Hypodermoclysis

1. Hypodermoclysis Joshua Plants, RN, BSN

2. OBJECTIVES At the completion of this presentation you should be able to: • Define Hypodermoclysis • State the indications and contraindications for this therapy • Identify acceptable infusion sites

3. OBJECTIVES • Relate the types of solutions used • State the potential complications of therapy • Understand monitoring parameters and documentation responsibilities

4. Age Related Changes • Contributing factors to dehydration • Kidney • Reduction in size and nephron function • Decreased GFR—decreased ability to concentrate urine, balance H20, K and Na • Homonal changes • ADH, ANP, Aldosterone • Regulate fluids and electrolytes

5. Age Related Changes • Contributing factors to dehydration • Body fluid content • Young adult 60%--older adult 40% • Decreased sensation of thirst (Scales, 2011)

6. Dehydration • Increased morbidity and mortality • Mental function • Increased irritation, behaviors, cognition problems, confusion • Infection • Renal stones • Falls • Constipation • Thrombosis (Scales, 2011)

7. Dehydration • Compounding factors: • Fears of incontinence • Inability to obtain drinks/liquids • Lack of access to fluids of choice • Temperature (Remington & Hultman, 2007)

9. What is Hypodermoclysis? • Treatment /Prevention of mild to moderate dehydration • ‘Clysis’ for short • Administration of fluids to the hypodermis • “Subcutaneous infusion” • Between skin and fascia

12. Route of Administration SUBCUTANEOUS INTRAVENOUS • Easy to initiate and maintain • Minimal complications • Edema • Insertion site issues • Inadvertent IV access • Can be difficult for staff to initiate or maintain • Missed doses • Precise locations • Therapeutic levels • Multitude of potential complications • Phlebitis • Infiltration • Sepsis • Fluid Overload • Catheter related issues

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

14. Advantages • 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

15. Advantages • Reduced levels of patient discomfort • Size of needles • Number of rotations required • Care provider technique • Reduces potential for hospitalization • $1 billion annual US cost of avoidable hospitalizations for dehydration (Lybarger, 2009) • Re-hospitalization • Nosocomial infection

16. 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; education • Admission/Re-admission

17. Disadvantages • 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

18. Indications • Mild to moderate dehydration • Adults, Children, Geriatrics • Alternative to the intravenous route • When intravenous access cannot be achieved or reliably maintained

19. Contraindications • Emergency situations • Shock • Circulatory failure • Severe dehydration • Severe electrolyte imbalance • Coagulopathy/blood dyscrasia • Fluid overload • Congestive heart failure • Marked edema • Ascites

20. 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)

21. Hypodermoclysis Fluids • The preferred solution is 0.9% sodium chloride (normal saline) • Other solutions include: • Lactated ringers (LR) • D5 ½ NS • D5 NS • D5 LR • D5 ¼ NS • D2.5 in ½ NS

22. 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)

23. 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 tissue • Dose: 150 units (Clinical Pharmacology, 2013) • NOTE: SUB-q bolus, DO NOT add to solution bag

24. Sub-Q Devices • Rates of infusion are based on gauge size and device type. Manufacturer’s recommendations should be followed. • Norfolk Medical • http://norfolkmedical.com/Aqua-C%20Brochure%20.pdf • MarCal Medical • http://marcalmedical.com/subQsafetySubQ.htm • Churchhill Medical Systems • http://www.churchillmedicalsystems.com/products.asp?catID=56 • Smiths Medical • http://www.smiths-medical.com/landing-pages/promotions/md/cleo-home.html

25. Rates of Infusion • Lumens • Single—80 ml/hour • Double—62 ml/hour at each of two sites • Total Rate: 124 ml/hour • Multiple—used for non-hydration sub-q therapies

26. 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

27. Site Selection • Abdomen • Note: area within two inch radius of umbilicus excluded • Anterior or lateral thigh • Note: avoid in ambulatory patients • Posterior upper arms • Anterior chest wall • Subscapular • Lower back

28. Site Selection • AVOID: • Scarred tissue, bruised areas, areas of impaired skin integrity • Areas prone to mechanical friction from clothes, equipment or patient movement • Edematous areas • Painful or infected areas • Hard or bony areas, near the breast(s), perineum or waistline • Dependent areas • Poorly vascularized

29. Site Rotation • After: • 1500-2000 ml/24 hours at single site • 3000 ml/24 hours for double site • Q24-48 hours • New site proximity • When complications are noted • PRN • Positional

30. Monitoring Parameters • Site surveillance/monitoring should occur a minimum of every two hours: • Erythema • Gross swelling/edema • Leakage • Pain/discomfort • Overall patient tolerance of therapy

31. Complications • 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

32. 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)

33. Complications • Cellulitis • Technique • Rotation • Pain/discomfort • Technique • Rate • Infection • Oversaturation

34. Complications • Inadvertent IV access • Check for blood return (INS, 2011) • Pulmonary edema • 0.6% of 600+ patients (Sasson and Shvartzman, 2001)

35. Care Plan • Problem • Patient requires short term hydration for mild to moderate dehydration. • Potential for leakage, prominent swelling and localized infection

36. 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

37. 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

38. Care Plan • Interventions • Monitor site Q2 hours during therapy • At least once per shift • Change dressings PRN • Ensure ordered rates are maintained • 80 ml/hour at single site • 62 ml/hour at double site (total 124 ml/hour)

39. Care Plan • Interventions • Rotate needle sites Q 24-48 hours during therapy • After 1.5-2 liters at single site • After 3 liters at double site • PRN • Provide staff with safety needle technology • Needle-stick prevention • Non-metal devices preferred (INS, 2011) • Needle-stick • Increased dwell

40. 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

41. Documentation Parameters • Follow local/institutional policy and procedures • Valid prescriber order for therapy • Use MAR/TAR/POS specific to therapy as indicated

42. 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

43. Documentation Parameters • Site selection/assessment • Complications noted during therapy • Interventions and inter-disciplinary communication • Patient/family teaching • Patient response to therapy

44. References • 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.

45. 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.