[Silver_Girl]

I'm a new ICU nurse and 2 days ago I gave my first ever enema, period. But it was apparently a really weird enema, 0.5 of Vanco in 1L NS to be retained for 60 minutes, was my order. The patient had major C. Diff colitis and was on IV Flagyl and PO Vanco 500mg already. She was also on bowel rest, receiving TPN and had a NGT to intermittent low wall suction except for when I clamped it after giving PO meds. So apparently this Vanco enema was some sort of act of desperation because the IV & PO therapies weren't really working. I asked for help on this treatment because a) it was my first enema ever and I wanted to make sure I was doing it right, and b) I've never heard of Vanco in enema form. But everyone I approached sort of went "*******" o_O including 3 senior nurses, the pharmacy, and my group leader. But my gl helped me give it anyway, putting the solution in a soapsuds enema bag/tube, but the whole 60 minutes retention goal was absurd...it came pouring right out the second it went in because the patient couldn't hold it. AND what came out was all bloody and full of clots. So we stopped it after 200ccs, and told the docs. But the attending wanted us to keep at it anyway. So, we tried again with a 3 way foley and inflated the 30cc balloon and clamped it after the solution went in in order to try to keep it retained. No luck. the solution came pouring out despite the balloon, around the catheter. she retained maybe 80cc of the entire enema, and I only asked her to try to retain it for maybe 10 minutes so as not to torture the poor woman any more because it was clear that the vast majority of it came out already anyway. Long story short, that order was d/ced.


only 1 other senior nurse had experience giving it before and when she did, she said she didn't even finish the infusion, she just said "this is dumb, its coming right out, I'm not doing this." =/

so...I was wondering, has anyone else received an order like this before? and have you had more luck than we did with it? how did you administer it? and ...does it even work?

Thanks!

[ghillbert]

Not heard of using that - sounds awful! We do give a solution called "MUDD" for sterilization of the GI tract - given postop while intubated for certain at-risk patients, like post LVAD implants.

It's a solution of gentamicin, colemycin and nystatin, given q6hrs via NG tube until pt is extubated and taking oral fluids.

[Toby's mum]

I heard of this for the first time recently. Pt received vancomycin enema--it was dc'd after repeated enemas resulted in frank blood gushing out of rectum. Supposedly used for CDiff.

[pinksugar]

Awhile ago I had a pt with an order for a vanc retention enema TID, but I only gave it once. My pt was completely confused and couldn't hold it. The pt had toxic megacolon and C. diff colitis. He ended up dying.

Supposedly these antibiotic enemas really can help - I just wish that it could have been some more use to my little old man.

[LuckyoneRN]

I have seen an order like this...we gave the vancomycin in about 100 mls NS (don't quote me on the 100mls...it was something like that amount, maybe up to 300mls, no where near 1L), and through a rectal tube/Malecott (sp?)--clamped the tube for 30-60ish minutes and then let it drain. I think our pharmacy directions state something like "mix vancomycin with an adequate amount for instillation". When I asked "how much is adequate?" that's where the 100 (or so)mls came from.

[sharann]

I am not an ICU nurse but as a nurse with inflamm. bowel disease I was shocked by the amount of fluid ordered and the time for "retention". I cannot imagine having that much saline instilled and retained, for more than a minute or two if that!
This seems like it could put the patient at risk for hypernatremia, bowel damage and hypovolemia. Not to metnion it would be painful.

[rgroyer1RNBSN]

Originally Posted by sharann

I am not an ICU nurse but as a nurse with inflamm. bowel disease I was shocked by the amount of fluid ordered and the time for "retention". I cannot imagine having that much saline instilled and retained, for more than a minute or two if that!
This seems like it could put the patient at risk for hypernatremia, bowel damage and hypovolemia. Not to metnion it would be painful.

As a pt. also besides a nurse I couldnt imagine this either it would be horrible, now maybe the vanco with the 100 mls of NS I could manage that, but I cant see anyone holding a litre for an hour!! Sounds awful!!!

[cardiacRN2006]

Yep, I've done it a few times. Did a vanco and another one recently (flagyl maybe?) Luckily, we have the flexiseal system, so it's quite easy to do. We infuse it, clamp the flexiseal, and then unclamp later. Works with any enema...

[ukstudent]

I've done a Kayexalate enema of a liter over an hour. The flexiseal system has a port for infusing/flushing. Most stays in if you clamp the tube.

[Silver_Girl]

Thanks for your responses everyone! The flexiseal idea sounds like it could work. The 3 way foley catheter was probably too skinny for the enema. We have flexiseals but I never noticed an infusion port on ours before...I'll have to go investigate. I heard from other nurses who took care of the lady later on that they reordered the vanco enema on her. She looks a lot better now, just seeing her in the unit (haven't taken care of her since) but I can't say if it was due to the vanco enema or not (which was STILL putting out bright red blood & clots!). I just went to a GI talk recently and they mentioned PR Vanco & Flagyl as valid treatments for cdiff colitis, so I guess they weren't crazy. As for volume though...what's the largest volume you'd instill for a retention enema? it did look like a lot, but nobody seemed disturbed by instilling a liter when we did it (probably also because it was all coming right out...but you know..)