Acute

Polyuria Diagnosis and Workup 1

Definition: ICU: Urine output >300ml/hour for 2hours
Acute Care: Urine output >1000ml over 4 hours

STEP 1: Make an accurate diagnosis EARLY in the course of acute polyuria
DI is common in patients with TBI, SAH, post craniotomy or TSS and can occur rapidly
o DI is often transient and may resolve in 24-72 hours
Labs: STAT serum basic metabolic panel and osmolality
urine sodium, osmolality, glucose and specific gravity (SG)

Diabetes Insipidus: DIAGNOSIS
Lab values Additional factors
Serum Na and Osm HIGH or HI normal No hyperglycemia or glucosuria
Urine SG <1.005 No mannitol administration
Urine Osm < Serum Osm No AKI


STEP 2: IF DI is diagnosed, decide on Treatment:
*No Action is NOT an option. Reassessing in a few hours without treatment can result in severe
hyperosmolarity*

Examine and categorize the patient:
1) For patients capable of reliable, self-regulated oral free water replacement (awake, alert, upper
extremity use ok, normal thirst mechanism):
a) plenty of ice-cold water within easy reach at the bedside
b) labs: measure plasma Na+ and K+, urine Na+ and osmolality q4hours x24h. If plasma Na+
normal after 24h or DI resolves reduce frequency. Replace K+ if hypokalemia occurs
c) consider treatment with dDAVP (0.5-1.0 microgram sc/iv) if any of the following:
i) ongoing DI after 48h,
ii) ongoing DI and hypernatremia (esp. in catheterized patients),
iii) ongoing DI and poor sleep due to nocturia

2) For patients whose medical status DOES NOT allow reliable, self-regulated oral free water
replacement:
a) Evaluate:
i) Patients diagnoses,
ii) Urine OUT,
iii) All IV and enteral INs (fluid or feeding with osmolarity <500mOsmol/L) not related to
replacing urine output
b) Utilize the figure and table on the following page to determine management
c) Utilize the Diabetes Insipidus Powerplan to initiate treatment
 Acute Polyuria Diagnosis and Workup 2

DI Treatment Specifics
dDAVP* Free Water Replacement
Dose: 0.5-1.0 microgram iv/sc/im x 1** 1) Evaluate urine OUT volume, serum Osm, urine Osm (either q2h or q4h)
- duration of action 8-12h, rapidly reduces 2) Free water loss = UVol (Uosm/POsm)xUVol e.g.
UO, no BP effect 1000ml (160mOsm/320mOsm)x1000= 500ml
Always consult with fellow and/or attending 3) Replace free water IV (D5W) or PFT/NG (water) over the same time
before ordering. interval (either 2 or 4hours)
(oral or nasal dDAVP is variably absorbed and e.g. 500ml free water = D5W at 250ml/h for 2 hours
should not be used in hospitalized patients) n.b.: Most ICU patients should have IV water replacement

dDAVP: give subsequent dDAVP doses ONLY if urine OUT again meets polyuria criteria (see above)
and labs again meet DI diagnostic criteria (see above)
Free water: In general, to avoid hyponatremia** free water replacement should be reduced or
discontinued if dDAVP treatment is initiated. If plasma Osm <310 mOsm/kg free water replacement
should absolutely be discontinued.
Monitor: urine OUT (q1-4h), plasma Na+ and K+, urine Na+ and osmolality q4hours x24h
*dDAVP should be considered for patients with DI to:
1. Prevent complications related to massive (IV or enteral) free water replacement (especially in
ICU patients this may include hyperglycemia, neuronal injury, IV access problems),
2. To prevent washout of the renal medulla which secondarily impairs renal urinary
concentrating ability
**Patient harm from hyponatremia related to dDAVP therapy occurs in the following
situations:
1. Wrong diagnosis,
2. Scheduled doses of dDAVP when DI resolves or when patient transitions to the second phase
of pituitary stalk injury (uncontrolled ADH release from damaged neurons),
3. Excess IV fluid administration OR po fluid intake (includes all liquids i.e. NS, tube feeds, etc.
that are hypo-osmotic compared to the URINE Osm after dDAVP Rx)
 Acute Polyuria Diagnosis and Workup 3


3) For patients with increased ICP, hypotension, hypovolemia, shock or severe polytrauma:
(1) Resuscitate to normovolemia using isotonic crystalloid (Plasma-Lyte or normal saline
[NOT lactated Ringers]).
(2) For ongoing polyuria with urine output > 500 ml/hour, start IV vasopressin: shorter
duration of action than dDAVP, titratable, simultaneously treats DI and hypotension
(a) Dose: Start at 0.04 units/minute and titrate by 0.01 units/minute every hour to
maintain urine output < 500 ml/hour, serum Na+ 140-145 meq/L (max rate 0.10
units per minute)
(b) Adjust IV/FT free water replacement based on serial monitoring of UOsm/POsm and
UO as shown above.




 Acute Polyuria Diagnosis and Workup 4


Differential Diagnosis of Other Causes of Polyuria
Diagnosis Lab values Additional factors
Serum Na+ low
Serum Osm high
Urine Osm low, BUT
Osmotic diuresis Mannitol, glucose, contrast dye
Urine SG high
Serum and urine
glucose high
Serum Na+ variable
Post-operative or post- Serum Osm normal
Check Medic One, ED, OR Records
resuscitation diuresis Urine Osm Serum
Osm
Serum Na+ & Osm
History (recent AKI, bladder outlet
AKI or post-obstructive diuresis normal initially
Urine Osm < serum Osm obstruction, etc)
Serum Na+ and Osm
Acromegaly, post-pituitary History (chronic salt and water retention
normal
resection Urine Osm < serum Osm
with acromegaly)
Serum Na+ and Osm
normal Seen with induced hypertension (e.g.
Vasoconstrictor therapy Urine Na+ low treatment of vasospasm)
Urine Osm variable
Serum Na+ low
Serum Osm low Typically occurs after SAH
Cerebral salt wasting Urine Na+ > 50 Intravascular volume reduced
Urine Osm normal-high
Serum Na+ normal-low
Serum Osm normal-low
Loop diuretics Urine Na+ normal-high

Urine Osm not low


Treatment of Other Causes of Polyuria:
Osmotic
Monitor volume status; resolves once the drug clears
Mannitol
Insulin, d/c glucocorticoids, switch from continuous to
Glucose
intermittent tube feeding
Postoperative/postresuscitative
Monitor fluid status and electrolytes; resolves spontaneously
diuresis
Monitor volume status and electrolytes, replace fluids if patient
Post-obstructive/AKI
becomes dehydrated or develops electrolyte abnormalities
Monitor volume status; resolves spontaneously without
Acromegaly
electrolyte imbalance
Vasoconstrictor therapy Monitor fluid status, discontinue/reduce pressors if possible
Cerebral salt wasting Fludrocortisone 0.1-0.3 po/pft bid