2023 FSA Podium and Poster Abstracts

P051: NEW ONSET INTRAPROCEDURAL DIABETES INSIPIDUS: CHALLENGES OF DIAGNOSIS AND TREATMENT IN THE OPERATING ROOM.
Rodolfo Prado Torres, MD; Stuart van der Greeff, MD; Diego Lozano, MD; Gretel Carmenate, MD; Nathalie Abitbol, MD; University of Miami / Jackson Memorial Hospital

Introduction: Diabetes insipidus (DI) results from decreased antidiuretic hormone (AVP) production or secretion from the neurohypophysis or from an impaired renal response to AVP leading to inadequate water reabsorption from urine resulting in hypo-osmotic polyuria. The standard of treatment in central DI is desmopressin (DDAVP) administration.

Methods: We describe the case of a 67-year-old female patient with PMH of hypertension, hypothyroidism and osteoporosis, who presented for orbitozygomatic craniotomy for excision of a planum sphenoidale meningioma. Preoperative workup demonstrated normal plasma sodium and osmolality; intraoperatively, patient developed polyuria along with increased serum sodium suggesting a diagnosis of DI.

Results: Following standard induction and uneventful airway management, total intravenous anesthesia technique was achieved with remifentanil and propofol infusions. Mannitol (0.5 mg/kg) was administered after intubation, and redosed 3 hours later per surgeon request; both doses with appropriate urine response and improved field visualization. Ten hours later, urine output rapidly increased with dilute volumes over 350mL/h (Figure 1). An arterial blood gas demonstrated sodium level of 144 mmol/L that progressively worsened to 150 mmol/L. Though urine samples were not sent to the lab, a presumptive diagnosis of DI was made based on the acute onset of polyuria and hypernatremia in the setting of an intracranial procedure. Surgeon and anesthesiologist agreed upon administration of desmopressin. However, concise evidence regarding intraoperative desmopressin dosing regimens lacks across the literature. A 2 mcg dose of desmopressin was initially administered, resulting in decrease of sodium level to 147 mmol/L by the second hour after infusion. Another 1 mcg dose of DDAVP was given resulting in continued correction in sodium levels to 145 mmol/mL and normalization of urinary output until the end of surgery. Patient was kept intubated and transported to neurosurgical ICU where polyuria recurred overnight. Urine studies were sent by the intensivists resulting in specific gravity at the lower limit of normality and high-normal plasma osmolality of 290 mosm/kg. Desmopressin was given once more (1 mcg) on postoperative day 1, again improving the polyuric state and Na values. Patient was extubated on postoperative day 3 and discharged from ICU on postoperative day 4.

Discussion: Diabetes insipidus etiologies include hypophyseal neoplasms, head trauma, radiation, surgery and infections. Modern practice anesthetics agents such as propofol, sevoflurane, dexmedetomidine, and ketamine were also found to be implicated in a number of case reports. Clinical definitions of polyuria are inconsistent across the literature reflecting the lack of a consensus statement. During anesthesia it is marked by significant urine output of >125 mL/h or 50ml/Kg/24h in adults. Societal guidelines for treatment with desmopressin commonly pertain to the inpatient and intensive care unit populations, where urine samples can be sent for specific gravity and osmolality. In a recent literature review of anesthetic-related DI, treatment doses ranged from a single dose of 2mcg up to 30mcg reflecting lack of standard regimens. Successful management was achieved by titrating DDAVP dosing to Na values, and urine output, with caution to avoid rapid overcorrection of hypernatremia.