Trust Guideline All Sites

Hydration by Subcutaneous Infusion

(HYPODERMOCLYSIS) Guidelines for Nurses
All healthcare professionals must exercise their own professional judgement when
using guidelines. However any decision to vary from the guideline should be
documented in the patient records to include the reason for variance and the
subsequent action taken.

Lead Clinician: Designation:

Lead Director: Jane Pugh Date seen by lead director:

Provenance of guideline Best Practice

Ratified by Clinical Quality Group March 2005

Noted by the Clinical Governance Committee March 2005

This guideline should not be used after end of: March 2007

Links into Healthcare standard Second Domain Clinical

Effectiveness
PCT aim Six Clinical and cost
effectiveness
 THIS DOCUMENT MUST NOT BE PHOTOCOPIED
If you require a copy for your department, please contact
The Clinical Governance Co-ordinator on 01527 507052

PLEASE NOTE THAT ALL CLINICAL GUIDELINES ARE AVAILABLE ON

www.RandB-pct.nhs.uk

CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation

Alison Glover District Nurse

Vicky Preece Assistant Director of Nursing/Professional
Adviser District Nursing
Dr Ian Douglas Consultant in Palliative Medicine
Kate Hall Community Macmillan Nurse

Circulated to the following individuals for comments

Name Designation
Dawn Pattison Palliative Care Unit, POWCH
Maria Wilday Matron Manager POWCH
Sue Lunec PCT Pharmaceutical Adviser
Nicola Ross District Nurse
Elaine Jones District Nurse
Dr J. Wells GP
Cathy Greaves Team Leader-District Nursing Team 5

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CONTENTS

No Title Page
1.0 Introduction 4
2.0 Purpose of the guidelines 4
3.0 Scope of the guidelines 4
4.0 Responsibility and accountability 4
5.0 Definitions 5
6.0 Background 5
7.0 Indications for administration of subcutaneous fluids 6
8.0 Contra-indications for administration of subcutaneous 6
fluids
9.0 Cautions 7
10.0 Ethical considerations in palliative care 7
11.0 Prescription 8
12.0 Equipment 8
13.0 The procedure 8-9
14.0 Potential complications for treatment 10
15.0 References

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1.0 Introduction

Hypodermoclysis is a term used for the subcutaneous administration of fluids.

This method of patient rehydration has been increasingly used in elderly
care and palliative care settings where maintaining hydration is a common
problem. The low technology nature of this method is well suited to less
acute care settings and has potential for people who have swallowing
problems or other problems which make them prone to dehydration, but
who do not need to be cared for in a acute hospital setting.

2.0 Purpose of the Guidelines

The purpose of these guidelines is to:-

• Provide an up-to-date, evidence based guideline from which to support
nurses involved in administering hypodermoclysis to patients.
• Provide guidance on the ethical issues associated with this type of treatment.
• Provide instruction on the procedures associated with this treatment.

3.0 Scope of the guidelines

The guidelines are relevant to all nurses working for the Redditch and
Bromsgrove Primary Care Trust.
These guidelines cross reference with:
The PCTs Consent to Treatment Policy
The PCTs Infection Control Policy and Procedures

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The PCTs Medicines Policy

4.0 Responsibility and Accountability

All nurses who perform this procedure should be aware of the content of these
guidelines. Nurses carrying out the procedure are reminded that they should at
all times adhere to the Nursing and Midwifery Council Code of Professional
Conduct : standards for conduct, performance and ethics (2002). Nurses
have a responsibility to ensure that they are competent to carry out any
procedures and be accountable for their practice. They should inform their
manager if they feel they are not competent, and identify any training needs
relating to this area of practice.

5.0 Definitions

The term hypodermoclysis is used to describe the infusion of fluids into the
subcutaneous space (Steiner and Bruera, 98). These guidelines relate to the
infusion of larger volumes of fluids for the purpose of supplementing an
inadequate oral intake and not to the subcutaneous infusion of drugs via a
syringe driver.

6.0 Background

Hypodermoclysis is an old technique widely used in the 1940’s and 1950’s and
has been largely replaced by intravenous infusions (Steiner and Bruera, 98).
However, it has recently become more popular particularly in the non acute
environment and has the following advantages:-
1. Easy to set up – no vascular access needed.
2. Can be started by nursing staff competent at administering a
subcutaneous injection.
3. Relatively safe and easy to manage in the home setting.

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 4. Eliminates potential side effects of IV infusions, e.g. phlebitis (Abdulla
and Keast, 97).

A butterfly infusion set and a regular IV giving set is used to deliver

approximately 1-2 litres of fluid over 24 hours. Because of the relative safety of
the method there is no need for a pump to regulate administration. Fluids may be
administered continuously, overnight or by short 1-2 hour infusions for patients
that are more mobile.

7.0 Indications for Administration of Subcutaneous Fluids

• When the patient requires fluids to supplement their oral intake, and
adequate oral intake is not sufficient to achieve rehydration.

The definition of ‘adequate’ will vary depending on individual factors and needs.
Studies suggest that terminally ill cancer patients may achieve adequate
hydration with much lower volumes of fluid than those required for average
medical and surgical patients (Steiner 98).

For older people with mild dehydration or at risk from dehydration, subcutaneous
fluids are a safe intervention that could potentially prevent the need for
hospitalisation. Symptoms associated with dehydration can include; thirst, dry
mouth, dysphagia, nausea and vomiting, muscle cramps, apathy, disorientation
and depression.

A natural consequence of the process of dying is a reduction in oral intake. How

symptomatic patients become as a result of this is unclear. The symptom that
most patients’ carers and clinicians worry about is thirst. The symptom of thirst
should be assessed.

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8.0 Contraindications for Administration of Subcutaneous Fluids

• Patients with coagulation defects.

• Patient refusal.
• Should not be used as an IV substitute in life threatening situations.

9.0 Cautions

The method should be used with caution at sites where radiotherapy has
previously been given, and in patients with pre-existing heart disorders because
of the risk of circulatory overload (Noble-Adams, 95). It should not be used in
lymphoedematous areas.

10.0 Ethical Considerations in Palliative Care

The decision to give parenteral fluids in a palliative care situation is one that
needs careful consideration and should involve the patient, carers and be
discussed widely within the multidisciplinary team caring for the patient. Families
and the patient should understand why the subcutaneous fluids are being used
and the aims of supplementary fluid as a treatment. If the aims of treatment are
not met the treatment should be discontinued. The difficulties of withdrawing
such treatment once started should be taken into account when making a
decision to start such treatment.

The appropriateness of supplementary fluids should be assessed on a day to day

basis (Dunphy et al, 95). The evidence of thirst in the dying patient is a
complicated process, often associated with multiple factors such as drug therapy.
An often cited opinion is that good mouth care could be used to prevent the need
for artificial hydration. While many dying patients are not symptomatic from
dehydration, there may be others who do manifest symptoms and some
researchers believe these can be alleviated by supplementary fluids.

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The National Council for Hospice Palliative Care Services (1997) produced a
statement on the ethics of artificial hydration for people who are terminally ill in
which they stated that ‘ the appropriateness of artificial hydration continues to
depend on regular assessment of the likely benefits and burdens of such
intervention’.
11.0 Prescription

Fluids to be infused will normally be prescribed by either the GP or palliative care

consultant, noting the type, volume and rate. Isotonic solutions should be used -
Normal saline (sodium chloride 0.9%) or dextrose saline (dextrose 4%, sodium
chloride 0.18%) are fluids of choice (Fainsinger et al, 94).

The rate of infusion can be up to 100mls/hour with a maximum of 2 litres in 24

hours. However 1 litre in 24 hours is often adequate in palliative care (Taylor et
al, 98). Steiner and Bruera (98) suggest that boluses of 500mls over 1 hour, two
or three times a day with hyaluronidase given into the subcutaneous site prior to
the first infusion, can be advantageous for active patients.

12.0 Equipment

Standard IV infusion set Infusion fluids

Drip stand Alcohol swab
Non sterile gloves Adhesive tape
Transparent semi permeable dressing
Butterfly needle or butterfly cannula (19g-25g, size used varies with no research
on which to base recommendations).
2ml syringe and needle to prime butterfly cannula if used.
Sharps box

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13.0 The Procedure

A subcutaneous infusion of fluids will be implemented only after an holistic

assessment of the patient and discussion involving, when possible, the patient,
carers and members of the multidisciplinary team.

• Explain the procedure to patient and carers. Assess the ability of the patient
and carers to cope with the procedure and organise extra carers if needed.
• Place patient in a comfortable position.
• Check the fluid with the prescription.
• Ensure all equipment is assembled
• Wash hands in accordance with Trust’s Infection Control guidelines.
• Prime infusion set and butterfly needle (if used) with fluid and suspend fluid
bag on drip stand.
• Put on non sterile gloves.
• Choose a suitable site that is oedema free and in a fatty area that will be able
to accommodate the infusion of a large volume of fluid. Flank or abdomen
and inner thigh are commonly used. The lateral chest wall can also be used.
• Cleanse site with alcohol swab and allow to dry
• If a butterfly needle is used, insert into site at an angle of 45 degrees. If blood
appears in the line, withdraw needle and repeat process. Coil butterfly line
and secure with film dressing.
• Remove gloves and wash hands.
• Set infusion at prescribed rate and complete medication sheet.
• Ensure the patient is comfortable and the patient/carers know how to contact
the nurse if a problem (see below) occurs.
• Advise patient/carers how to stop the infusion in the event of a problem,
disconnect the infusion when complete, or to leave in place until the next visit
from the nurse.

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• Change infusion site at least 48 hourly (Noble-Adams, 95) covering previous
site with a film dressing. Change infusion set at least 72 hourly (Mallett and
Bailey, 96).
• Evaluate the need for continued hydration in collaboration with patient, carers
and multidisciplinary team.

14.0 Potential Difficulties with/and Complications of Treatment

At infusion site there may be;

• Local oedema and slow absorption from the infusion site resulting in
subtherapeutic volume being administered or localised swelling. ACTION: first
consider a different site for infusion. Secondly consider adding Hyaluronidase.
It is recommended for 1500iu to be dissolved in 1 ml of water for injection or
normal saline, which can be injected directly into the site or added to the
infusion.
• There may be soft tissue infection/ pain or bruising. ACTION: dependent upon
severity, firstly observe the site. Secondly, consider the use of antibiotics.
Dress the site as required.

Systemic complications could include;

• Heart failure or pulmonary oedema – stop the infusion and inform GP.

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References

Abdulla, A and Keast, J (1997). Hypodermoclysis as a means of rehydration.

Nursing Times July 16 vol.93 no.29; 54-55.

Dunphy, K et al (1995). Rehydration in palliative and terminal care if not – why

not? Palliative Medicine 9; 221-228

Fainsinger, R and Bruera, E (1994). The management of dehydration in

terminally ill patients. Journal of Palliative Care 10:3; 55-59

Fainsinger, R et al (1994). The use of hypodermoclysis for rehydration in

terminally ill cancer patients. Journal of Pain and Symptom Management vol.9
no.5; 298-302

Mallett, J and Bailey, C (1996). The Royal Marsden NHS Trust Manual of Clinical
Nursing Procedures 4th Edition. Oxford, Blackwell Scientific

Noble-Adams, R (1995). Dehydration: subcutaneous fluid administration. British

Journal of Nursing vol.4 no.9; 488-494

Nursing and Midwifery Council (2002). The Code of Professional Practice

Steiner, N and Bruera, E (1998). Methods of hydration in palliative care patients

Journal of Palliative Care 14:2; 6-13

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