Hypodermoclysis for Adults Procedure

(Hydration by Subcutaneous Infusion)

Equipment required for hypodermoclysis

Drip stand
500mls or 1 litre bag on 0.9% Sodium Chloride for infusion
Standard giving set & IV extension line
Sof-Set Infusion set/ 24 or 25 gauge butterfly needle (do not use the McKinley lines due to the anti-syphon device).
Semi-permeable film dressing/IV dressing
70% Isopropyl alcohol swabs
Fluid Balance Chart
Prescription chart (signed by prescriber)
Non-sterile gloves
Sharps waste container

Patient preparation

Gain informed consent
Explain the procedure to the patient
Prepare patient, environment and necessary equipment and check expiry dates of prescribed fluids
Check that the fluid that is to be administered is clear and colourless
Check that the prescription is signed

Preparation of site

Clean skin for a minimum of 30 seconds using 70% isopropyl alcohol and allow to dry for 60 seconds.

Cannula site choice

Individual patient assessment is essential to ascertain the most appropriate site.

The needle should be inserted into loose subcutaneous tissue where the needle will not be mechanically dislodged

Suggested potential sites are –

Anterior chest wall (below clavicle)
Abdominal wall (umbilical region)
Anterolateral aspect of thigh
Back (below scapula)
Lateral aspects of upper arms

Sites should be rotated to decrease the likelihood of irritation and to ensure optimum absorption. The Sof-Set Infusion set is not suitable for chest wall or scapula application or where there is a risk of bone contact during insertion.

Cannula sites to avoid

Lymphoedematous limbs
Sites over bony prominences
Sites which are oedematous, bruised, hard, scarred or painful
Previously irradiated skin areas (radiotherapy can cause sclerosis of small blood vessels thus reducing skin perfusion)
On the side of a mastectomy or close to a stoma
Sites near a joint (excessive movement may result in cannula displacement and patient discomfort)
Sites with a skin rash
Peripheral extremities

Cannula insertion procedure

Select site for cannula insertion as per guidance above.
Wash hands as per hand hygiene procedures.
Attach giving set to the infusion fluid using an aseptic non-touch technique and prime needle by gently opening the clamp on the giving set. Close clamp when fluid is seen on the distal tip of the needle.
Clean selected skin site by saturating it using isopropyl alcohol 70% in a circular motion for a minimum of 30 seconds. Ensure to agitate the skin sufficiently to saturate resident flora. Leave to dry for 30-60 seconds.
Wash hands again as per policy and put on sterile gloves.
Gently pinch the skin into a fold to elevate the subcutaneous tissue which lifts the adipose tissue away from the underlying muscle.
Insert a 24g or 25g butterfly (winged) needle, bevel down, at 45° into the subcutaneous tissue.
If blood appears in the line on the insertion of the needle, withdraw the needle immediately. Replace butterfly needle, prime and repeat the process using a different site previously cleaned with 70% isopropyl alcohol.
Coil the tubing and secure with a semi-permeable film dressing.
Set the infusion at the prescribed rate.

Fluids

Sodium chloride 0.9% for infusion will be the only acceptable fluids administered by Hypodermoclysis in the community setting. No other fluids or drugs additives will be used.

Sodium chloride 0.9% will need to be prescribed.

Typically 1 litre of 0.9% sodium chloride for infusion will be given over 12 or 24 hours up to a maximum of 2 litres in 24 hours

Fluids must be gravity fed and regulated (i.e. using a device to hold the normal saline at an appropriate height and standard giving set and calculating the drip rate) and NOT infused using a pump.

Care of the patient undergoing Hypodermoclysis

Hypodermoclysis infusions can be intermittent or continuous

The patient undergoing Hypodermoclysis will have a baseline test for urea and electrolytes, and consider daily blood tests thereafter, at the clinician’s discretion but reviewing every 24 hours, to establish the appropriate treatment and care for correction of dehydration.

Following commencement of Hypodermoclysis, the patient, infusion rate, expected volume of fluid administration and infusion site will be checked by the nurse within an hour of the infusion commencing and regularly thereafter.

The infusion site will be checked, and site changed if the following is observed:

Redness
Pain/Tenderness
Cellulitis
Inflammation/signs of oedema
Leakage at site
Abscess formation
Bleeding/bruising

The infusion site should be changed every 48-72 hours if no complications are detected at the infusion site.

The patient will be checked for signs of fluid overload, pulmonary oedema (dyspnoea) and/or peripheral oedema. In the event of any of these the infusion should be stopped and the future patient management discussed with the GP or relevant healthcare team.

The giving set should be changed every 72 hours if the infusion is continuous or changed every time fluids are to be administered for intermittent infusions.

With intermittent infusions, the butterfly can be capped off using a sterile bung.

Evaluation of the patient’s on-going need for Hypodermoclysis should be considered and discussed with the patient, carer and wider health and social care teams.

Potential Complications

COMPLICATION	ACTION	RATIONALE
Local oedema	May be resolved by gently massaging the area Infusion should be re-sited if patient discomfort is experienced	To aid absorption
Redness, swelling or inflammation at the infusion site (may be due to local reaction to the cannula)	A Teflon cannula may be used as an alternative Change infusion site	To reduce risk of potential nickel allergy
Cellulitis	Change infusion site Treat cellulitis according to patient’s clinical condition Perform wound swab if clinically indicated Follow Infection control policy and ensure aseptic non-touch technique	To identify pathogen To minimise the risk of infection
Pain or discomfort at infusion site	Adjust/change needle position Slow infusion rate	Needle may have been inserted intradermally (at too shallow an angle) Infusion rate is too rapid
Leakage at site	Adjust/change needle position Slow infusion rate	Needle may have been inserted intradermally Infusion rate is too rapid
Abscess formation (rare)	Reassess patient’s clinical condition and need for Hypodermoclysis Treat abscess according to patient’s clinical condition Perform wound swab if clinically indicated Follow infection control policy and ensure aseptic non-touch technique Change infusion site	To reduce the risk of further complications To identify pathogen To minimise the risk of infection
Bleeding/bruising at site	Re-site needle if bleeding occurs on needle insertion	Needle may have been inserted intradermally
Pulmonary oedema (dyspnoea)	Infusion should be stopped immediately and medical advice sought	To ensure patient safety
Peripheral oedema	Infusion should be stopped immediately and medical advice sought	To ensure patient safety

Records and record keeping

Nurses will adhere to the Nursing and Midwifery Council Guidelines for records and record keeping (2005).

Record of details of infusion to include:-

Date and time the infusion commenced
Observation of infusion site
Date and time anticipated infusion completion
Completion of fluid balance chart
Patient’s response to therapy and any adverse effects observed
Signature

Once Hypodermoclysis is established, the patient or their carer or NOK should be educated about checking the infusion at agreed intervals. They should also be shown how to stop the infusion if any potential complications occur and informed how to contact the relevant healthcare team.

Date: January 2024

Version: 6 (Review)

Acknowledgements:

NHS Surrey – East Locality

CHS Surrey

Birmingham East and North Primary Care Trust