ADH secretion.inhibit ADH secretion.

Page 17: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Etiology of SIADHEtiology of SIADH

• Head TraumaHead Trauma• Cerebral TumorsCerebral Tumors• MeningitisMeningitis• Cerebral HemorrhageCerebral Hemorrhage• Pulmonary DiseasesPulmonary Diseases• Chronically ill or malnourished childrenChronically ill or malnourished children• Spinal surgerySpinal surgery• BMT or Stem Cell TransplantsBMT or Stem Cell Transplants• MedicationsMedications• Positive pressure ventilationPositive pressure ventilation

Page 18: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Signs and Symptoms of Signs and Symptoms of SIADH SIADH

• Low urine output in absence of Low urine output in absence of hypovolemiahypovolemia

• Hyponatremia (serum Hyponatremia (serum sodium<135mEq/L)sodium<135mEq/L)

• Low Serum osmolality (<285 mOsm/L)Low Serum osmolality (<285 mOsm/L)

• High urine specific gravity (>1.020)High urine specific gravity (>1.020)

• Nausea and vomitingNausea and vomiting

• Mental status changesMental status changes

Page 19: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Clinical ManagementClinical Management

• Normalize serum sodium over 24 to 48 Normalize serum sodium over 24 to 48 hourshours

• Normalize serum osmolalityNormalize serum osmolality

• Correct excess extravascular fluid volumeCorrect excess extravascular fluid volume

• Prevent neurological sequelaePrevent neurological sequelae

• Restrict fluidsRestrict fluids

• 3% NaCl3% NaCl

• Loop diureticsLoop diuretics

Page 20: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Nursing ManagementNursing Management

• Close monitoring of intake and Close monitoring of intake and outputoutput

• Maintain fluid RestrictionMaintain fluid Restriction

• Frequent Hemodynamic monitoringFrequent Hemodynamic monitoring

• Frequent Neuro assessmentsFrequent Neuro assessments

• Serial labs: serum electrolytes, Serial labs: serum electrolytes, serum osmolality, specific gravityserum osmolality, specific gravity

Page 21: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

ComplicationsComplications

• SeizuresSeizures

• Cerebral edemaCerebral edema

• Cerebral hemorrhageCerebral hemorrhage

• Pulmonary edemaPulmonary edema

• Muscle cramps or weaknessMuscle cramps or weakness

Page 22: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Triphasic response post Triphasic response post Neurosurgery Neurosurgery

• Transient DI 12-48 hours postopTransient DI 12-48 hours postop

• SIADH after transient DI phase SIADH after transient DI phase lasting up to 10 days postoplasting up to 10 days postop

• Permanent DIPermanent DI

Page 23: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Case Scenario #1Case Scenario #1

A 3 month old is admitted to the PICU A 3 month old is admitted to the PICU for shock with a 2 day history of for shock with a 2 day history of fever and irritability. Blood and CSF fever and irritability. Blood and CSF cultures are positive for cultures are positive for Streptococcus pneumoniae. He has Streptococcus pneumoniae. He has had decreasing urine output over the had decreasing urine output over the last 24 hours (< 0.5 ml/kg/hr)last 24 hours (< 0.5 ml/kg/hr)

Page 24: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

? Assessment? Assessment

? Labs might be ordered? Labs might be ordered

Page 25: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

LabsLabs

SerumSerum

Na 126 mEq/L se osmo 260mOsmo/LNa 126 mEq/L se osmo 260mOsmo/L

Cl 98 mEq/L Bun 4mg/dlCl 98 mEq/L Bun 4mg/dl

K 3.7 mEq/L Cr 0.4 mg/dlK 3.7 mEq/L Cr 0.4 mg/dl

CO2 25mEq/L glucose 129 mg/dlCO2 25mEq/L glucose 129 mg/dl

Urine sp gr 1.025Urine sp gr 1.025

Page 26: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

? Abnormal findings? Abnormal findings

? Etiology? Etiology

? Treatment? Treatment

Page 27: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

AbnormalitiesAbnormalities

• HyponatremiaHyponatremia

• OliguriaOliguria

• Concentrated urineConcentrated urine

• Low serum osmolalityLow serum osmolality

Page 28: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

SIADHSIADH

Treatment:Treatment:

Fluid RestrictionFluid Restriction

Page 29: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

Case Study #2Case Study #2

A 5 year old (15kg) boy is admitted to the PICU A 5 year old (15kg) boy is admitted to the PICU with a history of MVA 2 days ago. He with a history of MVA 2 days ago. He sustained an isolated head injury with an sustained an isolated head injury with an intraventricular hemorrhage and multiple intraventricular hemorrhage and multiple cerebral contusions. Three hours ago he had cerebral contusions. Three hours ago he had an episode of severe intracranial an episode of severe intracranial hypertension (ICP 90mmHg, MAP 50 mmHg) hypertension (ICP 90mmHg, MAP 50 mmHg) requiring volume and an epi drip for requiring volume and an epi drip for hypotension. Over the last 2 hours his uo has hypotension. Over the last 2 hours his uo has increased to 130-150 ml/hr (~8ml/kg/hr.)increased to 130-150 ml/hr (~8ml/kg/hr.)

Page 30: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

? Assessment? Assessment

? Labs might be ordered? Labs might be ordered

Page 31: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

LabsLabs

Serum:Serum:

Na 155mEq/L BUN 13 mg/dlNa 155mEq/L BUN 13 mg/dl

Cl 114 mEq/L Cr 0.6 mg/dlCl 114 mEq/L Cr 0.6 mg/dl

K 4.2 mEq/L glu 86 mg/dlK 4.2 mEq/L glu 86 mg/dl

CO2 22 mEq/L se osmo 320 mOsmo/LCO2 22 mEq/L se osmo 320 mOsmo/L

Urine sp gr 1.005Urine sp gr 1.005

Page 32: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

?Abnormal Findings?Abnormal Findings

? Etiology? Etiology

? Treatment? Treatment

Page 33: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

AbnormalitiesAbnormalities

• HypernatremiaHypernatremia

• PolyuriaPolyuria

• Dilute urineDilute urine

• High serum osmolalityHigh serum osmolality

Page 34: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

DIDI

Treatment:Treatment:

Acute: Vasopressin infusionAcute: Vasopressin infusion

Chronic: DDAVPChronic: DDAVP

Monitor for HyponatremiaMonitor for Hyponatremia

Page 35: DI AND SIADH DI AND SIADH Pat Hock RN Pat Hock RN PICU Nurse Educator PICU Nurse Educator Lucile Packard Children’s Lucile Packard Children’s Hospital

ReferencesReferences

• Curley, Curley, Critical Care Nursing of Critical Care Nursing of Infants andInfants and ChildrenChildren. Saunders. Saunders

• Hazinski. Hazinski. Manuel of Pediatric Critical Manuel of Pediatric Critical CareCare. Mosby. Mosby

• Kliegman. Kliegman. Nelson’s Textbook of Nelson’s Textbook of PediatricsPediatrics. Saunders. Saunders

• Slota. AACN’s Slota. AACN’s Core Curriculum forCore Curriculum for Pediatric Critical CarePediatric Critical Care. Saunders. Saunders