Hypodermoclysis (subcutaneous infusion) effective mode of treatment of dehydration in long-term care patients

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Abstract

Dehydration is associated with morbidity and mortality in frail elderly patients. Intravenous fluid administration in these patients is sometimes hard, especially in agitated patients. The purpose of this study was to review of 57 long-termed care patients received hypodermoclysis infusion on 118 different occasions during the 9 months. Data collection included: demographic data, functional and mental status, indication hypodermoclysis, duration of the infusion, type of solution, laboratory data, adverse effects, and outcome. The main reasons for initiation of the hypodermoclysis were either dehydration (64%) or febrile illness (21%). The average duration of infusions was 15.9 days and average daily volume was 1161 ml per day. After hydration by hypodermoclysis, in 77% of the patients, clinical improvement occurred manifested as general improvement (88%), cognitive status improvement (84%), and improved oral intake (81%). During the course of the study, failure of the treatment was observed in 12% of the patients, mortality of 11% was observed. Nobody developed signs of fluid overload. Local complications were reported in 12% of patients: local swelling (6/57), complain of local pain at site (3/57) and local inflammation (2/57).

Hypodermoclysis is a safe, effective and suitable alternative to intravenous re-hydration in long-term care patients.

Introduction

Physiologic age related changes in the water homeostasis, which are affected by internal and external factors, predispose elderly patients to dehydration. Dehydration is associated with a high prevalence of morbidity and mortality in the elderly as described in the USA (Health Care Financing Review, 1991). 6.7% of the elderly in Medicare, had a diagnosis of dehydration, and 1.4% had dehydration as their primary diagnosis. The mortality rate for patients diagnosed with dehydration within 30 days of admission was 18%, approximately three times the comparative rate for hip fractures. A third of nursing home residents are diagnosed as having dehydration. Dehydration is the second cause of death in nursing home patients, following pneumonia (Aangenendt-Siegers and Cools, 1992). The rate of mortality due to untreated dehydration in the long-term care patients exceeded 50% (Phillips et al., 1984).

When a patient requires parenteral fluid or drug administration and venous catheterization cannot be performed, other less typical infusion routes such as interosseous, intrarectal or hypodermoclysis are employed. The Stedman’s Pocket Medical Dictionary (Hensyl, 1987) defines hypodermoclysis (as washing out) as a subcutaneous infusion of saline or other solutions. The mechanism of hypodermoclysis is infusion of fluid slowly into subcutaneous tissue. The fluid is transferred into the circulation by the combined effect of the forces of diffusion and tissue perfusion and does not cause tissue edema. Hypodermoclysis was widely used in the 1940s and 1950s after the publication of “Hyalyronidase in Paediatric Practice” (Gasford and Evans, 1949). In the last two decades, there has been a return to hypodermoclysis in clinical practice. In this study, we have examined the clinical benefits of hypodermoclysis in long-term care patients.

Hypodermoclysis is effective method of hydration in patients with inadequate oral fluid intake secondary to age-related reduced thirst, anorexia, difficulty in swallowing fluids, in uncooperative, agitated, confused or demented patients, with failure to increase oral fluid intake or instigating tube feeding, following febrile illness (Ferry et al., 1999). Hypodermoclysis is an alternative to intravenous infusion also for antibiotics (Champoux et al., 1996), opioid analgesics (Bruera et al., 1990, Jain et al., 1999) correction of electrolyte disturbance (Schen and Arieli, 1982) and amino acid solution to prevent of protein malnutrition (Ferry et al., 1997).

Section snippets

Design and setting

This study was conducted prospectively over the 9-month period from 1 July 2001 to 31 March 2002. Data collected included the patient’s age, gender, co-morbidity, functional and mental status, indication for initiation of the hypodermoclysis, duration of the infusion, type of solutions used, volume infused per day, number of acute medical conditions during the study period, laboratory data, adverse effects, and clinical outcomes.

Functional status, defined as the capacity to perform basic

Results

Hypodermoclysis was given 908 treatment days, on average for 15.9±14.7 days (range from 5 to 60 days) for patients. Eight (14%) of the subjects received hypodermoclysis on routinely (two to three times weekly), 27 (47%) on as needed basis, according to their oral intake and urine output. The most commonly used solutions were 0.9% sodium chloride (56%), 3.3% dextrose in 0.3% sodium chloride (38%), and 5% glucose (6%). Usually (77%), an infusion was overnight (from 08:00–10:00 p.m. to 08:00

Discussion

In long-term care patients, in nursing home residents and in terminally ill patients, infusion is used mainly to relieve the distressing symptoms of dehydration. To avoid dehydration in the elderly, especially in high-risk patients, fluid consumption and voiding volume is monitored. The average daily fluid intake for adult weighing approximately 70 kg is 1500 ml. Additional fluids are needed for increased ambient temperature, humidity, febrile illness, gastrointestinal losses mainly through

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