Annals of Long Term Care

Dehydration is a serious complication that is associated with significant morbidity and mortality for many older adults with concomitant chronic illnesses, diminished thirst sensation, and reduced kidney function. Dehydration is also a common complication of acute infections in older adults, which oftentimes requires hospitalization for intravenous rehydration. Hypodermoclysis is an optimal means of administering nonemergency fluids for families and patients who wish to be treated at home or in the nursing home in a familiar environment, without the stress, expense, and inconvenience of hospitalization. Because of the invaluable potential benefits of administering fluids subcutaneously for the mild to moderately dehydrated elderly patient, more research is needed. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[5]:28-30)

Introduction

As the world’s aging population rises exponentially, demands for newer, cost-effective, and better treatment techniques are inevitable. Hypodermoclysis (HDC), also known as “clysis,” an infusion of isotonic fluids into the subcutaneous (SC) space, is a safe, simple, and low-cost alternative method for rehydrating elderly persons at home, in long-term care (LTC) facilities, or in hospitals.1-5 It was introduced by Gaisford and Evans in the 1940s for the hydration of children. Because of its ease of administration, few adverse effects, and relatively low cost, HDC rapidly gained popularity. However, with incidents such as a 5-month-old infant being given an “unspecified amount of normal saline and 5% glucose SC resulting in near death and the development of hypovolemic shock in some patients,”6 all as a result of misuse of hypertonic solutions, this effective alternative means of hydration is now rarely used.

Rationale for Expanding the Use of Clysis in the Care of the Frail Older Adult

Dehydration is a serious complication that is associated with significant morbidity and mortality for many older adults with concomitant chronic illnesses, diminished thirst sensation, and reduced kidney function.2 Dehydration is also a common complication of acute infections in older adults. It oftentimes requires hospitalization for intravenous (IV) rehydration.

IV infusion requires close supervision by skilled medical or nursing staff, and the cost of initiating and maintaining IV access can be high. It is particularly difficult to maintain IV access in confused and dependent patients.

Indications and Contraindications

HDC fluids are indicated for maintaining adequate hydration in mild to moderately dehydrated patients who are unable to take adequate fluids orally, patients with active fluid loss (eg, from diarrhea or vomiting), or in whom it is difficult or impractical to insert an IV line7 (eg, those with dysphagia following a stroke, the frail and ill, the postoperative older patient).6 HDC is not indicated for emergency situations such as shock, severe electrolytic disturbances, major dehydration (eg, serum sodium > 150 mEq/L, osmolality > 300 mOsm/kg, blood urea nitrogen/creatinine ratio > 25 mg/dL), coagulopathies, and heart failure.1,7 It is not meant to replace IV administration where an acute precise direct line is clearly indicated.8

Additives, Techniques, and Materials

Some studies have used hyaluronidase to accelerate diffusion of fluid across SC tissue. The recommended dose is 750 U/L of fluid, either added to the solution bag or injected SC, although lower doses have also proved to be effective without changing the patient’s comfort level. Most investigators agree that it is not necessary to use hyaluronidase when the infusion rate is less than 125 mL per hour.9

The technique for HDC is similar to that used for IV administration. First and foremost, explain the procedure to the patient.