QJM vol. 97 no. 11 © Association of Physicians 2004; all rights reserved.
Commentary |
Using subcutaneous fluids to rehydrate older people: current practices and future challenges
From the 1Medical Directorate, Furness General Hospital, Barrow-in-Furness, 2 Medical Department for the Elderly, The General Infirmary at Leeds, and 3 Elderly Services, St. James's University Hospital, Leeds, UK
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Introduction |
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 Top Introduction Current practice: mechanisms of...Identifying the role of...Future challengesConclusionsReferences |
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The management of unwell older people who have poor venous access, or who are unable to tolerate intravenous cannulation, presents a common and difficult challenge for clinicians in many specialities. Whilst the use of subcutaneous infusions (hypodermoclysis) is commonplace in a palliative care environment and elderly medical wards in UK hospitals, its use, particularly outside of hospice and acute hospital (medical centre) settings, remains rather variable. Medical and nursing staff working in the aforementioned places are relatively familiar with the practicalities of the technique. Therefore in this commentary, we will discuss and review the evidence for its use in the hospital setting, but also explore future developments including the potential use of hypodermoclysis for antibiotic administration and as a method of fluid delivery for older people resident in long-term care settings.
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Current practice: mechanisms of administration and absorption |
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TopIntroductionCurrent practice: mechanisms of...Identifying the role of...Future challengesConclusionsReferences |
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Hypodermoclysis has been an alternative option to the traditional intravenous route for over 50 years.1 This method involves the insertion of a 21 or 23 gauge butterfly cannula under aseptic conditions into subcutaneous tissue.2 As subcutaneous tissue tends to diminish peripherally and increase in central areas as part of the ageing process, the abdomen, scapula or thighs are all prime sites for administration of subcutaneous fluids.3 Once the cannula is inserted, it is attached to a giving set and connected to a bag of parenteral fluids, commonly infused at a rate of 2 l over a 24 h period.2 As the use of electrolyte-free and hypotonic solutions has been associated with cardiovascular collapse and shock, it is now standard practice to use either 5% dextrose or 0.9% saline solutions.4,5 Up to 34 mmol of potassium can be given safely with each litre of fluid.6
Absorption of subcutaneous fluids in older subjects has been studied using uptake of technetium boluses and radioisotope imaging.7,8 The administration and absorption of subcutaneous vs. intravenous saline in elderly patients has been studied with radioisotope tracers, and no difference in absorption rates was demonstrated between either infusion type, and the absence of radioactivity 1 h after the completion of the subcutaneous infusion indicated complete clearance from subcutaneous tissue.7 Comparisons of hypodermoclysis with intravenous fluids have found no significant differences in electrolyte measurements or osmolalities.9,10
Uptake of subcutaneous fluid can also be improved by the use of hyaluronidase, an enzyme that makes subcutaneous tissue more permeable to fluids by increasing the distribution and absorption of local administered fluids and drugs. It is used in the treatment of extravasation injuries, and in local anaesthesia and plastic surgical procedures.11–13 Radioisotope modelling has shown increased speeds of fluid absorption with the addition of hyaluronidase.8 However, work in palliative care has demonstrated little change in patient comfort levels with the addition of hyaluronidase to hypodermoclysis fluids or syringe drivers.14,15 To date, there remains no consensus on its usage, due to the small sample sizes of studies, ranging from 4 to 25 participants.
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Identifying the role of hypodermoclysis: benefits and disadvantages |
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TopIntroductionCurrent practice: mechanisms of...Identifying the role of...Future challengesConclusionsReferences |
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There are many different clinical situations where fluid administration is vitally important. Within a hospital setting, patients who have had an acute stroke are at risk of dehydration, and post-operative elderly patients may similarly require supplemental fluids until their oral intake is satisfactory. Many older patients suffering from intercurrent illnesses such as gastro-intestinal upset and infections become dehydrated, often contributing to their admission to hospital. The attendant dangers of hospital admission include delirium as a consequence of environmental change, life-threatening nosocomial infections and exposure to prescribing errors.16,17
A summary of the important benefits and problems associated with hypodermoclysis is shown in Table 1, and some of its advantages merit further discussion. Delirious patients often remove intravenous cannulae; this necessitates re-siting in people who are already agitated and can lead to delays in restarting fluids. Comparisons of hypodermoclysis with intravenous fluids in elderly patients with cognitive impairment have reported a marked reduction in agitation in confused patients receiving subcutaneous fluids (37% vs. 80% in the intravenous group, p < 0.005).18 Given the ease of administration, one could debate whether hypodermoclysis in these patients might be the first choice for rehydration alone in non-emergency settings.
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Hypodermoclysis also attracts cost savings, both in terms of equipment and staff time.10,18 Insertion of the butterfly cannulae used for fluid administration is not only less painful (because of the smaller bore needles), but easily undertaken by nursing staff without need for resident medical input. Any member of staff capable of giving subcutaneous injections may perform cannula insertion.19 The cost benefits are also attractive, as there is a reduction in both medical staff input and equipment costs, with fewer attempts at recannulation.18
Finally, studies have shown fewer infective complications with the use of hypodermoclysis. There is no risk of intravascular infection, no line maintenance is required and the possibility of thrombophlebitis is not a concern.20 The accidental infusion of fluids at too rapid a rate seen with intravenous fluids is similarly not an issue with hypodermoclysis.
There are few disadvantages of subcutaneous fluid administration for rehydration.21 This method is clearly unsuitable for resuscitating shocked, hypotensive patients who often require rapid delivery of large volumes of fluids in a hospital setting. A review of 639 patients showed that just 16 (2.5%) reported adverse effects.6 These problems related predominantly to local side-effects, e.g. 5% per day for hydration subcutaneously vs. 25% per day via intravenous rehydration, predominantly due to erythema in the hypodermoclysis group.2 Caution also needs to be exercised in the fluid balance management of patients in long-term care with hypoalbuminaemia and/or heart failure, but this applies equally to managing such patients with intravenous fluids.
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Future challenges |
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A novel route for antibiotic administration?
While the administration of drugs for symptom control in palliative care is well established,19 the administration of other drugs by this route remains largely restricted. However, hypodermoclysis represents a viable route for the administration of antibiotics. In veterinary medicine, subcutaneous administration of antibiotics is a common practice, and animal studies have shown equivalent subcutaneous absorption of cephalosporins and clindamycin when compared with intravenous absorption.22,23
In human subjects, one study has examined the pharmacokinetics of subcutaneous ampicillin, a commonly used first-line antibiotic, and tobramycin in both younger and older volunteers.24 Whilst subcutaneous ampicillin absorption was slower than intravenous administration (time to tmax 49 min vs. 27 min), subcutaneous delivery of the antibiotic gave higher plasma concentrations at the end of the infusion (32 µg/ml subcutaneously vs. 23 µg/ml intravenously (p < 0.05)). If further trials confirm the efficacy of this mode of drug delivery, its practical benefits would be significant, particularly in the management of agitated patients with no intravenous access, and in whom intramuscular injections are to be avoided.
Is there a role for hypodermoclysis in UK care homes?
While little research presently exists into the use of hypodermoclysis in the UK care home setting, studies in North America have demonstrated its successful use in community settings. In one study, hypodermoclysis was initiated by nursing home staff in 36 nursing home residents, with a median age of 85 years.25 All were frail, with >80% of the group both functionally dependent and significantly cognitively impaired, much like the population of many EMI (Elderly Mentally III) Nursing Homes in the UK. Seventy-one percent of subjects returned to their usual functional abilities following rehydration with hypodermoclysis, with the only reported complications being minor local skin reactions. Monitoring of electrolyte biochemistry before and after hypodermoclysis demonstrated no significant adverse effects.
A descriptive study was undertaken in a 284-bed long-term care facility in Canada with subcutaneous fluid therapy commenced by family physicians. The need for fluids was most commonly due to decreased fluid intake or the concurrent management of acute infection.26 The study examined nursing staff competencies and demonstrated that a 1 h information and education session was enough to allow registered nurses to be proficient in hypodermoclysis. The session focussed on administering fluids subcutaneously and recognizing complications. This was facilitated by clinical nurse specialists, who also covered decision-making issues relating to hypodermoclysis. Finally, while a largely descriptive study, this paper did demonstrate considerable cost savings: CD$600 (£246, 
366 on current currency exchange) per patient per day when compared with hospital admission for rehydration. This was based around a CD$795 daily rate for hospital care (£326, 485) vs. CD$209 (£86, 128) for long term care, with a CD$30 cost for hypodermoclysis (£12, 18).
While these findings are persuasive, it is vital that community use of hypodermoclysis forms part of the effective management of older people. The introduction of this form of treatment would largely be for a temporary period of 48 to 72 h, to facilitate rehydration whilst the older person has treatment and recovers from any intercurrent illness. It should not under any circumstances be implemented as a bar to hospital admission with the full benefits of comprehensive geriatric assessment. It is also clear that the views of general practitioners are equally important if the challenges of introducing hypodermoclysis into UK care homes are to be examined. When the views of general practitioners from primary care trusts in Leeds were studied, 50% of respondents felt that hypodermoclysis had a role in the management of older people in nursing homes, with some indicating prior experience in this field.27 These GPs are responsible for commissioning services, and qualified their responses with concerns regarding training, resourcing and support by secondary care. However, the introduction of intermediate care services in the UK may present an opportunity for further research into the use of hypodermoclysis in care homes through partnership between primary and secondary care.
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Conclusions |
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TopIntroductionCurrent practice: mechanisms of...Identifying the role of...Future challengesConclusionsReferences |
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Hypodermoclysis represents a valuable alternative method of fluid delivery to the traditional intravenous route in older people. It has many advantages over parenteral fluid administration, including ease of administration, fewer systemic side effects, cost savings and appropriate use of staff time through ease of cannula insertion. For agitated older patients, it may be the optimal means of administering non-emergency fluids.
Early research into the use of hypodermoclysis as a method of delivering antibiotics is promising, and this route may be a worthy addition to the management of unwell patients with poor intravenous access. The successful use of subcutaneous fluids in North American long-term care settings represents a promising opportunity for general practitioners and geriatricians to research the challenges of the viable use of hypodermoclysis in UK care homes.
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Footnotes |
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Address correspondence to Dr Barton, Medical Directorate, Furness General Hospital, Barrow-in-Furness, LA14 4LF. e-mail: alan.l.barton{at}fgh.mbht.nhs.uk
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References |
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TopIntroductionCurrent practice: mechanisms of...Identifying the role of...Future challengesConclusionsReferences |
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