Professional Documents
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Version 1.00
ADMINISTRATION OF SUBCUTANEOUS
FLUIDS (HYPODERMOCLYSIS) TO ADULT
PATIENTS IN COMMUNITY SETTINGS
GUIDELINES
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Title:
Version 1.00
Summary:
HCHC/CLI/95/V1.00
Version Number:
1.00
Target Audience:
Review Date:
March 2014
Approved by:
Date of meeting:
Policy Management
Group
Ratified by:
16/03/11
Date of meeting:
05/04/11
Date Issued:
April 2011
Author:
Custodian:
Sue Harriman
Date:
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Document Control
Change Record
Date
Author
Version
Reviewers/contributors
Name
Steve Mennear
Tina Baker
Carol Mayl
Michelle Morron-Ryan
Janet Holden
Vicky Melville
Debbie Wakeford
Suzie Ingram
Position
Lead Pharmacist
Community Matron
Modern Matron
Community Matron
Community Matron
Clinical trainer
Distribution
Name
Community matrons
Modern Matrons
Community Care Teams
Position
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Contents page
1 Introduction
2 Status
3 Scope
4 Definitions
5 Ethical issues
6 Resources and equipment
7 Rehydration in older people
8 The Use of Fluids Licensed for Intravenous Use
9 Advantages
10 Disadvantages
11 Sites
12 Choice of cannula
13 Fluids
14 Use of Hyaluronidase
15 Monitoring the infusion
16 Documentation
17 Training
18 Audit and Monitoring
19 References
6
6
6
6
7
7
8
8
8
8
9
9
9
11
11
11
12
12
12
Appendix
1. Procedure for the administration of subcutaneous fluids
2. Infusion record
3. Competency tool
4. Training needs analysis
5. Equality Impact tool
14
16
17
21
22
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1. Introduction
This guideline identifies the principles and procedures for the management of subcutaneous fluids to
adult patients for the management of symptoms of dehydration.
2. Status
This is a clinical guideline
3. Scope
The contents of this document apply to all Registered Nurses working within Hampshire Community
Health Care (HCHC).
4. Definitions
Hypodermoclysis
Hypodermoclysis is a technique used for the subcutaneous administration of large volumes of fluids
and electrolytes in order to achieve fluid maintenance or replacement in mildly dehydrated patients for
whom intravenous access may be difficult to obtain, or who cannot tolerate sufficient oral intake
Hypodermoclysis can be considered for use in patients with:
Life-limiting conditions
Difficulty maintaining oral hydration
Mild to moderate dehydration
Difficult venous access
Stroke, palliative care and cognitive impairment
Hypodermoclysis should not be considered for the following:
Children
Patients experiencing severe dehydration (where IV fluids are required)
Severe Renal Failure
Severe Hepatic Failure
Hypercalcaemia
Shock or poor tissue perfusion
Any patient for whom fluid balance management requires accurate and intensive monitoring
If > 3 Litres fluid to be administered over 24 hours
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5. Ethical issues
Patients who are in the last few days or weeks of life are often unable to tolerate oral hydration. The
prime goal of any treatment towards the end of life must be the comfort of the patient. Considerations
around how to approach the issue of hydration at the end of life are complex and involve not only
physical, psychological and social concerns, but also ethical dilemmas. (Salt, S. 2007). A review of the
literature continues to give conflicting views as to the role and effectiveness of hypodermoclysis and a
comprehensive reading list is provided in this guideline for those interested in further information
regarding these views. In summary there are two schools of thought those who believe artificial
hydration for this group of patients is unnecessary, not beneficial and potentially harmful, whilst others
contend that dehydration in patients who are dying can be extremely distressing and should be given
the same priority in terms of symptom control as is given to the control of pain, nausea and vomiting
etc.
Whilst it is important that clinicians have information about the latest evidence base regarding
hypodermoclysis so that they can contribute to the decision making process about whether or not to
use subcutaneous hydration for a dying patient, the purpose of this guideline is to support clinicians in
the safe delivery of subcutaneous fluids.
In order for the patient to give their informed consent (which can be written or verbal), they need to
have a clear understanding of:
What the subcutaneous fluids are being used for (with particular reference to them being used
off license)
The purpose of administering them
How the decision will be made to stop the infusion (if appropriate)
It is important that the practitioner understands the reasons behind the decision for each individual
patient so that she (he) is able to discuss this with the patient/carers/family as required. It is also
important that the situation is constantly reassessed in terms of whether the hydration regime is helping
to relieve symptoms.
Where a patient may lack capacity to consent to hypodermoclysis and the treatment is considered in
their best interests practitioners will need to refer to the guidance contained in the Mental Capacity Act
2005 Code of Practice.
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9. Advantages
The infusion is usually easier to set up than intravenous (IV) fluid therapy and can be set up by
a nurse in almost any setting
It does not cause thrombophlebitis
It is often better tolerated by the patient
It can be discontinued and commenced with no ill effects, as part of the patients management
plan (e.g. where patients are mobile and active)
It can be administered in the patients own home or nursing and residential care homes, thus
possibly preventing hospital admission or enabling speedier discharge
10. Disadvantages
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11. Sites
The site for placement of the cannula should be chosen with consideration to the
following:
The abdomen, chest and lateral aspects of the upper arm or thigh are recommended sites. The following
areas should be avoided:
Areas of lymphoedema or ascites as absorption will be restricted and breaches in skin integrity
could increase risk of infection
Bony prominences
Recently irradiated skin sites
Joints and skin folds
Sites of tumour
Areas of broken skin
Areas of inflammation or infection
Areas where medication patches or other topical applications are in place
If resiting and need to use same area, the needle must be at least 3cm away from problem site.
13. Fluids
Fluids that can be administered by hypodermoclysis:
Sodium chloride 0.9% or 0.45%
Dextrose (Glucose) 5%
Dextrose saline (Glucose 4% with sodium chloride 0.18%)
Potassium infusion of no more than 20mmol/L (pre-prepared infusion e.g. potassium chloride and
sodium chloride infusion)
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When administering the above fluids under no circumstances should any medications be
added to them.
Under no circumstances should any other fluids (other than those mentioned) be
administered via the subcutaneous route.
Special precautions:
Sodium chloride infusion:
Maximum 3 litres in 24 hours
Maximum 2 litres using a single site
Dextrose (Glucose) 5% infusions:
Maximum2 litres in 24 hours
Regular monitoring of the site to look for early signs of irritation and inflammation due to acidic pH
of glucose
Potassium infusions:
Maintain strict site observation because of risk of irritation
Do not exceed recommended concentrations
Sodium chloride 0.9% would normally be used where the patient is suffering electrolyte losses such as
gastro-enteritis.
Dextrose (Glucose) 5% is more commonly used where dehydration is present due to fluid losses
exceeding intake such as coma and dysphagia.
Regimens using both Dextrose (glucose) 5 % and saline in combination or saline 0.18% and glucose
4% (Dextrose saline), can be used where patients need both electrolyte and fluid replacement.
Injudicious use of the latter may cause hyponatraemia in the elderly.
The rate setting for 1 Litre over 12hrs will be 28 drops per minute (when using an administration set that
delivers at 20 drops /minute).
Volume of fluid (ml) x set value (drops/ml) /minutes = Flow rate (drops/min) duration (hr)
Fluids may also be infused more slowly, for example 1 Litre over 24 hours in which case the rate would
be 14 drops per minute.
Fluids must be gravity fed and regulated (i.e. using a drip stand, giving set and calculating the drip rate)
and NOT infused using a pump (Hypodermoclysis working Group 1998)
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16 Documentation
Documentation in the patients nursing record should contain complete information regarding infusion
therapy (INS 2000; ICNA 2000), and should comply with the guidelines for record keeping (NMC 2008).
This should include:
evidence of consent (or other measures taken where a patient lacks capacity)
date and time of insertion/commencement of therapy and site
rate of infusion, and fluid being infused
evidence of consequent monitoring to include report on site check, rate of infusion, patients
tolerance of therapy
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discontinuation of therapy(including date/time and volume infused) and document the reason for
discontinuation - either due to completion, adverse reaction, patient decision/choice or if the
infusion is considered to be no longer beneficial.
signature and printed name
Staff should use the infusion record for the administration of subcutaneous or intravenous fluids
(Appendix 2)
19. References
Hypodermoclysis working group. Hypodermoclysis : guidelines on technique.1998. Wrexham: CP
Pharmaceuticals (111)
Intravenous Nurses Society (INS,2000) Standards for Infusion Therapy. Cambridge, MA ins AND
Becton Dickinson (III)
Infection Control Nurses Association (ICNA, 2000) Guidelines for preventing intravascular catheterrelated infections. Fitwise Publications (III)
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Nursing and Midwifery Council (2008) The Code - Standards of conduct , performance and ethics for
nurses and midwives
Nursing and Midwifery Council (2008) Standards for Medicines Management
Nursing and Midwifery Council (2008) Record Keeping Advice Sheet
Salt, Susan. (2007) When a terminal patient is no longer able to eat or drink. End of Life Care, 2007,
Vol1, No. 3
The Mental Capacity Act 2005 Code of Practice
Reading List
Campbell, C. Partridge, R. (2007) Artificial Nutrition and Hydration Guidance in End of Life Care for
Adults. National Council for Palliative Care. London
Dunphy K, Finlay I, Rathbone G & Hicks F (1995) Rehydration in palliative care: if not - why not?
Palliative Medicine 9: 221 - 228
Fasinger RL, MacEachern T, Miller MJ, Bruera E, Spachyski K, Juehn N & Hanson J, (1994) The use of
hypodermoclysis for rehydration in terminally ill cancer patients. Journal of Pain and Symptom
Management 9 (5); 298-302.
Ferry M, Daradire V & Constans T (1999). Subcutaneous infusion of hypodermoclysis : a practical
approach. Journal of the American Geriatrics Society;47:93-95.
Gill S, Daspupta M & Rochon P(2001) Hypodermoclysis for dehydration. American Family
Physician;64:9,1516-1518.
Lanuke, K. Fasinger, R.L. (2003) Hydration management in palliative care settings a survey of
experts. Journal of Palliative Care. 19 (4): 278-9
Morita, T. Hyodo, I. Yoshimi, T. et al (2006) Artificial hydration therapy, laboratory findings, and fluid
balance in terminally ill people with abdominal malignancies. Journal of Pain and Symptom
Management 31(2): 130-9
Steiner,N , Bruera,E (1998) Methods of Hydration in Palliative care patients. Journal of palliative
care,14 (2) 6-13 Summer.
Jilek R. (1999) Subcutaneous Fluid Administration: An effective alternative to intravenous therapy.
Geriatrician; 17 (1) 16-18.
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Appendix 1
Procedure for the administration of subcutaneous fluids
Action
1. Identify the patient correctly using name, date of
birth, NHS number and wristband
2. Explain the procedure to the patient and/or
carer, allowing time for any questions. Ensure they
understand the use of IV fluids for subcutaneous
use is unlicensed but best/accepted practice and
have the required information for monitoring.
3. Assess the patient for a suitable site. (See 11.0
above)
4. Before administering any prescribed fluid check
that it is due and has not already been given.
5.Check the fluid against the prescription chart and
ascertain and record the following:
a) prescription is valid
b) fluid name, strength and volume
c) batch number and expiry date
d) infusion route and rate.
6. Check expiry date and integrity of the fluid
container to be used. Check infusion fluid for
discolouration/ crystalline or particulate matter.
Prepare the fluid for infusion by inserting line into
infusion bag and priming line with fluid
7. Clean the injection site with swab saturated with
70% Isopropyl alcohol for 15 30 seconds and
allow to dry.
8. Introduce the Butterfly needle/ peripheral
cannula at the angle recommended by the
manufacturer bevel up.
Technique gently pinch a well-defined
amount of tissue between the index finger and
thumb and insert the needle into the base of
the pinch.
9. If blood appears in the line on insertion of the
needle, withdraw immediately and repeat the
process in a different site.
10.Coil the tubing and secure with a semi
permeable film dressing e.g. Tegaderm
Rationale
To identify the right patient
To ensure the patient/family are fully informed
and to gain valid consent where appropriate
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complications
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Appendix 3
Administration of subcutaneous fluids clinical competencies
Name:
Role:
Base:
Competency Statement:
The participant demonstrates clinical knowledge and skill in the administration of subcutaneous fluids
without assistance and/or direct supervision (level 3)
See page 5 for level descriptors.
Performance Criteria
Assessment
Method
Level achieved
Date
Assessor/self
assessed
Direct
observation
Direct
observation
Direct
observation
Direct
observation
Direct
observation
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Performance Criteria
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Assessment
Method
Level achieved
Date
Assessor/self
assessed
Direct
observation
Direct
observat
ion
Direct
observation
Direct
observation
Questioning /
Direct
observation
Direct
observation
Direct
observation
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I confirm that I have attended initial training on _________and that I am confident and competent in
administration of subcutaneous fluids
_______
I confirm that I have assessed the above named Registered Nurse and can verify that he/she
demonstrates competency in administration of subcutaneous fluids
Verifier
_______________Signature _______________Status
___________
Date ____
Review
Competent
Registered Nurse
Dates:
Yes / No
Signature
Verifier signature
Comments
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Novice
Competent
Practitioner
Expert
Level of achievement
Cannot perform this activity satisfactorily to the
level required in order to participate in the clinical
environment
Can perform this activity but not without constant
supervision and assistance
Can perform this activity with a basic
understanding of theory and practice principles,
but requires some supervision and assistance
Can perform this activity with understanding of
theory and practice principles without assistance
and/or direct supervision
Can perform this activity with understanding of
theory and practice principles without assistance
and/or direct supervision, at an appropriate pace
and adhering to evidence based practice
Can perform this activity with understanding of
theory and practice principles without assistance
and/or direct supervision, at an appropriate pace
and adhering to evidence based practice.
Additionally demonstrating initiative and
adaptability to special problem situations.
Can perform this activity with understanding of
theory and practice principles without assistance
and/or direct supervision, at an appropriate pace
and adhering to evidence based practice.
Demonstrate initiative and adaptability to special
problem situations, and can lead others in
performing this activity
Level
0
1
2
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Type
of
Trainin
g
Target
Audience (by
division)
Frequency
Length
Delivery Method
Trainer
Recording
attendance
Strategic responsibility
Operational
responsibility
What
type of
training
is
required
?
Identify specific
staff groups who
need to attend
from each
Business Unit
How long
will the
training
take?
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Name of policy
Directorate/ Department
SCREENING
1
This policy sets out the standards and procedures for any member of staff , irrespective
of age, race, colour, religion, disability, nationality, ethnic origin, gender, sexual
orientation or marital status, domestic circumstances, social and employment status,
HIV status, gender reassignment, political affiliation or trade union membership
To provide guidance to registered nurses on the safe administration of subcutaneous
fluids to adult patients in the community for the management of symptoms of
dehydration
1.2 Who will be affected by the outcomes of the proposal?
Who is the policy aimed at? How will they benefit?
The contents of this document apply to all Registered Nurses working within Hampshire
Community Health Care (HCHC). The policy will be available to other staff
independently contracted to the trust
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COLLECT INFORMATION
It is important to have as much up to date and reliable information about the different groups the
proposal is likely to affect.
2.1
2.1a
First Level Data
If the main impact of the proposal is employees include demographic data.
Also detail in terms of age, gender, race, religion or belief, sexual orientation, disability.
If the main impact is patients and public, demographic data should be collated.
2.2
Which stakeholders have been involved / consulted in the development of the
proposal?
(Those who are directly affected by the policy or external bodies with an interest in this proposals
impact.)
Community Care teams and Community hospital staff
2.3
2.4
Summary of data/responses
A summary of all data is required here. Specific data relating to each equality strand will be
required within each equality review in the Full Assessment.
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Eliminate
discrimination?
Promote equality of
opportunity?
Race
yes
yes
Promote good
relations between
people of the
same or of
different groups?
yes
yes
yes
yes
Disability
yes
yes
yes
Gender
yes
yes
yes
Age
yes
yes
yes
Sexual Orientation
yes
yes
yes
If an impact is anticipated a Full Assessment for the relevant equality strand will need
completing.
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4.1
State specifically which minority community are affected (or state all)?
travellers
asylum seekers
people for whom language is
a barrier
refugees
religious and faith groups
those involved in the criminal
justice system
4.2
4.3
immigrants
homeless people
People from different racial or
ethnic groups
What is the anticipated impact of the proposal on the identified minority communities?
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FULL ASSESSMENT
5 Disability Equality Review
5.1
mobility disabilities
older people
5.2
What is the anticipated impact of the proposal on those people with a disability?
5.3
5.4
5.5
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FULL ASSESSMENT
6
6.1
men
women
boys
girls
lesbian
gay
bi-sexual
transgender
pregnant women
people with caring
those on low incomes
other please state
responsibilities
6.2
What is the impact of the proposal on gender, age and sexual orientation issues?
6.3
6.4
6.5
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7.1
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Proposed Actions
It is proposed that the policy is implemented and disseminated to all managers and staff at the earliest
opportunity
7.2
7.4
Policy Group
7.5
7.6
This paper does not have any impact however will be monitored by Datix
Impact assessing this proposal will be an ongoing process
As more data becomes available it will be added to the Assessment as appropriate
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