How do I order a Fleet (sodium phosphate) enema?

How to Order Fleet Enema

Fleet enema (sodium phosphate) should be ordered with caution, particularly in elderly patients, those with renal insufficiency, or bowel disorders, as it carries risks of severe electrolyte disturbances and should be limited to low-risk patients only. 1, 2

Appropriate Indications

Fleet enemas are typically used for:

• Relief of constipation
• Bowel preparation before procedures (e.g., flexible sigmoidoscopy)
• Management of inadequate bowel preparation during colonoscopy

Ordering Protocol

1. Patient Assessment:

   • Check for contraindications:
     • Renal insufficiency/failure
     • Bowel obstruction or perforation
     • Inflammatory bowel conditions
     • Congestive heart failure
     • Electrolyte imbalances
     • Age <2 years (absolute contraindication)
     • Age 2-5 years (use with extreme caution)
     • Neutropenia or thrombocytopenia
     • Recent colorectal or gynecological surgery
     • Recent anal or rectal trauma
     • Toxic megacolon
     • Undiagnosed abdominal pain
     • Recent pelvic radiotherapy 1, 3

2. Dosing:

   • Standard adult dose: 118 mL (4.5 oz)
   • Pediatric dose (>2 years): 66 mL (2.25 oz)
   • Never exceed recommended dosage (severe complications reported with doses of 250-798 mL) 2

3. Administration Instructions:

   • For flexible sigmoidoscopy: Order 2 Fleet enemas to be administered prior to the procedure 1
   • For constipation relief: Single enema as needed
   • Include specific timing (typically 30-60 minutes before procedure)

4. Patient Monitoring:

   • Monitor for signs of electrolyte disturbances:
     • Hypocalcemia (tetany, seizures)
     • Hyperphosphatemia
     • Hypernatremia
     • Hypokalemia
     • Acute renal injury 4, 2

Alternative Options

For high-risk patients, consider safer alternatives:

• Normal saline enemas
• Tap water enemas
• Glycerin suppositories
• Polyethylene glycol (PEG) preparations 4, 5

Documentation Requirements

When ordering Fleet enemas, document:

1. Clinical indication
2. Assessment of contraindications
3. Specific dosage
4. Timing of administration
5. Instructions for patient monitoring

Special Considerations

• Elderly patients: Particularly susceptible to adverse effects even with standard doses; consider alternatives 2
• Renal patients: Contraindicated due to risk of hyperphosphatemia 4, 5
• Bowel disorders: Increased risk of absorption and toxicity 6
• Repeat administration: Allow sufficient time between doses to avoid toxicity

Common Pitfalls to Avoid

1. Ordering excessive volume (mortality reported with doses >250 mL) 2
2. Failing to recognize high-risk patients
3. Not providing clear administration instructions
4. Inadequate monitoring for complications
5. Repeated administration in short time periods

Fleet enemas can cause serious metabolic disorders with high mortality (45% in one study), even when used at standard doses 2. For most patients requiring bowel cleansing, especially those with risk factors, safer alternatives like PEG solutions should be considered 5.