Joshua Plants, RN, BSN

Hypodermoclysis

At the completion of this presentation you should be able to:

Define HypodermoclysisState the indications and contraindications for this therapy

Identify acceptable infusion sites

OBJECTIVES

Relate the types of solutions used

State the potential complications of therapy

Understand monitoring parameters and documentation responsibilities

OBJECTIVES

Contributing factors to dehydration

KidneyReduction in size and nephron function

Decreased GFR—decreased ability to concentrate urine, balance H20, K and Na

Homonal changesADH, ANP, Aldosterone

Regulate fluids and electrolytes

Age Related Changes

Contributing factors to dehydration

Body fluid contentYoung adult 60%--older adult 40%

Decreased sensation of thirst (Scales, 2011)

Age Related Changes

Increased morbidity and mortality

Mental functionIncreased irritation, behaviors, cognition problems, confusion

Infection

Renal stones

Falls

Constipation

Thrombosis (Scales, 2011)

Dehydration

Compounding factors:

Fears of incontinence

Inability to obtain drinks/liquids

Lack of access to fluids of choice

Temperature (Remington & Hultman, 2007)

Dehydration

Treatment /Prevention of mild to moderate dehydration

‘Clysis’ for short

Administration of fluids to the hypodermis“Subcutaneous infusion”Between skin and fascia

What is Hypodermoclysis?

SUBCUTANEOUSEasy to initiate and

maintain

Minimal complications

EdemaInsertion site issuesInadvertent IV

access

Can be difficult for staff to initiate or maintain

Missed dosesPrecise locationsTherapeutic levels

Multitude of potential complications

PhlebitisInfiltrationSepsisFluid OverloadCatheter related issues

Route of Administration

INTRAVENOUS

Go to Maine State Board of Nursing Website

At the far right select the hyperlink entitled ‘Practice Questions’

Select the link entitled ‘Scope of Practice Decision Tree’

Use tree to determine SOP

Maine State Board of Nursinghttp://maine.gov/boardofnursing

Ease of access with subcutaneous administration

Easy for nurses to insert and maintain

Minimal number of complications when compared to intravenous therapy

Minor complications with SC versus IV

Advantages

Reduced levels of patient discomfortSize of needles

Number of rotations requiredCare provider technique

Reduces potential for hospitalization$1 billion annual US cost of avoidable

hospitalizations for dehydration (Lybarger, 2009)Re-hospitalization

Nosocomial infection

Advantages

Cost effective

Subcutaneous fluid group cost “much lower” than IV group (Sasson and Shvartzman, 2001)

Per kit price $13.74; case of five $68.70

Nursing time costs; educationAdmission/Re-admission

Advantages

Limited volume of administration

Localized edema is created

Isotonic or near isotonic fluids only No medications

Gravity versus pump

Sub-Q versus IV

Reimbursement rates

Disadvantages

Mild to moderate dehydrationAdults, Children, Geriatrics

Alternative to the intravenous route

When intravenous access cannot be achieved or reliably maintained

Indications

Emergency situations Shock Circulatory failure Severe dehydration

Severe electrolyte imbalance

Coagulopathy/blood dyscrasia

Fluid overload Congestive heart failure Marked edema Ascites

Contraindications

Need for additional intravenous medications or antibiotics

Renal dialysis

Need for precise control of fluid balance

Lack of sufficient subcutaneous tissue to safely perform the therapy (cachectic)

Contraindications

The preferred solution is 0.9% sodium chloride (normal saline)

Other solutions include:Lactated ringers (LR)D5 ½ NSD5 NSD5 LRD5 ¼ NSD2.5 in ½ NS

Hypodermoclysis Fluids

D5W and D10W solutions are not recommended as the dextrose component is quickly metabolized. The remaining free water is hypotonic and causes a subsequent osmotic draw in the reverse direction of that which is desired. Increased edema and secondary discomfort is likely to result.

Glucose pH 3.5-6.5 (acidic); no greater than 5%

Osmolality less than 280 mOs/kg (Medicines Information, 2001)

Fluids

Note: No medications should be added to subcutaneous hydration solutions.

Exception: hyaluronidase—Hydase, Amphadase, Wydase

Used to enhance fluid absorption by decreasing viscosity of subcutaneous tissueDose: 150 units (Clinical Pharmacology, 2013)

NOTE: SUB-q bolus, DO NOT add to solution bag

Fluids

Rates of infusion are based on gauge size and device type. Manufacturer’s recommendations should be followed.

Norfolk Medicalhttp://norfolkmedical.com/Aqua-C%20Brochure%20.pdf

MarCal Medicalhttp://marcalmedical.com/subQsafetySubQ.htm

Churchhill Medical Systemshttp://

www.churchillmedicalsystems.com/products.asp?catID=56Smiths Medical

http://www.smiths-medical.com/landing-pages/promotions/md/cleo-home.html

Sub-Q Devices

Lumens

Single—80 ml/hour

Double—62 ml/hour at each of two sitesTotal Rate: 124 ml/hour

Multiple—used for non-hydration sub-q therapies

Rates of Infusion

Sizes

6-20 mm lengths

Shortest possible size based on subcutaneous tissue

Cleo—6mm Marcal—6mm Aqua-C—9mm

21-29 gauge

Cleo—29 ga Marcal—27 ga Aqua-C—25 ga

Rates of Infusion

AbdomenNote: area within two inch radius of umbilicus

excludedAnterior or lateral thigh

Note: avoid in ambulatory patientsPosterior upper armsAnterior chest wallSubscapularLower back

Site Selection

AVOID:Scarred tissue, bruised areas, areas of

impaired skin integrityAreas prone to mechanical friction from

clothes, equipment or patient movementEdematous areasPainful or infected areasHard or bony areas, near the breast(s),

perineum or waistlineDependent areasPoorly vascularized

Site Selection

After:

1500-2000 ml/24 hours at single site

3000 ml/24 hours for double site

Q24-48 hoursNew site proximity

When complications are noted

PRNPositional

Site Rotation

Site surveillance/monitoring should occur a minimum of every two hours:

ErythemaGross swelling/edemaLeakagePain/discomfortOverall patient tolerance of therapy

Monitoring Parameters

Risks are minimal when indications, guidelines and P&P are followed.

Adverse effects are rare and related to:

Solution type

Volume administered

Rate of infusion

Complications

Edema

Most common

Massage

Redness, swelling and inflammation at infusion site

5% of 46 patients with clysis versus 25% of 18 patients IV (Sasson and Shvartzman, 2001)

Complications

Cellulitis

TechniqueRotation

Pain/discomfort

TechniqueRate InfectionOversaturation

Complications

Inadvertent IV accessCheck for blood return (INS, 2011)

Pulmonary edema0.6% of 600+ patients (Sasson and Shvartzman,

2001)

Complications

Problem

Patient requires short term hydration for mild to moderate dehydration.

Potential for leakage, prominent swelling and localized infection

Care Plan

Goal/Outcome

Patient will return to baseline hydration level

Patient will not develop erythema, prominent swelling, pain, drainage or elevated temperature for duration of therapy

Access will remain patent

Care Plan

Interventions

Ensure clean/aseptic technique is maintained for all clysis procedures

Including during needle rotation

Administer the correct solutions for the type of therapy

Select appropriate sites for subcutaneous infusion

Avoid aforementioned site selection locations

Care Plan

Interventions

Monitor site Q2 hours during therapyAt least once per shiftChange dressings PRN

Ensure ordered rates are maintained80 ml/hour at single site62 ml/hour at double site (total 124 ml/hour)

Care Plan

Interventions

Rotate needle sites Q 24-48 hours during therapy

After 1.5-2 liters at single siteAfter 3 liters at double sitePRN

Provide staff with safety needle technologyNeedle-stick prevention

Non-metal devices preferred (INS, 2011) Needle-stick Increased dwell

Care Plan

Interventions

Use administration sets with rate flow controller or electronic infusion device (INS, 2011)

CAUTION: Pumping fluids into subcutaneous tissue may mask oversaturation

Increased edema and pain/discomfort

Notify physician/LIP with complications

Care Plan

Follow local/institutional policy and procedures

Valid prescriber order for therapy

Use MAR/TAR/POS specific to therapy as indicated

Documentation Parameters

Specific data to be documented by the nurse in the medical record include:

Date and time

Medications/solutions to be infused

Rate of infusion and start/stop times

Device specific information

Documentation Parameters

Site selection/assessment

Complications noted during therapy

Interventions and inter-disciplinary communication

Patient/family teaching

Patient response to therapy

Documentation Parameters

Medicines Information Centre at Calderdale Royal Hospital. (2001). Hypodermoclysis-subcutaneous administration of fluids. Pharmacy news, 7(4).

Omnicare. (2012). Hypodermoclysis. Sasson, M., & Shvartzman, P. (2oo1).

Hypodermoclysis: An alternative infusion technique. American Family Physician, 64(9), 1575-1578.

Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1S), S84-85.

References

Lybarger, E. (2009) Hypodermoclysis in the home and long-term care settings. Journal of Infusion Nursing, 32(1), p.40-44.

Clinical Pharmacology. (2013). Wydase. Retrieved from: http://clinicalpharmacology.com/

Scales, K. (2011). Use of hypodermoclysis to manage dehydration. Nursing Older People, 23(5), 16-22.

Remington, R., & Hultman, T. (2007). Hypodermoclysis to treat dehydration: a review of the evidence. Journal Of The American Geriatrics Society, 55(12), 2051-2055.

References