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• W1983062207 abstract "To the Editor: Older patients, especially the “oldest old” (85 years or older) are extremely sensitive to some types of treatment,1,2 and clinical circumstances as simple as constipation can lead to dependence3 and death, much like the case reported here. An 88-year-old woman with hypertension and chronic renal failure probably secondary to nephroangiosclerosis (creatinine clearance, 20 mL/minute) was attended in the emergency room for abdominal pain attributed to chronic constipation. The patient was discharged to her home with dietary recommendations. Two days later the patient returned to the emergency room, this time because of a hemorrhoidal prolapse that was reduced manually, and a sodium phosphate enema (Casen: 250 mL, Na2HPO4.12H2O 8 gm and NaH2PO4H2O 16 gm per 100 mL) was prescribed; the patient was again discharged to her home. The patient fell at home; bed rest, which probably exacerbated her constipation, was recommended by a physician. After administration of another sodium phosphate enema to overcome her problem, the patient gradually began to deteriorate mentally, and delirium developed. She was again brought back to the emergency room. Physical examination revealed an extremely ill patient with tachypnea, abdominal pain, wheezing, and stridor. There were signs of neuromuscular hyperexcitability (tetany), twitching of both arms and legs, and the Chvostek sign was easily elicited. A chest film showed a enlarged heart and clear lung fields; there was no evidence of congestive heart failure. The electrocardiogram showed normal sinus rhythm with prolongation of QT interval. The laboratory tests in the emergency room showed the following: hematocrit, 25%; white cell count, 16.000/mm3, with 81% polymorphonuclear leukocytes, 5% lymphocytes, 3% monocytes, and 11% bands; urea 80 mg/dL; creatinine 3,4 mg/dL; normal electrolytes except for a serum calcium of 3,5 mg/dL (9-11 mg/dL); a serum phosphate 16,9 mg/dL (2-4 mg/dL); and blood glucose 189 mg/dL. Measurement of arterial-blood gases while she was breathing room air revealed a partial pressure of oxygen of 117 mmHg, a partial pressure of carbon dioxide of 41 mmHg, pH 7.32, and a base excess of −5 mEq/L. A plain abdomen film showed fecal material in the large bowel, and an ultrasound scan revealed gallstones without signs of infection or inflammation. The patient experienced two seizures in the emergency room, with a probable bronchoaspiration. Intravenous calcium and phosphorus chelators were administered with discrete improvement of her consciousness level. The parathormone level was 480 pg/mL (12-43 pg/mL). After 48 hours of treatment, the calcium and phosphate levels returned to normal, but the patient died suddenly after unsuccessful attempts at resuscitation. Autopsy was not allowed. Adverse reactions after the administration of sodium phosphate enemas have been reported,4,5 especially in infants6; most frequently these are alterations in the inorganic phosphate and calcium homeostasis. Patients with chronic renal failure usually have secondary hyperparathyroidism, as was the case in our patient, as a result of the chronic hypocalcemia secondary to retention of phosphate in plasma and the impaired ability of the diseased kidney to synthesize the active metabolite of vitamin D (1,25-dihydroxyvitamin D). Older patients are at risk, as Grosskopf et al.7, recently demonstrated in an experimental setting. A review of the literature cited by Grosskopf et al. shows that three of the latest 15 reported cases (from 1974 to 1989) were old, and that the only fatality occurred in the “oldest old” patient (91 years). Most of the patients in the “oldest old” group have an age-related decline in renal function that may predispose to hyperphosphatemia upon administration of a phosphate enema. Our patient, therefore, had presented with two conditions favoring this complication: she was in the “oldest old” age group and had chronic renal failure. This case is important in illustrating the hazards of the use of phosphate enemas in geriatric patients and suggests that other approaches, such as lifestyle interventions, dietary prevention, and bulk laxatives, should be used." @default.
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• W1983062207 date "1995-12-01" @default.
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• W1983062207 title "FATAL HYPOCALCEMIA FROM SODIUM PHOSPHATE ENEMAS" @default.
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• W1983062207 doi "https://doi.org/10.1111/j.1532-5415.1995.tb06637.x" @default.
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