Hypodermoclysis for Adults Policy

(Hydration by Subcutaneous Infusion)

Introduction

Hypodermoclysis (subcutaneous fluid administration) is a method for replacing fluids to correct mild to moderate dehydration (O’Keefe and Geoghegan, 2000) or to maintain hydration (Donnelly, 1999).
It is a simple, safe and reliable method of treating dehydration and symptoms of thirst in the elderly or palliative care patients (Schen and Singer-Edelstein, 1981, Constans et al, 1991) and can, if tolerated, be used as an adjunct for oral fluids.
Hypodermoclysis is not suitable for emergencies or to correct severe dehydration or severe electrolyte imbalance.
This method is well suited to less acute settings and is suitable for administration in the home environment (Mallett and Dougherty, 2004).
The purpose of this document is to provide guidance on the safe administration of subcutaneous fluids to adult patients in the community for the management of mild to moderate dehydration, to maintain hydration and/or manage the symptoms of thirst.
These guidelines relate to the infusion of 0.9% Sodium Chloride (with no additives) ONLY to manage mild to moderate dehydration as a supplement to oral fluids. No other fluids or additives will be used.
Hypodermoclysis is not suitable for patients requiring more than 2 litres of fluid in 24 hours as a supplement to oral fluids and as a means of correcting mild to moderate dehydration.
These guidelines do not refer to the administration of subcutaneous fluids via a syringe driver.
The guidelines are particularly relevant to community nurses and staff who are engaged in the activities covered by these guidelines are obliged to comply fully.

Definitions

Hypodermoclysis: the infusion of fluids into the subcutaneous space (Steiner and Bruera, 1998)

Dehydration: occurs when water is lost without corresponding loss of salts and occurs in patients unable to take sufficient fluids or who have excess insensible water loss via the skin and lungs or as a result of an excess of certain drugs (Mallett and Dougherty, 2004).

Consent

Consent is usually implied through a combination of verbal consent and patient cooperation. However, in law, touching a patient’s body without consent could be regarded as assault. Therefore, case law on consent has established three principles that must be confirmed before any procedure is commenced:

Consent should be given by someone with the capacity to do so.
Sufficient information must be given to the patient on which they can base their decision to consent.
Consent must be given freely.

The Nursing and Midwifery Council (NMC) Code of Conduct (2008) assumes competency to consent unless the patient is assessed as unable to do so by an appropriate practitioner and it suggests referral to local guidelines where any ambiguity exists.

Ethical decision making in Palliative Care: artificial hydration for people who are terminally ill.

The issues surrounding subcutaneous hydration for people who are terminally ill are complex. Good practice suggests that decisions regarding artificial hydration should involve the multidisciplinary team, the patient, relatives and carers, although a senior doctor will have the ultimate responsibility for the decision. All patients have the right to refuse artificial hydration and those who are unable to communicate their wishes retain this right through advance refusal.

Further statements from the National Council for Hospice and Specialist Palliative Care Services include:

A blanket policy of artificial hydration or no artificial hydration is ethically indefensible
At the end stages of life the desire for food and drink decreases. Research is limited but the available evidence suggests that artificial hydration in dying patients influences neither survival nor symptom control and as such may constitute an unnecessary intrusion.
Thirst or dry mouths in people who are terminally ill are frequently caused by medication. In such circumstances, artificial hydration is unlikely to alleviate the symptoms. Good mouth care and a reassessment of the medication may be the most appropriate intervention.
Appropriate palliative care will involve consideration of the option of artificial hydration where dehydration results from a correctable cause, e.g. over treatment with diuretics and sedation, recurrent vomiting, diarrhoea and hyper-calcaemia.
It is the responsibility of the clinical team to make assessments concerning the relevance of hydration to the experience of individuals, the appropriateness of which should be judged on a day to day basis. Relatives frequently express concern regarding diminishing or absent fluid and nutrient intake. Clinicians should not subordinate the interests of the patient to the anxieties of the relatives, but even so should strive to address these anxieties.
The appropriateness of artificial hydration continues to depend on regular assessment of the likely benefits and burdens of such interventions.

Indications

Hypodermoclysis should be considered when the patient requires fluids to supplement their oral intake, and adequate oral intake is not enough to achieve rehydration.

For older people with dehydration and those at risk of dehydration, subcutaneous fluids are a safe intervention that could potentially prevent the need for acute hospitalisation.

Precautions or Risk Factors

Caution should be taken in administering fluids subcutaneously to patients who have the following conditions:

Pulmonary Oedema
Cardiac Failure
Severe dehydration/electrolyte imbalance
Pre-renal or renal failure
Low platelet or coagulation disorders
Marked oedema

Contraindications

Caution should be taken with patients with pulmonary oedema or cardiac failure
Patient refusal or poor concordance
Severe dehydration/electrolyte imbalance
Fluid replacement that requires potassium or other additives. Hypodermoclysis is not suitable for dextrose infusions
Pre-renal or renal failure
Low platelet or coagulation disorders
Marked oedema

Date: January 2024

Version: 6 (Review)

Acknowledgements:

NHS Surrey – East Locality

CHS Surrey

Birmingham East and North Primary Care Trust