Hypodermoclysis (subcutaneous infusion) effective mode of treatment of dehydration 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
References (23)
- et al.
Hypodermoclysis for the administration of fluid and narcotic analgesics in patients with advanced cancer
J. Pain Symptom. Manage.
(1990) - et al.
Mini-Mental State Examination—a practical method for grading the cognitive state of patients for the clinician
J. Psychiatry Res.
(1975) - et al.
Subcutaneous fluid administration—better than the intravenous approach?
J. Hosp. Infect.
(1999) - et al.
Causes of death in nursing homes
Ned. Tijdschr. Geneeskd.
(1992) Nutrition by hypodermoclysis
J. Am. Geriatr. Soc.
(1984)Phlebitis due to venous catheter. Causes and occurrence
Ugeskr. Laeger.
(2000)- et al.
Single-dose pharmacokinetics of ampicillin and tobramycin administered by hypodermoclysis in young and older healthy volunteers
Br. J. Clin. Pharmacol.
(1996) - et al.
Hypodermoclysis in dehydrated elderly patients: local effects with and without hyaluronidase
J. Palliat. Care
(1991) - et al.
Subcutaneous fluid infusion in a long-term care setting
J. Am. Geriatr. Soc.
(2000) - et al.
Comparison of subcutaneous and intravenous administration of a solution of amino acids in older patients
J. Am. Geriatr. Soc.
(1997)
Subcutaneous infusion or hypodermoclusis: a practical approach
J. Am. Geriatr. Soc.
Cited by (26)
Efficacy of the subcutaneous route compared to intravenous hydration in the elderly hospitalised patient: A randomised controlled study
2014, Revista Espanola de Geriatria y GerontologiaApproach to lower respiratory tract infection in elderly
2013, FMC Formacion Medica Continuada en Atencion PrimariaTechnical Aspects of Fluid Therapy
2012, Fluid, Electrolyte, and Acid-Base Disorders in Small Animal PracticeSubcutaneous Infusion of Fluid in Children
2011, Journal of Emergency NursingCitation Excerpt :Reports of leaving a subcutaneous line in geriatric patients for longer periods have been published. In one study, the average duration of infusion was 15.9 days, with an average daily volume of 1161 mL per day.10 Can fluids other than NS or LR be administered?
Technical Aspects of Fluid Therapy
2011, Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice, Fourth EditionComparison of the tolerability of recombinant human hyaluronidase + normal saline and recombinant human hyaluronidase + lactated ringer's solution administered subcutaneously: A phase IV, double-blind, randomized pilot study in healthy volunteers
2009, Current Therapeutic Research - Clinical and Experimental