Hypodermoclysis: Maintaining Hydration in 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. 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;17:28-30) 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. Then select the infusion site, and wash hands prior to procedure (Table). Advantages and Disadvantages The main advantage of HDC is the prevention of hospitalization of patients with dehydration since it may be performed by any trained nonmedical persons at home.9 It reduces distress for patients,6 induces little pain or discomfort with line insertion, and causes no concerns of “line thromboses” with “stop-start infusions.”7 The ease of initiation in comparison to IV10 with greater infusion site selections, including the posterior upper arms, upper chest, abdomen, anterior or lateral thighs, infraclavicular areas and the flank areas with a fat fold of at least 1 inch thick,5 also spares limbs from infusions, permitting position changes in bed with only overnight infusions, and freeing up patients for rehabilitation services during the day. In addition, HDC can permit earlier discharge from the hospital to the home or a LTC facility if the only reason delaying discharge is the need for parenteral fluids.8 Earlier hospital discharge, along with lower needle costs at $0.20 for a 23-gauge, as compared to a $0.50 for an IV cannula of the same size,1 reduces the overall healthcare expenditure and adds to HDC’s many advantages. Disadvantages of HDC include: the limitation in the type of electrolyte administration, nutrition additives, and medications; and a usual rate of only 1-2 mL per minute, with infusion rate of 1.5 L per day per injection site, for a total maximum infusion of 3 L per day via two sites.1,7 It also cannot be used in severe dehydration and shock,1 or for any situation requiring more than 3 L over 24 hours. In circumstances where careful titration of fluid administration is crucial (eg, heart failure, renal failure), an infusion pump is required.6 Sites of infusion have also been suggested to be changed every 24 hours to reduce local inflammation and extravasation.1 Adverse Reactions HDC does not involve placing a needle into a vein, and therefore does not predispose to intravascular infection or thrombosis.1 Complications of HDC include local inflammation (16%), extravasation (15%), and bleeding (2.5%).4 Schen and Singer-Edelstein11 reported adverse effects including local edema, ecchymoses, and infection in only 12 of 634 patients given a total of 4500 SC infusions. In fact, a 23% lower complication rate was found in the SC infusion group in a prospective study by Dasgupta et al,12 and no significant difference was found in the rate of systemic complications (eg, hyponatremia, acute cardiac failure) between the SC versus IV infusion route in a randomized controlled trial by Slesak et al.13 Conclusions HDC 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 SC for the mild to moderately dehydrated elderly patient, future research is needed to further evaluate this effective rehydration technique with standard protocols and guidelines. The authors report no relevant financial relationships. _______________________ From the New York University College of Nursing, New York, NY.