Subcutaneous Hydration
This clinical information sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) in managing subcutaneous hydration within a palliative care context and in the clinical treatment of dehydration of residents
It covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Subcutaneous Hydration
Continuous subcutaneous infusion (CSCI), also called hypodermoclysis, is the administration of fluids into the subcutaneous layer of the skin where there is an extensive lymphatic and blood vessel system through which fluids can be absorbed [1].
A CSCI of fluids offers a method of hydration that can assist in care and symptom management in the RACF rather than moving a resident to an acute inpatient setting. CSCI is a valid method by which to manage dehydration, where the dehydration does not require rapid correction [1]. Its use can provide symptom control in a palliative care context [2-4].
The use of CSCI should be based on individual assessment, and can be a suitable option in some cases where a middle line between hospital transfer or no treatment is appropriate. Of the aged care residents referred to the Melbourne City Mission palliative care service approximately one third may have subcutaneous fluids used. This occurs usually when swallowing is no longer possible, and the transition time from deterioration to dying may be several days or weeks. Benefits include avoidance of relative/s distress at sudden loss of fluid intake, discussion and recognition of patient care being palliative, review of end-of-life goals of care, and avoidance of unnecessary hospital transfers.
As more residents develop Advance Care Plans and services are better equipped to provide palliative and medical care within facilities, subcutaneous hydration may become more widely used.
Assessment
The CSCI is appropriate in care when a resident:
Cannot swallow & requires or requests assisted hydration [1-4]; Has uncontrolled nausea and vomiting [1, 3, 4]; Has bowel obstruction [3, 4]; Requires management of recurrent hypercalcaemia [3, 4]; Has delirium whose aetiology is believed to be due to opioid metabolite accumulation [3]; Has impaired venous access [2, 4]; And/or the resident’s representative feels a need to continue hydration in end-of-life care and they remain firm in their belief [3, 4].
The CSCI is appropriate for short-term use when prescribed by a medical practitioner in other clinical contexts when:
There is a likely reversible clinical cause of dehydration; The underlying cause can be treated on site; Hydration by CSCI is likely to be effective; and Care options are discussed between doctor, care staff and the resident/representative, CSCI is preferred to ED transfer and/or therapeutic inaction [3].
CSCI does not prevent the resident from showering and bathing. The infusion can be discontinued at any time should the oral route become available again, the resident requires IV therapy, or decisions are made to limit or cease its use.
The GP and care team should consult the resident and relatives and provide simple and concise information about the use of CSCI, its benefits and problems that can be encountered. The effectiveness of education will depend on many factors, including the resident/carer levels of anxiety, command of English and literacy [3].
Risks and Contraindications
The resident or their agent/relative needs to agree to subcutaneous hydration as appropriate for the person’s wishes. CSCI should not be used as a method of hydration in emergency situations, e.g. shock, severe dehydration, or in residents with fluid overload, e.g. cardiac failure, pulmonary oedema, hypotension or clotting disorders [1, 4]. Relative risks are severe hypoalbuminaemia, lymphoedema with subcutaneous limb or truncal oedema, or evidence of subcutaneous sepsis/infection.
Complications of use include local adverse reactions such as oedema, cellulitis, erythema and strong pain [4, 5], and local complications have been reported to occur at approximately the same rate as in residents who are hydrated intravenously [5]. There is a small risk of systemic adverse reaction such as acute cardiac failure, hyponatraemia and development of sepsis, leading to death [4, 5]. The risk of serious complications from CSCI, however, has been reported as significantly lower than IV therapy [5].
Management
Procedure for Administering a Subcutaneous Infusion
CSCI Orders
Ensure there is a current, legible medical practitioner’s order in writing. CSCI is usually ordered in the volume of 0 to 1000ml per 24 hours as required [3], and should be administered at a rate not exceeding 1ml/min [1]. It is recommended that no more than 1.5L be administered per site per 24 hours. Where additional fluid is required, a second CSCI site should be established [1]. There is no consensus on the best fluid to use for CSCI, with recommendations varying from saline, dextrose solution or a combination of saline and glucose [1, 4]. A hypertonic solution should generally be avoided, as should using additives.
Equipment
The following equipment is required:
Fluid as prescribed (usually 1 LITRE Normal saline); 21G Saf-t-intima s/c needle set; Alcohol swabs; Semi-permeable transparent dressing; Standard IV giving set; IV pole; Non-sterile gloves; and Fluid balance chart;
Where a Saf-t-intima s/c needle set is unavailable, a 19 or 21 gauge butterfly needle can be used [1, 2, 4].
Ensure there is adequate stock to maintain the on-going infusion (eg additional fluid bags, IV giving sets) or arrange for supplies of same as per facility policy.
Site of Insertion
Select a site where the needle will not be jostled, and ask the resident his or her site preference. Appropriate locations would be:
Areas of oedema are not suitable for absorption If there are absorption problems select abdomen or chest Remember it is difficult finding an area of adequate subcutaneous tissue in a cachectic or emaciated resident Rotate site regularly if skin reactions are identified A second butterfly needle can be inserted elsewhere for easy access for administration of subcutaneous medication
Clinical procedure [1-4]
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Procedure for Administering a Subcutaneous Infusion [1-4]
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1. |
Explain the procedure, answer questions and prepare resident. |
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2. |
Check fluid with written doctor’s order. Check the fluid is the correct type and amount and that the fluid has not expired. A visual inspection should be made of the bag to ensure it is intact and in good condition. |
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3. |
Wash hands. Assemble and set-up equipment. Prime the giving set including the winged needle with the prescribed fluid. |
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4. |
Choose site. |
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5. |
Wash and dry hands thoroughly and put on non-sterile gloves. |
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6. |
Cleanse site with alcohol swab. Allow to dry. |
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7. |
Insert saf-t-intima needle. Gently pinch a well-defined amount of tissue between your index finger and thumb. Insert needle into the base of the pinch at a 45-degree angle with beveled edge facing up. Remove the metal needle insert, leaving the plastic initima insitu. The needle should be situated in the subcutaneous space, above the underlying fascia. It should move freely in that space.
NB: When using the abdomen direct the needle laterally to prevent pinching when the patient sits or bends. If blood return is noted, withdraw the needle. Repeat the procedure using a new needle and an adjacent site. |
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8. |
Dress the insertion site with a clear occlusive dressing (e.g. opsite) to allow for regular observation of the site. Coil the butterfly line and apply transparent dressing, ensuring the needle and tubing are anchored well to avoid displacement. Ensure the resident is comfortable. |
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9. |
Attach giving set to winged butterfly needle. |
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10. |
Most infusions can be run by gravity. Attach the fluid bag to an IV pole positioned at least 1 metre above insertion site. |
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11. |
Document details in the resident’s progress notes and commence a fluid balance chart. |
Ongoing Use of a Continuous Subcutaneous Infusion
Administration and Cessation of Fluids
There is no need to flush between fluid bags if the same fluid is going into the same site. Use a separate site for medications being given subcutaneously. At any time the GP nursing staff, carers and resident and/or the resident’s representative may decide together to cease the CSCI.
Reasons for cessation include [3, 4]:
Resident in terminal phase of illness; Excessive fluid accumulation causing oedema and pain; Urinary frequency and /or incontinence; Absorbed fluid contributing to cardiac failure and pulmonary oedema; and Resident does not tolerate therapy, or requests the therapy to be ceased.
Monitoring CSCI
The site should be checked at least once per shift for signs of complications including oedema, redness, inflammation and pain. A clear occlusive dressing is best for the visibility and security of the site, eg. tegaderm or opsite[1-4]. The resident should be monitored for signs of fluid overload and a fluid balance chart should be maintained.
CSCI site and line changes
It is currently recommended that the giving set be changed every 72hrs to decrease potential complications [2, 4]. There is no consensus on the recommended frequency for cannula changes, with recommendations varying from 24-48 hours [1, 2, 4]. Before deciding to relocate the CSCI site, determine that any signs are related to inflammation rather than manipulation of the needle site (eg. starting a new site, changing the dressing). At the first sign of inflammation, change the site. If the redness is related to manipulation, do not relocate the site, however the site should be monitored more frequently. Sofsets or silastic catheters (small angio-catheters, size 24 or less), can be used in the case of metal allergies or rare absorption problems[3].
Sources of Information
Where to go for more information
Guidelines for a Palliative Approach in Residential Aged Care
Hydration for symptom control and comfort of a resident is discussed in the Guidelines for a Palliative Approach in Residential Aged Care, prepared by the Australian Palliative Aged Care Project.
Website: http://www.palliativecare.gov.au/pubs/workforce/pallguidea.pdf
Palliative Care Victoria
The Palliative Care Victoria web site has information on end of life hydration issues.
Website: www.pallcarevic.asn.au
RACF staff can contact their local Palliative Care Service for assistance and training in using subcutaneous hydration.
References
Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. S Mansfield, H Monaghan, J Hall, Subcutaneous fluid administration and site maintenance. Nursing Standard, 1998. 13(12): p. 56,59,60,62. Melbourne Citymission, Palliative Care Clinical Guidelines. Hypodermoclysis Procedure - Hydration using a continuous subcutaneous infusion. 2003, Melbourne: Melbourne Citymission. L Yap, S Tan, W Koo, Hypodermoclysis or subcutaneous infusion revisited. Singapore Medical Journal, 2001. 42(11): p. 526-529. G Slesak, J Schnurle, E Kinzel, J Jakob, K Dietz, Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomized trial. JAGS, 2003. 51(2): p. 155. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
The information provided was informed by a Joanna Briggs Institute Level IV evidence literature review of evidence on the effectiveness of subcutaneous hydration and aspects of its delivery. Supporting evidence from Melbourne Citymission was used with permission. Information on the contraindications and risks of CSCI was based on Level II evidence from a RCT conducted in RACFs. The level of evidence of references used to compile this Clinical Information Sheet is provided in the table below:
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Reference |
Year |
Level of Evidence |
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1. |
Joanna Briggs Institute |
2003 |
Level IV evidence |
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2. |
S Mansfield, H Monaghan, J Hall |
1998 |
Level IV evidence |
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3. |
Melbourne Citymission |
2003 |
Level V evidence |
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4. |
L Yap, S Tan, W Koo |
2003 |
Level IV evidence |
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5. |
G Slesak, J Schnurle, E Kinzel, J Jakob, K Dietz |
2003 |
Level II evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [12] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Subcutaneous Hydration
The following reference cards are designed to be used in conjunction with the Subcutaneous Hydration Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Subcutaneous Hydration
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