患儿男,4岁。行结肠息肉切除做术前清洁灌肠(灌筒距病床85cm)。首灌医用肥皂水300ml,经1小时未排便,又灌温水200ml。10分钟后,患儿烦躁,四肢抽搐。继而进入昏迷,瞳孔散大,经17小时抢救无效死亡。尸解后诊断患儿死于水中毒。分析其发生原因,认为①因近日进食量少,致某种程度的失水;②因灌肠压力过高,使灌入肠道的低渗水大量迅速被吸收,诱发致死性高容量血症及低电解质血症。 Children male, 4 years old. Colonic polyps resection of preoperative cleansing enema (filling the bed from the bed 85cm). The first medical soap water 300ml, after 1 hour without defecation, but also irrigation warm water 200ml. 10 minutes later, irritability, limbs and convulsions. Then into the coma, mydriasis, after 17 hours of rescue invalid death. Diagnosis of autopsy children died of water poisoning. Analysis of its causes, that ① due to recent eating less, resulting in a certain degree of dehydration; ② due to enema pressure is too high, so that a large number of infiltrated into the intestinal hypotonic water quickly be absorbed, induced fatal hypervolemia and low Electrolytic hyperlipidemia.