Phosphate Enemas (FLEET) May Pose a Risk for Elderly, Renal Patients

Phosphate-containing enemas are widely used in hospital and outpatient settings. The highly osmotic sodium phosphate causes fluid to move into the colon to exert a laxative effect. Little absorption of the enema contents occurs under normal conditions because the enema response typically occurs within minutes. However, the enema contents may be retained for longer periods in patients with atonic bowels caused by disease or anticholinergic medications such as diphenhydrAMINE, DITROPAN XL (oxybutynin), SPIRIVA (tiotropium), and dextromethorphan (Ori et al., 2012). Elderly patients and patients with renal impairment are at risk for metabolic abnormalities because of phosphate absorption from Fleet enemas. Symptoms include volume depletion, hypotension, acute renal failure, metabolic acidosis, hypernatremia, and extreme hyperphosphatemia with life-threatening hypocalcemia (Ori et al.).

A review of 11 patients who received Fleet enemas showed that, within 24 hours, 7 of those patients presented with hypotension, volume depletion, and hyperphosphatemia (Ori et al., 2012). Most patients also developed hypernatremia and hypokalemia. All 11 patients developed acute renal failure, and 2 patients required hemodialysis. Five of the patients died, and 3 of the remaining 6 experienced other problems that required prolonged hospitalizations. The average age of these patients was 80 years.

Special precautions are needed when regular Fleet enemas are prescribed for elderly patients, patients with renal impairment, or patients with atonic bowels. During order entry and validation, computer systems should warn practitioners when these agents are prescribed for at-risk patients. Consider the implementation of a constipation management order set that would not include Fleet enemas. Patients should never receive more than one phosphate-containing enema every 24 hours.

REFERENCE

Ori Y., Rozen-Zvi B., Chagnac A., Herman M., Zingerman B., Atar E, ..., Korzets A. (2012). Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: A single center's experience. Archives of Internal Medicine, 172(3), 263-265. [Context Link]

Benadryl Dispensed Instead of Vitamins

A 47-year-old woman with a history of multiple gastrointestinal surgeries experiences severe nausea, vomiting, and abdominal pain, requiring daily parenteral nutrition (PN). The patient's home infusion company made and delivered the supplies along with the 3-in-1 PN admixtures. Rather than dispensing the vials of multivitamins (which the patient adds at home), they inadvertently dispensed 84 vials of diphenhydrAMINE injection (BENADRYL). Unfortunately, the patient added diphenhydrAMINE to the PN that infused over 14 hours for 2 consecutive nights, resulting in significant drowsiness. She called the home infusion company on the third day to inquire about the different looking vials she was using and the error was discovered. The home infusion company retrieved the remaining vials of diphenhydrAMINE and replaced them with the multivitamin. The infusion company completed an internal investigation and is taking steps to avoid a similar error in the future. A further improvement would be to require a documented, independent double-check of all supplies against the original patient's orders before delivery. Patients should review their supplies when they arrive and again before beginning the infusion. Verification of the infusion against the current PN order is optimal.

Twice per Week or Twice per Month?

Biweekly is sometimes used to mean once every 2 weeks. Bimonthly usually means once every 2 months. However, these words are likely to cause confusion. According to online and print dictionaries, biweekly is also used to mean twice per week and bimonthly can also indicate twice per month. So, when ordering medications and transcribing orders, these words should be avoided. Instead, use and write out terms such as "twice per week," "every other week," "every 2 weeks," "every other month," or "alternate months."