130: Diabetes Insipidus Complicating Management in a Child With COVID-19 ARDS: A Novel Use for Furosemide

INTRODUCTION: A delicate balance of fluid status is needed for optimal management of ARDS Achieving optimal fluid balance is difficult in patients with disorders of fluid homeostasis such as diabetes insipidus (DI) There is little data on the use of Furosemide to aid in balancing fluid and electrolytes in patients with DI METHODS: Here we present an 11-year-old female with developmental delay, septo-optic dysplasia and central DI who required careful titration of a Vasopressin infusion in addition to IV Furosemide for successful management of fluid overload The patient was admitted to our Pediatric ICU with acute Sars-CoV2 infection, respiratory failure, and ARDS (PaO2/FiO2=120) On admission, she demonstrated high volume urine output and a serum sodium level of 156 mmol/L Her home subcutaneous Desmopressin was changed to a 0 5 mU/kg/hr Vasopressin infusion Despite this, her urine output continued to increase;a maximum of 4L urine was voided resulting in severe hypernatremia (serum sodium of 171 mmol/L) This change occurred despite a maximum Vasopressin infusion rate of 8 mU/kg/ hr along with simultaneous adjustments in both the sodium concentration and rate of administered IV fluids By the second day of hospitalization, a net positive fluid balance of 2 8L was noted and severe hypernatremia persisted (serum sodium of 160 mmol/L) Her ARDS continued (PaO2/FiO2 = 132) When her hypernatremia persisted into the third day of hospitalization, a trial IV Furosemide in addition to down-titrating Vasopressin was attempted This resulted in successful diuresis (net balanced fluid status of -497 L) along with resolution of hypernatremia (serum sodium fell gradually to138 mmol/L) Her ARDS improved and the patient was extubated on hospital day 10 RESULTS: The combination of IV Furosemide with Vasopressin infusion resulted in tailored diuresis and more controlled titration of serum sodium levels than adjustment in Vasopressin and fluids alone These results are in contradistinction to the published literature, which endorse the use of thiazide diuretics in managing DI ∗ This experience highlights the potential for loop diuretics to aid in establishing desired fluid and electrolyte status in managing patients with both DI and ARDS