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The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department

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The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department children Article The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department Min-Jung Kim 1 , Yoo-Jin Choi 2, Jin-Hee Lee 3,*, Hyuksool Kwon 3 and Dongbum Suh 3 1 Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Gyeonggi-do 13496, Korea; [email protected] 2 Department of Emergency Medicine, Ajou University School of Medicine, Gyeonggi 16499, Korea; [email protected] 3 Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi 13620, Korea; [email protected] (H.K.); [email protected] (D.S.) * Correspondence: [email protected] or [email protected]; Tel.: +82-31-787-7586 Abstract: Objectives: We determined whether glycerin enemas were appropriately prescribed in pediatric fecal impaction patients using the Leech score and identified factors that influenced the prescription of glycerin enemas in the pediatric emergency department (PED). Methods: We included patients who received a glycerin enema at the PED of a tertiary teaching hospital. We divided the study subjects into two groups on the basis of their Leech scores: an appropriate enema group (Leech score ≥ 8), and an inappropriate enema group (Leech score < 8). Logistic regression was performed to determine the factors associated with glycerin enema administration. Results: The data of 998 patients, including 446 patients in the inappropriate enema group (Leech score 5.2 ± 1.7) and 552 patients in the appropriate enema group (Leech score 10.1 ± 1.7), were analyzed. A discharge diagnosis of fecal impaction was observed significantly more frequently (57.1%) in the appropriate enema group, and nonspecific abdominal pain (8.3%) and acute gastroenteritis (40.8%) were diagnosed significantly Citation: Kim, M.-J.; Choi, Y.-J.; Lee, J.-H.; Kwon, H.; Suh, D. The more frequently in the inappropriate enema group (p < 0.05). Constipation (2.8%) and irritability Appropriateness of Glycerin Enema (3.0%) were slightly more common in the appropriate enema group than in the inappropriate enema in Pediatric Patients Visiting the group (p < 0.05). According to multiple logistic regression, subjects aged 2–8 years (2–4 years, OR Emergency Department. Children 4.24; 4–8 years, OR 2.83), with vomiting (OR 1.72), with irritability (OR 4.52), and with a prolonged 2021, 8, 364. https://doi.org/ last defecation day (OR 1.2) were most likely to receive appropriate enema administration (p < 0.05). 10.3390/children8050364 Conclusion: The results showed that in those aged 2–8 years, with vomiting and irritability, and with a prolonged last defecation day, an enema was generally administered appropriately. Academic Editor: Richard Lichenstein Keywords: pediatric; fecal impaction; glycerin enema Received: 30 March 2021 Accepted: 28 April 2021 Published: 2 May 2021 1. Introduction Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Abdominal pain is a common cause of pediatric emergency department (PED) visits published maps and institutional affil- in children [1–5]. In one-third of patients with abdominal pain, the pain is caused by iations. constipation [3,4], and 81% of patients with constipation experience abdominal pain. The reason why most pediatric patients with constipation visit the emergency de- partment is because of secondary symptoms such as fecal impaction, and in most cases, disimpaction is necessary [6]. Enema administration is a procedure that can cause discomfort in a child [4,6]. It is also Copyright: © 2021 by the authors. known to cause various complications, such as colon damage due to physical stimulation Licensee MDPI, Basel, Switzerland. This article is an open access article by an enema catheter, ischemic colitis, and malignant hyperthermia after undergoing a distributed under the terms and glycerin enema [7–10]. Therefore, it is important to prescribe enema appropriately for conditions of the Creative Commons relevant situations. Attribution (CC BY) license (https:// There are some studies on the efficacy and safety of glycerin enemas [4,6,11–13], creativecommons.org/licenses/by/ however, there has been no study about the appropriate prescription of glycerin enemas in 4.0/). crowded emergency departments. Children 2021, 8, 364. https://doi.org/10.3390/children8050364 https://www.mdpi.com/journal/children Children 2021, 8, 364 2 of 9 The aim of this study was to determine whether glycerin enemas were appropriately prescribed for pediatric fecal impaction patients using the Leech score and to identify factors that influence the prescription of glycerin enema. 2. Materials and Methods 2.1. Study Design and Setting We retrospectively reviewed the electronic medical records of patients under the age of 15 who visited the PED from 1 January 2017 to 31 December 2017 at a tertiary teaching hospital that sees 20,000 pediatric patients annually. Pediatric patients are treated by emergency physicians or pediatric physicians supervised by board-certified pediatric emergency attending physicians. This study was approved by the hospital’s institutional review board. 2.2. Selection of Participants We included patients who underwent a glycerin enema while in the PED. Patients were excluded from the study if they had previous history of other natural causes, such as anal stenosis, congenital megacolon, imperforated anus, or other systemic diseases. 2.3. Data Collection The medical records of the patients were reviewed, and data were collected using a standard patient record form. We collected variables such as age, sex, weight, vital signs (blood pressure, pulse rate, respiratory rate, and body temperature), chief complaint and accompanying symptoms, location of abdominal pain, underlying diseases, previous medications (antibiotics, pro- biotics, laxatives, etc.), constipation history, abdominal tender points, laboratory results (white blood cells (WBCs), C-reactive protein (CRP), total carbon dioxide (TCO2), venous blood gas analysis (VBGA), pH, base excess (BE), and bicarbonate (HCO3)), abdominal X-ray findings, the number of glycerin enema attempts, intravenous or oral hydration solution, medications in the emergency department (ED) or discharge prescriptions, grade of the treating physician prescribing glycerin enema, diagnosis at discharge, length of stay, etc. 2.4. Procedures We divided the study subjects into two groups using the Leech score: an appropriate enema group and an inappropriate enema group. The Leech score was divided into three parts based on the total colon: the right, left, and rectosigmoid colon. Each colon section was assigned a score from 0 to 5. A score of 0 = no feces, 1 = a scant amount of feces, 2 = a small amount of feces, 3 = a moderate amount of feces, 4 = a large amount of feces, and 5 = a large amount of feces with bowel dilatation. The total score ranged from 0 to 15 points. A total score of 8 or more was considered indicative of a diagnosis of fecal impaction [14–16]. The same abdominal radiographs were scored by two pediatric emergency physicians. Reliability was assessed by the intraclass correlation coefficient (ICC) of continuous data from different observers. The number of cases required to perform the necessary analysis was determined as in Bonett et al. [17]. The required sample size was calculated; 78 patients were required to produce a two-sided 95% confidence interval with a width of 0.200 when the estimated intragroup correlation for each of the two measurements was 0.750. Data were analyzed using a two-way random-effects ANOVA model. 2.5. Outcomes The primary outcome was to identify factors predictive of appropriate enema administration. Children 2021, 8, 364 3 of 9 2.6. Statistical Analyses Continuous variables were analyzed using Student’s t-test, and if the data were not normally distributed, the Wilcoxon rank-sum test was used as a nonparametric method. Categorical variables were analyzed by Fisher’s exact test, and the results are presented as ratios. A p-value less than 0.05 was considered statistically significant. Logistic regression was performed to determine the factors associated with glycerin enema implementation. All statistical analyses were performed using STATA. 3. Results In total, 1076 patients under the age of 15 visited the PED and received a glycerin enema from 1 January 2017 to 31 December 2017. A total of 78 patients were excluded: 5 patients had underlying systemic diseases, 61 patients did not undergo abdominal X-ray examination, 10 patients did not proceed with the enema procedure, and 2 patients did not have evaluable abdominal X-ray images (no images of the rectosigmoid segment). A total of 998 patients were finally included. Among them, 446 patients were included in the inappropriate enema group (Leech score < 8) and 552 patients were included in the appropriate enema group (Leech score ≥ 8) (Figure1). Figure 1. Patient flow chart after application of the inclusion and exclusion criteria. The study selection process after applying the inclusion and exclusion criteria is shown. * no abdominal X- ray: did not undergo abdominal X-ray. * no enema: did not proceed with the enema procedure. * un-evaluable X-ray: no images of the rectosigmoid segment. We divided the study subjects into two groups based on the Leech cutoff value of 8 points; those with a Leech score less than 8 points were assigned to the inappropriate enema group, and those with more than 8 points were assigned to the appropriate enema group. The mean Leech score of researcher 1 was 10 (±3.11) and that
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