Fleet Enema - Detroit VA Medical Center

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Fleet Enemas

David F McAuley, Pharm.D., R.Ph Oct, 2 , 2007

Background

Pharmacists frequently receive written orders for multiple doses of Fleet enemas that may be inappropriate. Pharmacist intervention is necessary in some cases in order to safeguard the patient.

Goal

(Eliminate the following types of orders: )
1) Open-ended orders for multiple enemas given daily.
2) Orders for three or more enemas in a 24 hour period.

Recommended action:

Adult patients: All orders for multiple doses of Fleet enemas should be restricted to a single enema (118 ml). This dose may be repeated once if the desired response is not achieved. Note: if an order is received for two Fleet enemas x 1, separate the administration times by 1 hour – e.g. q1h x 2 (see pre-procedure example below). Rigid adherence to the one hour separation is not necessary in low-risk patients. [Low-risk patients: normal renal function, normal gut motility, absence of inflammatory bowel disease, and less than 65-70 years of age.]

Pre-Procedure Patients - sigmoidoscopy
1.	1st enema : the evening before the procedure.
2.	2nd enema : two hours before the procedure.
3.	3rd enema : one hour before the procedure.

Maximum daily dose:

Under no circumstances should more than two Fleet enemas be given in a 24 hour period in the absence of follow-up electrolyte levels. If greater than two enemas are to be given, the following electrolyte levels should be monitored prior to the third enema: serum phosphate, magnesium, and calcium. See ‘patients at greatest risk’ below.

Support:

Problem:

Inorganic phosphate salts are readily absorbed from the gastrointestinal tract.

Potential impact of repeated doses:

Significant electrolyte disturbances:
Severe hyperphosphatemia >> leading to acute hypocalcemia and hypomagnesemia.

Potential impact of the preceding electrolyte disturbances:

Tetany
Seizures
Bradycardia
Dysrhythmias

Prolonged QT interval
Cardiac arrest
Coma
Death

Which patients are at the

greatest risk??

Patients with renal impairment.
Patients with abnormal gut motility.
Patients with inflammatory bowel disease
Elderly patients.

Recommended reading:
Biberstein M, Parker BA. Enema-induced hyperphosphatemia. Am J Med. 1985 Nov;79(5):645-6.

Severe hyperphosphatemia and hypocalcemia developed following the administration of a single hypertonic sodium phosphate enema in an adult with mild chronic renal insufficiency.”

Farah R. Fatal acute sodium phosphate enemas intoxication. Acta Gastroenterol Belg. 2005 Jul-Sep;68(3):392-3.

We describe a patient who died as a result of severe hypocalcaemia and hyperphosphatemia after treatment with a sodium-phosphate enema. Physicians should be aware of the risk when using these enemas, even in normal doses, especially in elderly patients without signs of renal failure, as in our patient.

Korzets A, Dicker D, Chaimoff C, Zevin D. Life-threatening hyperphosphatemia and hypocalcemic tetany following the use of fleet enemas. J Am Geriatr Soc. 1992 Jun;40(6):620-1.

Reedy JC, Zwiren GT. Enema-induced hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center. Anesthesiology. 1983 Dec;59(6):578-9.

Rohack JJ, Mehta BR, Subramanyam K. Hyperphosphatemia and hypocalcemic coma associated with phosphate enema. South Med J. 1985 Oct;78(10):1241-2.

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