Hypodermoclysis - Nursing Home Help

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Gabrielle Walsh, RN, BSN, CRNI®
Hypodermoclysis
An Alternate Method for Rehydration
in Long-term Care
Abstract
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The hypodermoclysis technique of subcutaneous
infusion has many benefits for long-term care
patients and staff. Minor complications
associated with the procedure are easily
remedied, and studies have proved its
effectiveness. Hypodermoclysis provides an
easy-to-use, safe, and cost-effective alternative to
intravenous hydration for the elderly long-term
care patient.
S
ubcutaneous infusion of fluids, termed “hypodermoclysis,” is an infusion method often overlooked
for patients with limited vascular access. It is ideal
for elderly patients in long-term care facilities
when dehydration presents a serious problem. This article
discusses how hypodermoclysis works, its advantages and
disadvantages, patient and site selection, and fluid and access device selection. Case studies describing the effectiveness of hypodermoclysis for the elderly, and cost considerations as they relate to the use of intravenous therapy,
as compared with hypodermoclysis, also are examined.
Hypodermoclysis (HDC), also known as “clysis,” is
the infusion of isotonic fluids into the subcutaneous space
for rehydration or for the prevention of dehydration.1-4
Hypodermoclysis should not be confused with subcutaneous administration of medication. Although many
medications can be given subcutaneously, the volume of
fluid necessary for hydration is much larger than the small
volume used for medications administered in this manner.
Hypodermoclysis was used widely until the 1950s,
when the practice fell out of favor because of complications related to improper use. Poor patient selection,
incorrect rates of administration, and poor choices of
fluids led to the severe decline of this valuable means
of hydration.4-6 These complications and the increase in
the use of intravenous (IV) therapies contributed to the
near disappearance of this infusion method.
Gabrielle Walsh is the Director of Infusion Services for Omnicare Infusion Services in Des Plaines, Illinois. OIS is a long-term care
pharmacy providing infusion medication supplies and education to 200 facilities. She and her staff are responsible for basic,
advanced, and in-service infusion education for facility staff, PICC and midline placement, and all other aspects of infusion program
development. Her background includes clinical staff education and development, policy development, and clinical program
development. She has been using hypodermoclysis more than 7 years.
Address correspondence to: Gabrielle Walsh, RN, BSN, CRNI®, 2289, Mt. Prospect Road, Des Plaines, IL 60018
(e-mail: gmgmrn@aol.com).
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The hypodermoclysis technique is uncomplicated.
Fluid is infused into the subcutaneous space, below the
epidermis and dermis. The adipose tissue in this space
contains numerous blood vessels.7 Fluid is transferred
from the subcutaneous space to the circulation by diffusion and perfusion. When fluid is given at a rate of
approximately 1 mL per minute, it can be absorbed
without significant edema.8
• INDICATIONS
Hypodermoclysis is ideal for preventing dehydration in
patients who are mildly to moderately dehydrated, and in
patients who are dysphasic or confused.2,7 Fluid needs
should be less than 3 l/day. Patients with limited venous
access and those who require frequent catheteter reinsertions are excellent candidates for hypodermoclysis. The
procedure also has been used to hydrate patients with
poor venous access before catheter insertion is attempted
for intravenous medication that has been ordered.
• FLUIDS, RATES, AND METHODS OF
ADMINISTRATION
It is important to choose the correct type of fluid for
hypodermoclysis. Most isotonic fluids are acceptable.
Those containing sodium chloride, with or without glucose, are the most commonly used fluids.1,2,9-11 Electrolyte solutions including Ringer’s solution, lactated
Ringer’s solution, and Normosol R also can be used.1,6
Potassium chloride (20-40 mmol/l) can be added.7,12,13
Dextrose 5% without sodium chloride and dextrose
10% are not used.14
In my clinical experience, medications are not routinely administered by hypodermoclysis, although 2 references describe methods for doing so.4,15 Wydase
(hyaluronidase), had been added in the past to some infusions to facilitate absorption,9 but is not used in my
clinical practice because it was no longer available in the
• ADVANTAGES
The advantages of hypodermoclysis include ease of
initiation and maintenance by registered nurses or licensed practical nurses on the staff, reduction in
transfers for intravenous access, fewer complications,
less pain reported by patients, less cost, and huge savings in nursing time.1-3,5,6,8-10 Also, instruction to
available staff is minimized because vein access is not
an issue with hypodermoclysis.
• CONTRAINDICATIONS AND
DISADVANTAGES
Although hypodermoclysis can be used for many patients requiring hydration, for certain cases, it should
not be considered the therapy of choice (see next section). Patients needing immediate fluid replacement,
large volumes of fluid, electrolyte-free solutions, or hypertonic solutions require another method of hydration. Because of these limitations, hypodermoclysis
should not be used in emergency situations.2,6 Patients
with skin disorders limiting suitable sites for access device placement are not candidates for hypodermoclysis. Those with bleeding disorders also may require
another method of hydration. Hypodermoclysis may
not be suitable for extremely emaciated patients or hypoalbuminemic patients who are grossly edematous. It
is not routinely used to administer medications.
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FIGURE 1.
An example of Y-type infusion tubing set up for infusion.
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United States. Two new formulations of hyaluronidase
have become available for use, Amphadase™ (Amphastar Pharmaceuticals, Inc., Cucamonga, Calif) and
Vitrase® (ISTA Pharmaceuticals, Inc., Irvine, Calif). Local
reactions to hyaluronidase have been reported and one
reference suggests that hyaluronidase is not necessary for
infusion rates less than 125 mL/hr.8
Rates of fluid administration vary according to patient
needs and physician orders, and should be adjusted on
the basis of patient tolerance. A daily fluid total of 3 liters
can be tolerated by most patients. Rates varying from 20
to 125 mL/hour at a single site have been reported in the
literature. To achieve infusion of up to 3 l daily, two insertion sites must be used.
Different access devices can be used for hypodermoclysis. In the past, the most common delivery method
involved Y-type tubing attached to a fluid container
with large-gauge 2- to 6-inch needles on each branch of
the tubing. Each needle was placed into the subcutaneous tissue of one site, usually each thigh11 (Figure 1).
A more current method uses ordinary IV tubing
spiked into a fluid container and a smaller-gauge “butterfly” needle or hypodermic needle similar to that used
for intramuscular injections. The needle is placed into
the subcutaneous tissue of one selected site.1,2,5,9,10,16 To
administer the maximum volume of 3 liters in 1 day,
another complete administration setup would be
needed.
A special infusion set developed exclusively for hypodermoclysis appears to provide a superior setup.
The Aqua-C Hydration System (Norfolk Medical,
Skokie, Ill) combines infusion tubing with an integrated flow regulator spiked into a fluid container. The
“clysis strip,” which has two 25- or 27-gauge, 6-mmlong needles placed 11⁄2 inches apart on an adhesive
vinyl strip, attaches to the end of the tubing (Figure 2).
Using this device, the nurse can reach the subcutaneous space without risk of improper needle placement. The needle design allows two sites to be accessed
with one device. Using the Aqua-C Hydration System,
the maximum infusion rate can be achieved with a single administration setup. The use of a specialized set
FIGURE 2.
Clysis strip. Photo courtesy of Norfolk Medical, with permission.
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FIGURE 3.
Left upper arm site 5 hours into infusion of DF 1/S NS at
80 mL/hr using Aqua-C Hydration System Clysis Strip.
for hypodermoclysis also may decrease the possibility
of mistaking the subcutaneous infusion for an intravenous infusion.
• APPROPRIATE INFUSION SITES
To administer hypodermoclysis correctly, an appropriate site must be chosen. Suitable sites include those
used for subcutaneous medication administration: posterior upper arms (Figure 3), upper chest (avoiding
breast tissue), abdomen at least 2 inches from the navel
(Figure 4), anterior or lateral thighs, infraclavicular
area, and the flank areas in some patients.5,6,17,18 The
chosen site must have a fat fold at least 1 inch thick,
and once inserted, the needle tip must be able to move
freely between skin and muscle. If a “butterfly” or hypodermic needle is used, it is inserted at a 45º to 60º
angle. If blood is noted in the tubing, the needle must
be removed and another inserted at a different site.5,11
It is imperative that the needle be placed correctly into
the subcutaneous tissue. Blood flow to the skin is 12.8
mL/100 g/min, as compared with the 2.7 mL/100 g/min
blood flow to the muscle.6 Muscle irritation will occur
if the needle is placed too deeply, and painful swelling
will occur if it is placed too superficially.
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FIGURE 4.
Abdominal insertion site of Clysis Strip, Aqua-C Hydration
System for Hypodermoclysis.
If access devices designed for subcutaneous infusion
are used, the manufacturer’s directions should be followed. Areas to avoid include those that are scarred,
bruised, or broken down; those that are edematous,
hard, painful, or infected; those close to the breast,
perineum, or waistline; and those prone to irritation
from clothing or movement.
• PROCEDURES
The procedures used to deliver hypodermoclysis are
very similar to those used for peripheral intravenous hydration. An order must be obtained from a physician or
nurse practitioner to administer fluid using hypodermoclysis. A common order reads: “Infuse D5 1/2NS via
HDC up to 125 mL/hour for a total of 6 l over 2 days.”
The order must include the fluid, rate, and route.
Once the order is obtained, a site is chosen, and the
tubing and subcutaneous access device must be primed.
The skin is prepared with antimicrobial solution, and the
access device is inserted as previously described. The site
should be covered with a transparent semipermeable
membrane dressing once the access device is placed.
Fluid flow is started and adjusted to the ordered rate.
Use of an infusion pump may increase the possibility of
complications at the infusion site, although there is literature to support its use.16 The site should be assessed at
least every 2 hours and changed as needed, generally
after every 1500 to 2000 mL or when adverse effects are
noted. Tubing and solution containers are changed according to facility policy for intravenous hydration, or
every 72 hours. Dressings are changed with site rotations, or if loose, soiled, or damp. The patient is assessed
for fluid balance, and intake and output are recorded,
according to facility policy for intravenous hydration.
Hypodermoclysis sites are monitored for adverse effects at least every 2 hours. Although many possible adverse effects have been discussed in the literature, actual
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documentation of severe complications is extremely
limited.3,11 Adverse effects include edema, local access
device reactions, pain, discomfort or leaking at the infusion site, infection, cellulitis, inadvertent puncture of
blood vessels, and fluid overload.19 With the exception
of fluid overload, infection, or cellulitis, most adverse
effects resolve with site rotation.
Documentation of hypodermoclysis is similar to that
used for intravenous therapy. Insertions, site changes,
and removals are recorded. Infusion sites, tubing, and
fluid containers are labeled. Patient assessments are
documented. Facility policy for intravenous infusion
documentation should be followed.
• COST CONSIDERATIONS
One benefit of hypodermoclysis is its reduced cost, as
compared with intravenous hydration. When hydration
is necessary during long-term care, many factors contribute to overall cost. Facility staff members may be
able to insert peripheral intravenous catheters, but if
they are not experienced infusion nurses, catheter insertion may not be their primary function. Additionally,
more than one attempt may be necessary because of the
fragile and sometimes elusive veins of the dehydrated elderly patient. More than one staff member may be
needed for the insertion attempt, and depending on facility policy, a registered nurse may be required for intravenous access insertion. More time usually is involved for catheter insertion, and more time is spent
replacing peripheral catheters removed accidentally or
because of complications. The supply costs for peripheral catheter insertion may be similar to those for hypodermoclysis initiation, depending on the individual
products used, but the amount of time for insertion differs. According to data suggested in time and motion
studies, it may take 20 to 45 minutes for an experienced
infusion nurse to place a peripheral catheter.13 Anecdotal evidence suggests that it takes no longer than 10
minutes for long-term care staff nurses to initiate
hypodermoclysis.
If the long-term care facility uses an outside agency
to place a catheter, all the aforementioned costs are increased by professional service fees. Time spent waiting
for the agency personnel causes delay in treatment, and
agency assistance may not be available in all areas or
after hours, during weekends, or on holidays. Finally, if
long-term care patients must be transported to acute
care centers for vascular access, additional costs related
to ambulance, hospital, and physician fees can be extensive. Transport for treatment also can be detrimental
to patients in long-term care, especially those with confusion or dementia.
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CRITERIA
MET
COMMENTS
INITIATION OF INFUSION
Obtains physician order to begin HDC
Able to recall 2 acceptable solutions for
hypodermoclysis infusion
Gathers correct equipment
Verifies patient identity and explains procedure
Correctly assembles supplies and primes tubing
with attached needle
Selects appropriate site for HDC
Cleans site per policy
Correctly inserts HDC needle / “Clysis Strip”
Secures needle appropriately
Begins infusion and regulates rate:
By gravity:
By flow regulator:
MAINTENANCE
Able to state policy for site monitoring
Able to state signs/symptoms of site complications
Able to state signs/symptoms of fluid intolerance
Able to state policy for site rotation
Able to state policy for tubing/bag change
DISCONTINUING INFUSION
Obtains physician order
Stops flow
Dons gloves
Removes dressing
Pulls needle straight out and applies pressure
if needed
Applies dressing
DOCUMENTATION
Labels solution bag, tubing and insertion site
Documents patient or family education
Documents insertion date, time, site and description
of procedure
Q 4 hour site checks including rate, amount infused,
patient tolerance
Documents site rotations and indications
Documents discontinuation of therapy and indication
Nurse performing procedures: ___________________________________ Date: ___________
Observed by / Preceptor: _______________________________________ Date: ___________
FIGURE 5.
Hypodermoclysis Competency Skills Checklist.
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Hypodermoclysis can be initiated easily by facility
staff, and the numbers of supplies used can be reduced because more than one attempt to establish
subcutaneous access is rarely necessary. Less time is
associated with finding sites for hypodermoclysis,
and accidental removals or routine site rotations are
completed with ease.
•
HISTORICAL DATA
Literature review provides significant evidence for the
effectiveness of hypodermoclysis. In 1981, Schen and
Singer-Edelstein2 completed 1850 infusions for 270
hospitalized and long-term care patients. The reported adverse effects included occasional discomfort
at the site and extensive local edema experienced by
four patients that cleared rapidly with diuretic administration. These authors concluded that the advantages of hypodermoclysis are considerable, and
furthermore, that the procedure can be performed
safely in residential and long-term care facilities. In
1996, Hussain and Warshaw8 provided an excellent
description of 10 studies related to hypodermoclysis
use. Various researchers from 1936 to 1992 performed these studies. Only the two earliest studies,
performed in 1936 and 1952, described significant
adverse effects. All the others described positive experiences with hypodermoclysis and reported minor
or no adverse effects.
In 2004, the current author studied residents receiving hypodermoclysis infusions in a long-term care facility located on the southwest side of Chicago. Over a 4month period, 30 infusions were documented. The ages
of the residents ranged from 24 to 90 years. The duration of the infusions was 1 to 3 days. They were administered using the clysis administration set described
previously. Infusion pumps were not used. Fluids administered included solutions of sodium chloride
(0.45% or 0.9%), with or without 5% dextrose, depending on physician orders. Rates ranged from 40 to
125 mL/hour, with total daily fluid infused ranging
from 1 to 3 l per resident. All infusions were for treatment or prevention of dehydration.
Facility staff were instructed about hypodermoclysis
and related procedures before they initiated infusions.
Then they were observed for competency in insertion,
administration, and monitoring of hypodermoclysis
before they performed the procedure, with documentation of observed competency accomplished by preceptors using a standardized skills checklist (Figure 5).
During the study period, one incidence of marked
local edema occurred, which resolved without diuretic
administration after site rotation. All other infusions
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were completed without adverse reactions. Positive outcomes were demonstrated by completion of therapy as
ordered. The staff reported excellent experiences with hypodermoclysis, especially in terms of time saved and ease
of performance, as compared with their past experiences
using intravenous hydration. Facility management reported high levels of satisfaction with resident outcomes.
• CONCLUSION
When administered correctly, hypodermoclysis is safer,
easier, and less expensive than intravenous hydration.
For the elderly dehydrated patient, the benefits are numerous and the disadvantages are few. This method of
fluid administration should be considered regularly for
the elderly patient in long-term care. It has proved to be
a valuable, cost-effective tool.
A C K N O W L E D G M E N T S
The author offers sincere thanks and much appreciation
to Kathryn Phipps, RN, Henry Ecker Jr, RN, and the
nursing staff of the Renaissance at Midway for their assistance, excellent patient assessment, and “hydration
surveillance.”
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3. Fainsinger RL, MacEachern T, Miller MJ, et al. The use of hypodermoclysis for rehydration in terminally ill cancer patients. J
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in a long-term care setting. JAGS. 2000;48(7):795-799.
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13. Terry J, Baranowski L, Lonsway RA, Hedrick C. Intravenous
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Saunders; 1995:27.
14. Calgary General Hospital Educational Resources. Procedures for
hypodermoclysis. CGH Production 1990 Videotape.
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16. Addulla A, Keast J. Hypodermoclysis as a means of rehydration.
Nurs Times. 1997;93(29):54-55.
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technique. Am Fam Phys. 2001;64(9):1575-1578.
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