Severe hyperphosphatemia and hypocalcemia following the rectal administration of a phosphate-containing Fleet...

Area of Science:

• Pediatric Emergency Medicine
• Clinical Toxicology
• Gastroenterology

Background:

• Hypertonic phosphate enemas are commonly used for constipation relief.
• Toxicity from rectal hypertonic phosphate solutions is rare, especially in patients with normal renal function.
• This case highlights a severe adverse event following standard pediatric enema administration.

Observation:

• A 4-year-old female with spinal muscular atrophy experienced lethargy and respiratory distress after receiving two Fleet pediatric enemas.
• Physical examination revealed a depressed level of consciousness and shallow respirations.
• Laboratory results showed significant electrolyte abnormalities: calcium 3.3 mg/dL, phosphate 23 mg/dL, and sodium 153 mEq/L, with arterial blood gases indicating acidosis and a prolonged QT interval on ECG.

Findings:

• The patient developed a generalized seizure unresponsive to benzodiazepines but responsive to intravenous calcium chloride.
• Severe hyperphosphatemia and hypocalcemia were the primary metabolic derangements.
• The patient recovered fully within two days of presentation.

Implications:

• Osmotically acting hypertonic phosphate enemas carry a risk of severe toxicity if retained, regardless of pre-existing conditions.
• Clinicians should be aware of potential electrolyte disturbances and neurological complications associated with hypertonic enemas.
• This case underscores the importance of careful patient selection and monitoring when administering rectal hypertonic solutions.