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In-patient management protocol for diabetes insipidus associated with adipsia. Developed from a clinical case
Protocolo de manejo hospitalario de la diabetes insípida asociada a adipsia. Desarrollado a partir de un caso clínico
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Above, result for the first case in 2018, interpreted as haemoglobin J (Hb J). Below, results for the second case interpreted in 2015 as possible haemoglobin Shepherds Bush (left), in 2016 as possible haemoglobin Andrew-Minneapolis (centre) and in 2018 as possible haemoglobin Fannin-Lubbok (right). Under normal conditions, there is no haemoglobin J peak and more than 95% corresponds to haemoglobin A (Hb A). 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Desarrollado a partir de un caso clínico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Central diabetes insipidus (DI) results from complete or partial dysfunction of the neurons of the hypothalamus or the posterior pituitary gland.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> DI carries a risk of hypernatraemic dehydration if untreated<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and of iatrogenic hyponatraemia when treated with desmopressin (DDAVP).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Adipsic diabetes insipidus (ADI) is a rare disease associated with morbidity and mortality whose management represents a therapeutic challenge,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> with rates of hypernatraemia as high as 50% and rates of hyponatraemia of 25% observed during its treatment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report the inpatient management protocol for ADI of the Endocrinology Department of Hospital Universitario La Paz [La Paz University Hospital] (Madrid), as well as its scientific basis and its outcome in a patient managed from November 2018 to April 2019.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a previously healthy 33-year-old woman who developed complete ADI after a surgical procedure for a neurocytoma of the third ventricle, along with central hypogonadism and hypocortisolism, cognitive impairment and urinary incontinence. She needed to be hospitalised for 244 days owing to her need for complex management of plasma sodium levels as well as acute complications of her surgical procedure. From day three to day 193 of hospitalisation, the patient had 11 episodes of a lowered level of consciousness associated with major changes in plasma sodium levels (ΔNaS) of up to 42 mmol/l/48 h. Four of those 11 episodes required critical care unit admission and 10 of the episodes occurred without the use of the protocol.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient’s ADI was initially managed according to current clinical consensus recommendations; it was managed without the protocol (s¯P) for 110 of the 244 days (45%) of her admission. The protocol was initially implemented for 30 days (12.4%) and subsequently used for 104 days (42.6%) of the patient’s stay. In the s¯P management period, mean plasma sodium levels were 141.3 ± 9.2 mmol/l (p5-p95: 126−153 mmol/l), and in the c¯P management period, they were 140.2 ± 5.8 mmol/l (p5-p95: 134–148); the difference was statistically significant (p = 0.004). Higher rates of normal plasma sodium levels (135−145 mmol/l) were seen during c¯P management compared to s¯P management (79% versus 49.7%, p < 0.001). Similarly, rates of hyponatraemia (<135 mmol/l) and hypernatraemia (>145 mmol/l) during c¯P management were lower than those observed during s¯P management (8.3% versus 21%, p = 0.001, and 12.7% versus 29.3%, p < 0.001, respectively). As a result of improved management of the patient’s plasma sodium levels, the range of ΔNaS decreased and she was discharged.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The protocol was based on publications of physiology studies and clinical studies aimed at controlling water/sodium homoeostasis, which guided three essential aspects of ADI management: (1) fluid and electrolyte intake, (2) DDAVP dose and (3) correction of abnormal plasma sodium levels (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec1005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0015">Fluid and electrolyte intake</span><p id="par0035" class="elsevierStylePara elsevierViewall">Daily water requirements are lower in women and higher in environments with a temperatures ≥30 °C,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and depend on metabolic expenditure (∼1 ml/kcal/kg<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>) and solute load.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To achieve normal hydration, defined as plasma sodium levels of 135−144 mmol/l with urine osmolality (OsmU) <span class="elsevierStyleUnderline"><</span>500 mOsm/l, 40−45 ml/kg/day of fluids are needed.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, the usual fluid intake, extrapolated to a healthy person weighing 70 kg, is ∼28−35 ml/kg/day.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We use a maintenance fluid intake of 25−30 ml/kg/day, since temperatures in hospital settings are usually <30 °C and metabolic expenditure in hospitalised patients is typically minimal, except in inflammatory conditions. We also use a potassium intake of 1−2 mmol/kg and a sodium intake of 2−3 mmol/kg per day, as several studies have found intake of 1.3–1.7 mmol/kg/day of potassium and 0.9−3 mmol/kg/day of sodium to yield maximum benefits in healthy people.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec2005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect2015">DDAVP dose</span><p id="par0045" class="elsevierStylePara elsevierViewall">The effects of DDAVP peak two to four hours after administration, then plateau over the next four to eight hours, gradually decreasing in the last hour and then disappearing.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Given its half-life of six to eight hours, it should be administered every eight to 12 h in complete DI.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The DDAVP regimen should imitate the normal dynamics of arginine vasopressin in the hypothalamus. In dehydration, release of arginine vasopressin from the hypothalamus is seen to peak when plasma osmolality (OsmP) is >290 mOsm/kg,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> translating to an OsmU of <span class="elsevierStyleUnderline">></span>900 mOsm/kg. In overhydration, with an OsmP <280 mOsm/kg, plasma arginine vasopressin is nearly undetectable and OsmU is seen to be lower than OsmP.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In complete ADI treated with DDAVP, the relationship between OsmU and OsmP will enable interpretation of dose suitability.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We titre the DDAVP dose based on measurements of OsmU, OsmP and plasma sodium levels in the plateau period for the dose administered and one hour before the next dose. We consider the dose suitable when we observe OsmU values two to three times greater than OsmP values during the plateau period and >200 mOsm/kg in the hour prior to the next dose, in the presence of normal plasma sodium levels. In our case, we found that OsmU >200 mOsm/kg before the morning dose was associated with ΔNaS <6 mmol/l in 12 h (p = 0.013), which we believe to be ideal.</p></span><span id="sec3005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect3015">Correction of abnormal plasma sodium levels</span><p id="par0065" class="elsevierStylePara elsevierViewall">In hypernatraemia, we use DDAVP or supply fluids, and in hyponatraemia, we administer furosemide to counteract the action of active DDAVP or we reduce fluid intake.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The quantity of fluids that result in ΔNaS of 1 mmol/l is unknown. According to the Adrogué-Madias formula,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> intake of ∼3.5−4 ml of water per kilogram of weight would reduce plasma sodium levels by 1 mmol/l. Calculations from dehydration studies<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> indicate that a loss of ∼2.5−4 ml of water per kilogram would increase plasma sodium levels by 1 mmol/l. In our case, we found that a decrease in fluid intake by 0.5−1 ml/kg increased plasma sodium levels by 1 mmol/l. Therefore, we used 1−3 ml of water per kilogram to correct plasma sodium levels by 1 mmol/l.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Ultimately, in the absence of more clinically rigorous studies, we hope that our experience aids in the management of other patients with ADI, with due attention paid to the importance of personalised treatment.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Confidentiality and ethics</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that this study was conducted in accordance with accepted good clinical practice standards, the Declaration of Helsinki and Spanish regulations, following the current recommendations of the local independent ethics committee. Informed consent was not required for this study, given its retrospective design and data anonymisation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">JGRS has a contract as a researcher with the Fundación para la Investigación Biomédica [Foundation for Biomedical Research] at Hospital Clínico San Carlos [San Carlos Clinical Hospital] (Reference: INV-15-2019). However, no funds were received to help with the preparation of this manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1015">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest for the conduct of this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec1005" "titulo" => "Fluid and electrolyte intake" ] 1 => array:2 [ "identificador" => "sec2005" "titulo" => "DDAVP dose" ] 2 => array:2 [ "identificador" => "sec3005" "titulo" => "Correction of abnormal plasma sodium levels" ] 3 => array:2 [ "identificador" => "sec0005" "titulo" => "Confidentiality and ethics" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-Sánchez JG, Parra Ramírez P, Martín Rojas-Marcos P, Lecumberri Santamaría B, Álvarez Escolá C. Protocolo de manejo hospitalario de la diabetes insípida asociada a adipsia. Desarrollado a partir de un caso clínico. Endocrinol Diabetes Nutr. 2021;68:668–670.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Note:</span> Once stable plasma sodium levels are achieved, it is recommended that p[Na] checks be performed at least once every 24 h, at the same time each day, in order to prevent ΔNaS associated with neurological damage.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">DDAVP: desmopressin; p[Na]: plasma sodium levels; OsmU: urine osmolality; OsmP: plasma osmolality; ΔNaS: changes in plasma sodium levels.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1. Fluid and electrolyte intake</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. In prolonged fasting, calculate fluid, sodium and potassium requirements; if the enteral route is available, calculate fluid requirements only, considering that 20% of the requirements come from food.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Intake of 25−30 ml/kg of fluids, 2−3 mmol/kg of sodium and 1−2 mmol/kg of potassium per day. Divide intake uniformly across three periods in 24 h (in intravenous fluid therapy), or for the duration of patient monitoring.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3. Assess fluid balance daily.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">2. DDAVP dose</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. Start with 1</span> <span class="elsevierStyleItalic">μg of intravenous or subcutaneous DDAVP, or its oral equivalent, every 12 h (morning and night)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Measure OsmU:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a. 1 h before administering DDAVP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b. 8 h after administering the morning dose of DDAVP (plateau period) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c. The goal is OsmU >200 mOsm/kg 1 h before each dose and 2−3 times OsmP 8 h from the morning dose \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3. Measure p[Na]:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a. 1 h before administering DDAVP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b. 8 h after administering the morning dose of DDAVP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c. The goal is a p[Na] of 135−145 mmol/l at all times \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4. Change the DDAVP dose depending on OsmU and p[Na]:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a. The results for OsmU and p[Na] express the effects of the prior DDAVP dose; therefore, this would be the dose to modify \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b. Consider decreasing DDAVP dose if: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I. p[Na] 8 h after the morning dose increases by >5 mmol/l or is in hyponatraemia range on >2 consecutive days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II. OsmU 8 h after morning dose is >3 times OsmP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III. Morning or night p[Na] is in hyponatraemia range or has dropped by >6 mmol/l compared to prior 12 h and OsmU is greater than OsmP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c. Consider increasing DDAVP dose if: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I. p[Na] 8 h after morning dose increases by >5 mmol/l or is in hypernatraemia range on >2 consecutive days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II. OsmU 8 h after morning dose is less than OsmP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III. Morning or night p[Na] is in hypernatraemia range or has increased by >6 mmol/l compared to prior 12 h and OsmU is less than OsmP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5. Adjust dosing with 0.5-μg increases or decreases in parenteral DDAVP or its oral equivalent and wait 2 days</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">3. Correction of abnormal plasma sodium levels</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. Goal: avoid changes in p[Na] <span class="elsevierStyleUnderline">></span>8 mmol/l and 16 mmol/l after 24 and 48 h, respectively. Calculate the volume of water to be administered or restricted to arrive at a p[Na] below the established limits. The formula to be used is 1−3 ml of water per kilogram to correct 1 mmol/l of p[Na].</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Perform the correction whenever there is a change greater than those specified, regardless of whether the current values are in the normal range. Interpret only morning and night p[Na] values.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3. Interpretation:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a. In changes <span class="elsevierStyleUnderline"><</span>8 mmol/l in p[Na] per day where plasma sodium levels remain in normal range, do not perform correction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b. In changes <span class="elsevierStyleUnderline"><</span>8 mmol/l de p[Na] per day resulting in hypernatraemia or hyponatraemia: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I. <span class="elsevierStyleBold"><span class="elsevierStyleItalic">Correct hypernatraemia:</span></span> administer corresponding DDAVP dose, supply volume calculated over 4−6 h and check p[Na] after 8 h. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II. <span class="elsevierStyleBold"><span class="elsevierStyleItalic">Correct hyponatraemia:</span></span> administer corresponding DDAVP dose, restrict volume calculated over the next 8 h and check p[Na] after 8 h. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c. In changes >8 mmol/l in p[Na] per day: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I. <span class="elsevierStyleBold"><span class="elsevierStyleItalic">Correct hypernatraemia:</span></span> administer corresponding DDAVP dose, supply the volume calculated in the next 12 h, and also administer an extra DDAVP dose similar to the prior dose. Check p[Na] after 12 h. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II. <span class="elsevierStyleBold"><span class="elsevierStyleItalic">Correct hyponatraemia:</span></span> administer corresponding DDAVP dose, supply the volume calculated over the next 8 h and also administer 20 mg of intravenous or 40 mg of oral furosemide. Check p[Na] after 8 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4. Consider increasing or decreasing the daily fluid intake calculated or the DDAVP dose in cases of hypernatraemia or hyponatraemia, respectively.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2773040.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inpatient management protocol for diabetes insipidus associated with adipsia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of central diabetes insipidus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Garrahy" 1 => "C.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 25 | 15 | 40 |
| 2024 September | 29 | 27 | 56 |
| 2024 August | 28 | 14 | 42 |
| 2024 July | 16 | 17 | 33 |
| 2024 June | 15 | 10 | 25 |
| 2024 May | 9 | 9 | 18 |
| 2024 April | 14 | 7 | 21 |
| 2024 March | 11 | 7 | 18 |
| 2024 February | 18 | 3 | 21 |
| 2024 January | 14 | 2 | 16 |
| 2023 December | 10 | 6 | 16 |
| 2023 November | 17 | 1 | 18 |
| 2023 October | 21 | 1 | 22 |
| 2023 September | 12 | 1 | 13 |
| 2023 August | 9 | 0 | 9 |
| 2023 July | 7 | 1 | 8 |
| 2023 June | 14 | 2 | 16 |
| 2023 May | 31 | 1 | 32 |
| 2023 April | 30 | 0 | 30 |
| 2023 March | 34 | 6 | 40 |
| 2023 February | 35 | 1 | 36 |
| 2023 January | 12 | 5 | 17 |
| 2022 December | 13 | 3 | 16 |
| 2022 November | 10 | 10 | 20 |
| 2022 October | 10 | 4 | 14 |
| 2022 September | 8 | 5 | 13 |
| 2022 August | 14 | 4 | 18 |
| 2022 July | 9 | 6 | 15 |
| 2022 June | 14 | 10 | 24 |
| 2022 May | 13 | 8 | 21 |
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