腎臟不好的病人 千萬不要用fleet soda(sodium phosphate)來做colon prepare呀

昨天值班遇到一個病人突然喘起來 baseline BUN:80,Cr:5

因為懷疑sigmoid colon cancer要做colonscope

正使用fleet soda作colon prepare 結果一天拉了20幾次

結果一抽gas PH:7.0,HCO3:3,BUN:120,Cr:8,blood osmolarity:388,Na:162,

結果是colon prepare到severe dehydration,當場補了20隻jusomin,

到這裡我都還可以接受,結果病人到早上突然seizure,一抽磷竟然是33

第一次見到這麼高的值 真的是嚇到我了 趕快拖去急洗腎才結束了這一場鬧劇

也印證了主治醫師的話 病人突然發生的問題 有一半是我們搞出來的 XD!

查了一下  原來早就有paper提到囉

<Gastroenterology January 31, 2006>Renal Failure After Oral Sodium Phosphate for Colonoscopy

In three earlier reports, investigators described seven patients who developed chronic renal insufficiency after receiving oral sodium phosphate solution or sodium phosphate tablets before colonoscopy. Now, investigators from the center at Columbia College of Physicians & Surgeons, who reported 5 of the first 7 cases, describe those 5 patients plus 16 additional patients who developed renal insufficiency after oral sodium phosphate administration.

This patient group comprised 17 women and 4 men (mean age, 64; 17 white). Of 16 with hypertension, 7 were taking angiotensin-converting–enzyme (ACE) inhibitors, 7 were taking angiotensin-receptor blockers, and 4 were taking diuretics. Three patients were taking nonsteroidal anti-inflammatory drugs. Nineteen patients received standard doses of oral sodium phosphate solution (timing of the doses was not reported), 1 received a nonstandard high dose of oral sodium phosphate solution, and 1 received sodium phosphate tablets. Renal biopsies were performed at a mean 3.8 months after colonoscopy; mean serum creatinine level was 3.7 ng/dL (range, 2.2–8.0 ng/dL). Renal biopsies typically showed tubular injury, with tubular atrophy and interstitial fibrosis, and abundant calcium phosphate deposits in distal tubules and collecting ducts. During a mean follow-up of 16.7 months, four patients required renal replacement therapy, including one successful renal transplant; none of the patients completely recovered renal function.

Comment: These findings suggest that chronic renal insufficiency sometimes follows bowel preparation with oral sodium phosphate solution. The exact mechanism and incidence of this injury remain uncertain. The number of sodium phosphate doses administered yearly for colonoscopy in the U.S. is enormous, and this reporting group is at a referral center for renal biopsies. Nevertheless, this complication is almost certainly underreported, because the symptoms of chronic renal insufficiency often are mild and nonspecific.

So, what can we conclude? Certainly, sodium phosphate is a more effective bowel preparation than is polyethylene glycol (PEG), particularly if the doses are split so that one dose is given on the evening before the examination and the second dose is given on the morning of the examination. Splitting doses (by as long as 10–12 hours) also might improve safety by reducing the chances of developing very high serum phosphate levels. The results underscore the importance of using sodium phosphate appropriately. Patients should be selected properly and undergo aggressive hydration, preferably with oral rehydration solution. Regimens involving reduced dosages of sodium phosphate, perhaps by combining sodium phosphate with other laxatives, deserve evaluation.

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