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Mature Mommy Enemas

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Because enema is freely available and largely self-administered, with no or little inspection, we could not estimate the true rate of adverse events related to its use. Our study is the first to demonstrate the incidence of adverse events and the 30-day mortality rate after cleansing enema performed by a nurse, in acutely constipated patients treated at an ED. We found three cases of rectal perforation and one case of hyperphosphatemia in the first period of the study compared with no cases in the second period, and this may be due to the new comprehensive guidelines that were established and implemented by the physicians and nurses. The main difference in clinical behavior between the periods of the study was the preference for oral laxatives over enemas and the careful reassessment of the patient prior to discharge, shown in the second period. Of course, we could not separate the role of the enema in causing perforation and mortality from the other potential factors. In addition, we recommended using a flexible rectal tube to overcome the danger of perforation due to the rigid tip of the enema.

Some researchers (Lopes 2001; Romney 1981) have proposed that enemas should be used because:(i) they will lessen the degree of contamination of broken skin with faeces, thus reducing puerperal infections;(ii) women may regard cleaning their bowels as something good;(iii) they hope that they may diminish neonatal and puerperal infection rates by reducing contamination with faeces;(iv) for women who have not opened their bowels in the previous 24 hours and have an obviously loaded rectum on initial pelvic examination, bowel movement soon after delivery may cause discomfort with an episiotomy.

Others (Cuervo 2006) have opposed the use of enemas on the basis of:(i) unproven effectiveness;(ii) watery faeces may increase contamination, potentially increasing maternal and neonatal infections;(iii) it is widely accepted that this intervention generates discomfort to women and increases the costs of care.

There was less faecal soiling (one RCT; 152 women; RR 0.36, 95% CI 0.17 to 0.75; Analysis 1.20), higher satisfaction levels of labour attendants, accoucheurs and perineorrhaphy operators (one RCT; 1027 women; mean difference (MD) 0.17, 95% 0.08 to 0.26; MD 0.26, 95% 015 to 0.37; MD 0.11, 95% 0.02 to 0.20; Analysis 1.24; Analysis 1.25; Analysis 1.26) and more intrapartum infection rates (one RCT; 152 women; RR 4.62, 95% CI 1.03 to 20.68; Analysis 1.33) in the group of women randomised to receive enemas compared to those that did not.

Recommendations for laxatives in older adults are similar to those used in the general adult population.2 Bulking agents (eg, psyllium) are effective in the management of constipation in patients who can drink 1 glass of water with each dose. Mrs N.M. has tried psyllium, which resulted in fecal impaction due to low fluid intake. Treatment of impaction would include manual disimpaction using 2% lidocaine gel to anesthetize and lubricate the rectum and anus.29 A mineral oil enema would be preferred over a sodium phosphate enema. Repeat mineral oil enemas daily, for up to 3 days if required.

If the stool is located higher up in the intestine and manual disimpaction and enemas are ineffective, try 2 L of oral PEG 3350 with electrolytes for 1 to 2 days30 or 1 L of oral PEG 3350 with electrolytes for 3 days.31,32 Additional laxatives (oral or suppositories) or dose adjustments to maintenance therapy might be required. Avoid bulk-forming laxatives in the setting of impaction.

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon resulting in intravascular volume depletion. Second, these preparations can cause electrolyte disturbances including significant hyperphosphatemia, hypocalcemia, and hypokalemia. A significant clinically important rise in serum phosphate can even be seen in elderly patients with normal renal function. (J Gastroenterol Hepatol. 2004;19(1):68). Lastly, phosphate nephropathy may occur due to the transient and potentially severe increase in serum phosphate combined with volume depletion from the fluid shifts.

Yaacov Ori and colleauges conducted a retrospective case series of 11 elderly patients (mean age of 80) at the Rabin Medical Center in Israel. Ten of these patients received Fleet enemas for relief of constipation and one received it as a proctoscopy prep. Three of these patients received 500-800 mL of sodium phosphate and 8 patients received approximately 250mL (for a comparison, a typical over-the-counter Fleet enema comes in either a 118 and 197 ml dose). Baseline renal function was normal (eGFR by MDRD of 60mL/min) in 4 patients with a range of 25 to 57 mL/min in the other seven. 041b061a72


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