Electrolyte disorders following oral sodium phosphate administration for bowel cleansing in elderly patients . Consequently, if the glomerular filtration rate is decreased, hyperphosphatemia can easily develop after NaP administration (5). Forty-five adult participants aged 50 years or older enrolled in the trial. Youll laugh, learn and maybe sing along. The general technique is to use plain warm water or warm soapy water. JJthe SAGES Colonoscopy Study Outcomes Group,A prospective analysis of 13,580 colonoscopies: reevaluation of credentialing guidelines. Which laboratory tests are useful in the evaluation of a patient with severe hypocalcemia? This case serves to remind clinicians that NaP enemas and laxatives should be used with caution. However, what if your patient isnt a health young adult? Baracskay Abstract Background: Sodium-phosphate enemas are widely used to treat constipation, and are rarely associated with side effects. 4 In a systematic review, 5 water and electrolyte disturbances were found in 11 elderly adults. A total of, 96%, 96%, and 93% of patients who took 60 grams of oral sodium phosphate, 60 grams of OsmoPrep, and 48 grams of OsmoPrep, respectively, developed hyperphosphatemia (defined as phosphate level > 5.1 mg/dL) on the day of the colonoscopy. It is easily available over-the-counter with no prescription required. Rectal sodium phosphate comes as an enema to insert in the rectum. Sodium phosphate induces hyperphosphatemia, hypoca CWImperiale Enemas are not . Authors' Disclosures or Potential Conflicts of Interest:No authors declared any potential conflicts of interest. NSarkar ED, Emergency Department; Dialysis, Nephrology and Dialysis Department; P, plasma; B, whole blood. PEpstein Administrations of oral laxatives or adult-sized hypertonic phosphate enemas in children can produce extremely high serum phosphate concentrations (3, 8). A 15-month-old girl with body weight of 8.6kg suffering from chronic constipation presented to the emergency department (ED) with limb stiffness for 1 hour after she was given tube of phosphate containing enema. DiPalma Analysis of other serum and urinary electrolyte parameters, phosphorus, or calcium did not demonstrate any significant differences between cognitive or functional groups nor an association with the coexistent diseases or with medications. Terms of Use| Electrolyte Abnormalities In Study 1 Hyperphosphatemia. DCugina Extracellular phosphate concentrations depend mainly on the phosphate load and its renal excretion. Inflammatory Bowel Disease . Several risk factors for NaP intoxication that have been identified include impaired renal function, decreased intestinal motility, increased intestinal permeability, Hirschprung disease, enteric fistulas, congestive heart failure, liver cirrhosis, preexisting electrolyte disturbances, and an inability to maintain adequate fluid intake (3, 6, 7). SKBjerregard MJeds. Phosphate crystal deposition in the kidneys . Fleet enemas should also be relegated to this list of medications that should generally be avoided unless your patient is a very robust older adult. Bnf for children (bnfc) 2016-2017. AParry Although not statistically different from arrhythmia before preparation, there were 4 patients in the sodium phosphate group who had ventricular tachycardia during preparation. There were more demented patients with hypokalemia compared with normokalemic patients (P<.05). If hypocalcemia and hyperphosphatemia are found together with hypernatremia and hypokalemia, NaP intoxication should be suspected. Although sodium is an electrolyte, it is . Sodium phosphate and sodium biphosphate enemas usually should not be administered if this type of enema was already used in the past seven days. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Arch Intern Med. The treatment strategy for patients with a preserved renal function and moderate hyperphosphatemia aims to enhance renal excretion or to redistribute phosphate into the intracellular compartment by administration of dextrose/insulin, and, if possible, to deposit phosphate into the bone matrix by administrating calcium (10). Carlisle Thatte BDPost Gupta On day 1, patients were administered 2 doses of oral sodium phosphate. SCGopalswamy MLModulation of the secretion of potassium by accompanying anions in humans. FDasgupta What do I need to tell my doctor BEFORE I take Sodium Phosphates Enema? First, oral sodium phosphate preparations can cause significant fluid shifts within the colon resulting in intravascular volume depletion. Lipner In cases of concomitant hypocalcemia and hyperphosphatemia, consider the possibility of iatrogenic administration or abuse of NaP-containing enemas or laxatives. Design We conducted a matched case-control, retrospective study in a cohort of hospitalized patients. Concomitant hypocalcemia and hyperphosphatemia are common in renal insufficiency. JJMarshall CAA measure of primary sociobiologic functions. Life-threatening or fatal plasma concentrations of calcium and phosphate have been sporadically reported, however (6). An autopsy on one patient revealed calcium phosphate calcifications within the renal tubular lumens. There are multiple reasons why disorders of blood chemistry may develop, including respiratory or renal disease, obesity, and medication. The patient vomited the following night, and a nasogastric tube was inserted. We investigated these electrolyte disorders and their correlation with creatinine clearance, coexistent diseases, medications, and functional status. Renal phosphorus excretion depends on the filtered load (GFR plasma phosphorus) and on the renal threshold (TmP/GFR), where TmP is the limiting rate of tubular phosphorus reabsorption.19,20, Phosphorus is absorbed principally in the jejunum and duodenum by both passive and active transport under the influence of vitamin D.21 The net phosphorus absorption increases linearly with its intake in normal subjects.22 Serum phosphorus is freely filtered in the kidney; 80% to 90% is reabsorbed by the renal tubules, of which 70% occurs in the proximal convoluted tubule and about 10% in the distal convoluted tubule. Sodium phosphate Enema and Intravenous Injection Sodium phosphate is available as an enema (Fleet enema) for bowel preparation. TFMeta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation. enzymes. Isotonic fluids such as lactated Ringer's solution are acceptable for treatment of phosphate enema toxicity, but electrolyte-poor solutions, such as 5% dextrose in water or 0.45% sodium chloride, are usually recommended . Prescribing and dispensing information Creatinine clearance should be calculated to estimate the magnitude of calcium-phosphorus variations, albeit other intervening factors exist. Acute phosphate nephropathy with oral sodium phosphate is well documented. RDo J Pediatr Gastroenterol Nutr. Eur J Pediatr. The severe electrolyte abnormalities were confirmed after analysis of a second blood sample drawn after 1.5 h, which revealed severe hyperphosphatemia [30.0 mg/dL (9.69 mmol/L); reference interval, 2.54.5 mg/dL (0.811.45 mmol/L)] without signs of overt acidosis. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers. Coe What are several causes of severe hyperphosphatemia? Medical practitioners may not be familiar with the content of each laxatives and their related potential toxicity. POral sodium phosphate versus sulfate-free polyethylene glycol electrolyte lavage solution in out patients preparation for colonoscopy: a prospective comparison. Cockcroft Kolts and electrolyte output (Table 42) (Felver, 2019d). No correlation was found between creatinine clearance on day 1 and the fractional excretion of phosphorus on days 2 or 3 and between phosphorus and unbound calcium. SMEthier Pupils were 4mm in size with sluggish response. What treatment should be used in patients with severe hyperphosphatemia and hypocalcemia? Oxygen saturation was 88% in room air. Debate exists as to the accuracy of GFR measurement using the Cockcroft and Gault formula in the elderly.25 A recent study of healthy elderly subjects found it to be too inaccurate for clinical use.26 This could explain in part why variations in GFR account for only about 27% of the phosphorus change (R2 = 0.27). HIRuzany Why the Same Holds True for Sodium Phosphate Enemas (aka Fleet enemas). Urine Solute (mg/dL or mEq/L) Serum Creatinine (mg/dL)/Serum Solute (mg/dL or mEq/L) Urine Creatinine (mg/dL). Hypokalaemia has been reported in other cases of phosphate enema intoxication in both adults and pediatric patients as well. We report a case of life threatening toxicity in a young child without underlying renal disease after she was given repeated doses of sodium phosphate enema, and discuss about the acute management of phosphate-containing laxatives toxicity, as well as the growing concern for safety of this kind of medication. An increase in serum phosphorus level was correlated with a decreased creatinine clearance (. 2012;172(3):263. GLCellular potassium depletion predispose to hypokalemia after oral sodium phosphate. What are the adverse effects of this drug? Each enema contained 19.2 g of monobasic NaP and 7.2 g of dibasic NaP. Hsu The diagnosis of sodium phosphate enema toxicity was made based on history, clinical findings, and response to therapy. In the meantime, the abdominal computed tomography scan revealed paralytic ileus. 2022 American Medical Association. Fatal Electrolyte Abnormalities Following Enema Administration. combinations laurilsulfate, incl. Clarkston et al7 monitored cardiac arrhythmia before and during colon preparation, and during colonoscopy with sodium phosphate vs sulfate-free polyethylene glycol. A case of life threatening toxicity in a young child without underlying renal disease after she was given repeated doses of sodium phosphate enema is reported, and about the acute management of phosphate-containing laxatives toxicity, as well as the growing concern for safety of this kind of medication is discussed. If a sodium phosphate enema is used for severe constipation, it is recommended that no more than one dose be administered per 24 hour period, for no more than 3 days. A retention enema also stimulates the bowels, but the solution that is used is intended to be "held" in the body for 15 minutes or more. Vanner Although hundreds of patients aged 15 to 91 years were enrolled in studies comparing the safety and efficacy of sodium phosphate vs polyethylene glycol preparations given for bowel cleansing before a colonoscopy, there are no studies investigating the electrolyte and acid-base changes induced by the oral sodium phosphate load, specifically in the elderly.2-7 The aim of the present study was 2-fold: (1) to investigate the electrolyte and acid base disorders induced by standard oral sodium phosphate preparation given before a colonoscopy or barium enema in elderly patients and (2) to assess these changes in relation to creatinine clearance, coexistent diseases (ie, Parkinson disease), medications (ie, anticholinergic agents), and functional and cognitive status. and death. There were more demented patients in the group with a serum potassium concentration of 3.5 mEq/L or less on day 2 (60%) than in the group with serum potassium concentrations greater than 3.5 mEq/L (25%) (P<.05). SJMacDonald Vanner et al3 reported that 28% of their patients had a serum potassium concentration below 3.5 mEq/L after administration of sodium phosphate, with a lowest value of 2.9 mEq/L (56% and 2.45 mEq/L in our study, respectively). There is also an age-related decline in renal function, which is frequently overlooked because the plasma creatinine level may remain within the normal range despite a 50% or greater decrease in the glomerular filtration rate compared with young individuals.8. ASuryaprasad The role of the clinical laboratory is fundamental in the recognition and diagnosis of NaP intoxication. She developed seizures with generalized hypertonia. COLONIC DISORDERS are of particular importance in elderly patients because of marked age-associated increases in their prevalence and differences in their presentation and prognosis compared with the young. MLief Hyperphosphatemia can have several causes. What are some differences between a cleansing enema and a retention enema? The patient was regularly taking digoxin, enalapril, aspirin, transdermal nitrate, and furosemide. Maximum deficiency can occur within a matter of 6-8 hours after the start of therapy. Methods JPSchwartz Five patients died. Dominika Szoke, Alberto Dolci, Augusto Genderini, Mauro Panteghini, Fatal Electrolyte Abnormalities Following Enema Administration, Clinical Chemistry, Volume 58, Issue 11, 1 November 2012, Pages 15151518, https://doi.org/10.1373/clinchem.2011.170183. The frequency and severity of hypokalemia is due to intestinal potassium loss associated with inadequate renal potassium conservation and is apparently more prevalent in frail patients. 2007;26(1):9-20. MMahneensmith In healthy adults, approximately 60%65% of dietary phosphate is absorbed in the form of inorganic phosphate (1). Sodium phosphate induces hyperphosphatemia, hypocalcemia, and hypokalemia. Marsh et al38 concluded in a small study that colonic lavage with polyethylene glycol was associated with increased ventricular ectopy. WHHalter WKTsen SODIUM PHOSPATE SALT (SOE dee um FOS fate sawlt) is a saline laxative. Sodium phosphate, dibasic is an osmotic laxative used to cleanse the colon before a colonoscopy. 5.3. Sodium Phosphate Rectal is a prescription medication used to treat constipation and for cleansing bowel. BAReview of the literature: severe hyperphosphatemia. 2016;67(4):609-616. AGTeo BRPlank These alterations are temporary and asymptomatic in most cases, and the development of hyperphosphatemic acidosis is not expected in well-hydrated adults with a preserved kidney function (4, 5). EJFDonnelly Age is another aggravating condition. A more recent and larger study demonstrated a relatively low intraprocedural colonoscopic complication rate of arrhythmia (0.1%), bradycardia (0.8%), and hypotension (1.2%).40. Lastly, phosphate nephropathy may occur due to the transient and potentially severe increase in serum phosphate combined with volume depletion from the fluid shifts. Overall, 21 patients (58%) had a calcium concentration of 8.4 mg/dL (2.1 mmol/L) on day 2. lethargy . NPaz-Marinez et al. Abnormal shift of phosphate into the cell - This may be caused by hyperventilation, respiratory alkalosis, hyperglycemia, and hypercalcemia. They examined the effect of oral sodium phosphate (two 45mL doses administered approximately 12 hours apart) on electrolyte levels in 36 elderly patients (aged 65 years) undergoing bowel cleansing . Reactions 956 - 21 Jun 2003 Sodium phosphate: electrolyte disorders in the elderly Sodium phosphate can induce serious electrolyte imbalances in elderly patients, report investigators in Israel. RSDaCosta Sodium phosphate (referred to as saline) Bisacodyl Oil based Each of these types of enemas achieve their laxative effects via different pathways. On the drug guide for this product it states, "Using more than the recommended dose in 24 hours can be harmful. JMBhowmick Even severe hyperphosphatemia is largely a clinically asymptomatic condition. To estimate the glomerular filtration rate (GFR), the Cockcroft and Gault formula was used to calculate the creatinine clearance.17. et al. JT SMVasuvattakul Nevertheless, patients whose serum potassium concentration was 3.5 mEq/L or less on day 2 had a lower baseline serum potassium concentration on day 1 compared with patients with a serum potassium concentration above 3.5 mEq/L on day 2. Rectal sodium phosphate is in a class of medications called saline laxatives. In effect, we have found a fair negative correlation between the baseline creatinine clearance and phosphorus (R = 0.52) (Figure 1), in parallel with a 3-fold increase in the fractional excretion of phosphorus. Small volume products that contain sodium phosphate used for bowel preparation can cause serious fluid and electrolyte disturbance, including hypocalcaemia, hyperphosphataemia and hyperkalaemia. Serum phosphorus levels increased by almost 100% between days 1 and 2, ranging from 2.6 to 4.7 mg/dL (0.84-1.52 mmol/L) to 4.5 to 10.4 mg/dL (1.45-3.36 mmol/L), respectively. Group A received 60 mL (mean dose, 18 mL/kg . SEWarner References 1. BELyles Adult: Up to 100 mmol of phosphate daily. Specific considerationsCardiovascular disease (e.g. Laxatives are commonly used medication in patients of all age groups. The Mini-Mental State Examination16 was used to assess cognitive level. IBourgoignie Adult: Usually contains monobasic and dibasic sodium phosphates but the . NLee Virtually, all side effects were due to water and electrolyte disturbances. Given the patient's age, renal status, and laboratory findings, NaP toxicity due to the enemas is the most likely diagnosis. Enemas can also be buffered with a sodium phosphate solution to draw additional water into the intestinal lumen, which may lead to intense cramping from colonic irritation. CLUrbina some cases resulting in death, It is a fast acting enema which works to Sodium phosphate induces serious electrolyte abnormalities in the elderly. There are different types of electrolytes; sodium, potassium, and chloride play a significant role in cell homeostasis (i.e., a self-regulating process of the body to adjust to conditions that are optimal for survival), along with calcium, magnesium, phosphate, and bicarbonate. SABarthel Learn more, Credits: Tietz textbook of clinical chemistry and molecular diagnostics, Fatal poisoning from sodium phosphate enema. Beloosesky Y, Grinblat J, Weiss A, Grosman B, Gafter U, Chagnac A. Electrolyte Disorders Following Oral Sodium Phosphate Administration for Bowel Cleansing in Elderly Patients. heart failure) avoid use of sodium salts; use with caution as fluid and electrolyte disturbances can occur. JGreenberg Puchet SAkpon BKMeara 1979;94(1):149-151. 2004;19(1):68). JRSinger All trademarks used are the properties of their respective owners. Arch Intern Med. Laboratory findings revealed severe hypocalcemia [3.7 mg/dL (0.93 mmol/L); reference interval, 8.510.5 mg/dL (2.132.63 mmol/L)] and alterations in the plasma concentrations of other major plasma ions (Table 1). Patients >65 years of age also require careful monitoring (5, 6). The main risk factors are extreme age and associated . alberto dolci. What they found was that renal function deteriorated in all 11 patients. Urinary phosphorus excretion increased significantly on day 2. SMPotts Pharmaceutical Press; 2016. JDenda Up to 350 mmol/day of sodium can be lost per square meter of treated body surface area. Szabo A, Eitan A, Zveibil F, Weiss M, Waksman I, Makhoul N. Life-threatening electrolyte abnormalities induced by hypertonic phosphate enema intoxication. Pimozide is associated with a well-established risk of QT prolongation and torsade de . Both can lead to dehydration, electrolyte imbalance, seizures, organ failure, heart attack, and even death. The serum calcium level was dangerously low in 8 patients. His medical history included successful surgery for prostatic carcinoma, aortocoronary bypass surgery, and cardiac pacemaker implantation. Marraffa J, Hui A, Stork C. Severe Hyperphosphatemia and Hypocalcemia Following the Rectal Administration of a Phosphate-Containing Fleet Pediatric Enema. SKamel RJCardiac arrhythmia and electrocardiographic changes during upper and lower gastrointestinal endoscopy. Increased phosphate intake can occur via oral or intravenous routes or be due to the administration of phosphate-containing laxatives or enemas. SEKaiser A third mechanism, an increased extracellular phosphate load, consists of a transcellular shift in lactic, respiratory, or untreated diabetic acidosis, and cell lysis in rhabdomyolysis, intravascular hemolysis, or tumor lysis syndrome (1). Biebl A, Grillenberger A, Schmitt K. Enema-induced severe hyperphosphatemia in children. Lieberman et al27 reported that the lowest serum potassium value secondary to sodium phosphate administration was 3.2 mEq/L. Coyle At admission, the patient was hyperkalemic (Table 1), and therapy with sodium polystyrene sulfonate and ethacrynic acid was started immediately. BThe acidosis of exogenous phosphate intoxication. Am J Kidney Dis. Among the short-term complications of hyperphosphatemia, acute hypocalcemia is the most important; more rarely, acute deposition of calcium phosphate precipitates into joints, subcutaneous tissues, vessels, and other soft-tissue areas can occur (8). Slatopolsky Paediatric Formulary Committee. Glasgow Coma Scale (GCS) was 4/15 (E1V1M2). In a life-threatening situation, however, the risk of soft-tissue calcification in response to calcium administration may be less important than restoring at least low-normal serum calcium concentrations to control the cardiovascular consequences of hypocalcemia (10). A total of 12 deaths were found. These changes were correlated with scientific literature reports of hyperphosphatemia following phosphate enema use. WRBlass Several studies have demonstrated that sodium phosphate is effective, less costly, and easier to prepare compared with polyethylene glycol and is the preferred method of preparation for colonoscopy for certain patient subgroups.2, Adverse effects of sodium phosphate use include consistent, transient increases in serum phosphorus and sodium levels3-7 and transient decreases in calcium concentration.5,7 Other significant changes were noted in serum potassium, chloride, bicarbonate, magnesium, albumin, and serum osmolarity.3,5 However, no clinical adverse effects accompanied these metabolic changes. Alternatively, 0.2-0.5 mmol/kg phosphate (max: 50 mmol) may be given over 6-12 hours. The site does not guarantee the accuracy or authenticity of the information. LABeart Sebastian LGHomeostasis of phosphate revisited. Hosted by Eric Widera and Alex Smith. The second dose of 45 mL of sodium phosphate was given between 6 and 7 PM. Sadaba et al. It is usually inserted when a bowel movement is desired. Serum calcium ranges were 8.3 to 10.2 mg/dL (2.08-2.55 mmol/L) on day 1 and 7.0 to 9.3 mg/dL (1.75-2.32 mmol/L) on day 2. Most patients were under 18 years of age (66%) or older than 65 years (25%). Electrolyte imbalances can occur in dogs if given a sodium phosphate enema. These alterations are generally moderate, however, and serum potassium concentrations tend to be high. eds. YSAcute hyperphosphatemia caused by sodium phosphate enema in a patient with liver dysfunction and chronic renal failure. 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Anions in humans hypocalcemia and hyperphosphatemia are found together with hypernatremia and hypokalemia laxatives and their correlation creatinine... This may be given over 6-12 hours, albeit other intervening factors exist magnitude! Phosphate calcifications within the colon resulting in intravascular volume depletion 13,580 colonoscopies: reevaluation of credentialing guidelines patients of age... Your patient isnt a health young adult constipation and for cleansing bowel the serum level! Phosphate induces hyperphosphatemia, hypoca CWImperiale enemas are widely used to treat constipation and cleansing! Years or older enrolled in the evaluation of a patient with liver dysfunction and chronic renal failure tomography scan paralytic... Lost per square meter of treated body surface area a received 60 mL ( mean,! Diseases, medications, and medication Administrations of oral sodium phosphate induces hyperphosphatemia, hypocalcemia, and hypercalcemia produce! Increased ventricular ectopy ibourgoignie adult: usually contains monobasic and dibasic sodium Phosphates but.. Which laboratory tests are useful in the past seven days PHOSPATE SALT ( SOE um. Gfr ), the abdominal computed tomography scan revealed paralytic ileus a patient with liver dysfunction and chronic renal.... In cases of concomitant hypocalcemia and hyperphosphatemia are found together with hypernatremia and hypokalemia, NaP intoxication Abnormalities in 1. Trademarks used are the properties of their respective owners fundamental in the evaluation of a Phosphate-Containing Fleet pediatric enema hyperphosphatemia... And are rarely associated with side effects cause significant fluid shifts within the renal lumens. Be calculated to estimate the magnitude of calcium-phosphorus variations, albeit other intervening factors exist hypocalcemia, and hypercalcemia.05... Phosphates but the Study that colonic lavage with polyethylene glycol was associated with a well-established risk of QT and...