[Efficacy of the subcutaneous route compared to intravenous hydration in the elderly hospitalised patient: a randomised controlled study]

Factors Associated With the Occurrence of Adverse Effects Resulting From Hypodermoclysis in Older Adults in Palliative Care: A Cohort Study

This study aimed to analyze the factors associated with local adverse effects resulting from hypodermoclysis in older adult patients in palliative care. The study involved 127 older adults undergoing palliative care at a hospital in southeastern Brazil. Data collection was performed from August to November 2019. Patients aged 60 years or older, with a prescription for hypodermoclysis at the time of admission and who were not receiving hypodermoclysis at the time of admission, were included. Data collected included sociodemographic, clinical, pharmacotherapeutic, and adverse effects of hypodermoclysis administration. Most participants were women (59.0%), with a mean age of 78.5 years. Frailty was the most prevalent diagnosis (26.8%), and 80.2% of patients were in the end-of-life stage. There was an incidence of 24.0% of adverse events, with catheter obstruction and swelling in the surrounding area of the hypodermoclysis site being the most frequent at 11.3% and 8.5%, respectively. Ondansetron administration by hypodermoclysis was 3 times more likely to have an adverse effect compared to not using this drug. In contrast, a protective factor was evident with the administration of 0.9% sodium chloride, which contributed to the reduction of complications. The occurrence of adverse effects from hypodermoclysis in the study population of older adults in palliative care was low.

Comparison of feasibility between hypodermoclysis and intravenous hydration among palliative care patients in Thailand

BACKGROUND

Hypodermoclysis is a method of subcutaneous fluid administration. It has been used to treat palliative patients safely and effectively. However, the use of subcutaneous hydration is often overlooked.

AIM

This study aimed to compare the feasibility, pain experience and acceptability between subcutaneous and intravenous hydration in a hospital setting.

METHODS

A prospective, randomised clinical trial was conducted. Patients requiring fluid administration were randomly allocated an intravenous or subcutaneous route. Patients' pain score, satisfaction and acceptance levels were collected. The difficulty score of the needle insertion and acceptance scores from nurses were recorded.

FINDINGS

A total of 26 patients were enrolled. The difficulty scores and patients' pain scores were significantly lower in the subcutaneous group. The satisfaction and acceptance levels of the patients and nurses were similar in both groups. No systemic side-effects were found in either group.

CONCLUSION

Hypodermoclysis was acceptable and satisfying to patients and nurses. It was less painful than the intravenous route.

Investigating the benefits and harms of hypodermoclysis of patients in palliative care: A consecutive cohort study

BACKGROUND

Palliative populations are at risk for dehydration which can cause discomfort, distress and cognitive symptoms. Subcutaneous hydration ('hypodermoclysis') has been used as an alternative administration route to the more invasive intravenous route, but research is lacking on its net clinical effects (harms and benefits) for palliative populations, particularly in real world settings.

AIM

To quantify prospectively the net clinical effects of hypodermoclysis in palliative patients with advanced disease who required supplementary fluids.

DESIGN

Multisite, multinational consecutive cohort study.

SETTING/PARTICIPANTS

Patients receiving hypodermoclysis in an inpatient palliative care setting.

RESULTS

Twenty sites contributed data for 99 patients, of which 88 had complete benefits and harms data. The most common primary target symptom for infusion was generalised weakness (18.2%), and the most common non-symptom indication was supplemental hydration (31.8%). Benefits were experienced in 33% of patients in their primary target symptom, and in any symptom in 56.8%. Harms were experienced in 38.7% of patients (42% at Grade 1). Benefits increased with higher performance status, while harms were more frequent in patients with lower performance status (Australia-modified Karnofsky performance status ⩽40). Patients in the terminal phase of their illness experienced the least benefit (15.4% in any indication only) and had more frequent harms (38%).

CONCLUSIONS

Hypodermoclysis may improve certain symptoms in patients in palliative care but frequency of harms and benefits may differ at certain timepoints in the illness trajectory. Further research is needed to better delineate which patients will derive the most net clinical benefit from hypodermoclysis.

Adverse effects of subcutaneous vs intravenous hydration in older adults: An assessor-blinded randomised controlled trial (RCT)

BACKGROUND

Hydration therapy is essential in the care of the older patient. Subcutaneous (SC) hydration is a relevant method for parenteral hydration, but clinical trials on the subject have methodological shortcomings compared to updated standards.

DESIGN

Assessor-blinded, non-inferiority RCT to explore if SC is a safe alternative to intravenous (IV) hydration.

PARTICIPANTS

Eligible patients were: Admitted patients 65 years or older with a need for parenteral hydration. The targeted sample size was 67 patients in each group.

INTERVENTION

Patients were randomised to parenteral hydration via an IV or SC catheter during a 24 hours observation period. The non-randomised catheter (inactive) was placed as a sham on the patient, thereby blinding the caregivers and outcome assessors.

MEASUREMENT

Our primary outcome was the proportion of patients reporting at least one adverse effect with a non-inferiority calculation using a 20% margin.

RESULTS

We included 51 patients, with 24 randomised to SC and 27 to IV. We were unable to reach our target sample size due to challenges in recruitment, time limitation, and COVID-19. For the outcome of adverse effects, SC was non-inferior to IV (p = 0.012). Time spent on inserting the catheters was shorter with SC (p = 0.001). The groups did not differ by pain of insertion, discomfort during infusion, or the risk of developing delirium.

CONCLUSION

SC is a safe alternative to IV hydration, is faster to place and should be an available method for parenteral hydration wherever older adults are cared for.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03710408.

Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews

OBJECTIVE

To synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality.

INTRODUCTION

Peripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route.

METHODS

Systematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation.

RESULTS

The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery.

CONCLUSION

Subcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.

Harms and Benefits of Subcutaneous Hydration in Older Patients: Systematic Review and Meta-Analysis

OBJECTIVE

To review all available original publications on the harms and benefits of subcutaneous (SC) hydration in older patients.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

All studies on SC hydration in older patients without restrictions on design or language.

MEASUREMENTS

The Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Web of Science databases and trial registries were searched from inception to November 5, 2019, and two reviewers independently extracted the data and assessed the risk of bias of individual outcomes.

RESULTS

Thirty-one publications from 29 studies met the eligibility criteria. The data from six randomized controlled trials were used for the meta-analyses. The subgroup analysis including only the studies with the lowest risk of bias showed that SC hydration was associated with fewer adverse effects than intravenous (IV) hydration (risk ratio (RR) = 0.69; 95% confidence interval (CI) = 0.53-0.88; P = .003; n = 4; I² = 0.0%; 545 infusions in each group). In absolute numbers, patients treated with SC hydration had an incidence rate of 90 adverse effects per 1,000 infusions versus 130 adverse effects per 1,000 infusions (95% CI = 102-169) with IV hydration. Secondary outcomes comparing IV with SC hydration showed that SC was 3.2 minutes faster to set up and markedly reduced the risk of agitation (RR = 0.42; 95% CI = 0.22-0.79; P = .007; I² = 65%; n = 3); however, SC hydration delivered a lower volume of fluid and was less efficient at reducing serum osmolality (s-osmolality).

CONCLUSIONS

SC hydration is safer than IV hydration and potentially reduces the risk of agitation, but it is less effective. SC hydration should be available as an alternative to IV hydration when treating older patients for mild-to-moderate dehydration. More high-quality studies are needed in the field to increase the confidence in the estimates.

Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review

Subcutaneous infusion, or hypodermoclysis, is a technique whereby fluids are infused into the subcutaneous space via small-gauge needles that are typically inserted into the thighs, abdomen, back, or arms. In this review, we provide an overview of the technique, summarize findings from studies that have examined the use of subcutaneous infusion of fluids for hydration or nutrition, and describe the indications, advantages, and disadvantages of subcutaneous infusion. Taken together, the available evidence suggests that, when indicated, subcutaneous infusion can be effective for administering fluids for hydration or nutrition, with minimal complications, and has similar effectiveness and safety to the intravenous route. Of note, subcutaneous infusion offers several advantages over intravenous infusion, including ease of application, low cost, and the lack of potential serious complications, particularly infections. Subcutaneous infusion may be particularly suited for patients with mild to moderate dehydration or malnutrition when oral/enteral intake is insufficient; when placement of an intravenous catheter is not possible, tolerated, or desirable; at risk of dehydration when oral intake is not tolerated; as a bridging technique in case of difficult intravenous access or catheter-related bloodstream infection while infection control treatment is being attempted; and in multiple settings (eg, emergency department, hospital, outpatient clinic, nursing home, long-term care, hospice, and home).

Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study

BACKGROUND

Evidence indicates that hypodermoclysis is as safe and effective as intravenous rehydration in the treatment of the symptomatology produced by mild to moderate dehydration in patients for whom oral route administration is not possible. However, the knowledge about the use of the subcutaneous hydration and its correlates is still limited.

AIM

To explore the perceptions, attitudes and opinions of health professionals in palliative care on the administration of subcutaneous hydration.

DESIGN

This is a qualitative focus group study with health professionals of palliative care. Four focus groups were carried out until data saturation. A qualitative content analysis was performed.

SETTING/PARTICIPANTS

A total of 37 participants, physicians and nurses, were recruited from different services of palliative care in Spain.

RESULTS

In all, 856 meaning units were identified, from which 56 categories were extracted and grouped into 22 sub-themes, which were distributed among four themes: 'factors which influence the hydration decision', 'factors related to the choice of the subcutaneous route for hydration', 'the subcutaneous hydration procedure' and 'performance guidelines and/or protocols'.

CONCLUSIONS

Variables which most often influence the use of subcutaneous route to hydration are those that are linked to the characteristics of the patient, the team and the family, and other like the context and professionals' subjective perceptions about this medical practice.

Pilot study on the effect of subcutaneous administration of lactated Ringer's solution on biochemistry parameters in healthy euvolemic cats

Subcutaneous fluid administration is a commonly used therapy in veterinary practice. Its safety and efficacy have been demonstrated in human clinical studies, but have only rarely been discussed in the veterinary literature. This prospective observational study was performed to evaluate changes during a 24 h period in serum biochemistries associated with administration of lactated Ringer's solution subcutaneously to healthy cats. Lactated Ringer's solution was administered subcutaneously once to ten healthy, euvolemic cats at a dose of 22 mL kg⁻¹. Blood biochemistry analytes were sampled at baseline and at serial time points for a total of 24 h. Changes in biochemical analytes at each time point were compared to baseline and evaluated for statistical significance. Serum blood urea nitrogen (BUN) was significantly less than baseline at 4, 6, 12, 18, and 24 h post‐infusion. Serum creatinine was significantly less than baseline at 2, 4 and 6 h. Packed cell volume (PCV) was significantly less than baseline at 6, 12, 18, and 24 h. Total plasma proteins were significantly less than baseline at all time points. Serum electrolytes did not change from baseline at any time point. Urine specific gravity was significantly increased from baseline only at 6 h post‐Lactated Ringer's solution (LRS) administration. Subcutaneous administration of lactated Ringer's solution appears to result in haemodilution with minimal change to serum electrolyte concentrations in clinically normal, euvolemic cats.

Subcutaneous fluid and drug delivery: safe, efficient and inexpensive

Patients with difficult venous access or oral intolerance and clinical situations with inadequate response to oral therapy have generated the need for alternative routes of delivery for drugs and fluids.

The purpose of this study was to conduct a systematic review examining the evidence for subcutaneous (SC) administration of drugs and/or fluids.

We used a broad search strategy using electronic databases CINAHL, EMBASE, PubMed and Cochrane library, key terms and ‘Medical Subject Headings’ (MeSH) such as ‘subcutaneous route’, ‘hypodermoclysis’ and the name/group of the most used drugs via this route (e.g. ‘ketorolac, morphine, ceftriaxone’, ‘analgesics, opioids, antibiotics’).

We conclude that the SC route is an effective alternative for rehydration in patients with mild–moderate dehydration and offers a number of potential advantages in appropriately selected scenarios. Experience of administering drugs by this route suggests that it is well tolerated and is associated with minimal side-effects.

Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease

BACKGROUND

Dehydration is an important cause of death in patients with Ebola virus disease (EVD). Parenteral fluids are often required in patients with fluid requirements in excess of their oral intake. The peripheral intravenous route is the most commonly used method of parenteral access, but inserting and maintaining an intravenous line can be challenging in the context of EVD. Therefore it is important to consider the advantages and disadvantages of different routes for achieving parenteral access (e.g. intravenous, intraosseous, subcutaneous and intraperitoneal).

OBJECTIVES

To compare the reliability, ease of use and speed of insertion of different parenteral access methods.

SEARCH METHODS

We ran the search on 17 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE(R) and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), CINAHL (EBSCOhost), clinicaltrials.gov and screened reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing different parenteral routes for the infusion of fluids or medication.

DATA COLLECTION AND ANALYSIS

Two review authors examined the titles and abstracts of records obtained by searching the electronic databases to determine eligibility. Two review authors extracted data from the included trials and assessed the risk of bias. Outcome measures of interest were success of insertion; time required for insertion; number of insertion attempts; number of dislodgements; time period with functional access; local site reactions; clinicians' perception of ease of administration; needlestick injury to healthcare workers; patients' discomfort; and mortality. For trials involving the administration of fluids we also collected data on the volume of fluid infused, changes in serum electrolytes and markers of renal function. We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach for the following outcomes: success of insertion, time required for insertion, number of dislodgements, volume of fluid infused and needlestick injuries.

MAIN RESULTS

We included 17 trials involving 885 participants. Parenteral access was used to infuse fluids in 11 trials and medications in six trials. None of the trials involved patients with EVD. Intravenous and intraosseous access was compared in four trials; intravenous and subcutaneous access in 11; peripheral intravenous and intraperitoneal access in one; saphenous vein cutdown and intraosseous access in one; and intraperitoneal with subcutaneous access in one. All of the trials assessing the intravenous method involved peripheral intravenous access.We judged few trials to be at low risk of bias for any of the assessed domains.Compared to the intraosseous group, patients in the intravenous group were more likely to experience an insertion failure (risk ratio (RR) 3.89, 95% confidence interval (CI) 2.39 to 6.33; n = 242; GRADE rating: low). We did not pool data for time to insertion but estimates from the trials suggest that inserting intravenous access takes longer (GRADE rating: moderate). Clinicians judged the intravenous route to be easier to insert (RR 0.15, 95% CI 0.04 to 0.61; n = 182). A larger volume of fluids was infused via the intravenous route (GRADE rating: moderate). There was no evidence of a difference between the two routes for any other outcomes, including adverse events.Compared to the subcutaneous group, patients in the intravenous group were more likely to experience an insertion failure (RR 14.79, 95% CI 2.87 to 76.08; n = 238; GRADE rating: moderate) and dislodgement of the device (RR 3.78, 95% CI 1.16 to 12.34; n = 67; GRADE rating: low). Clinicians also judged the intravenous route as being more difficult to insert and patients were more likely to be agitated in the intravenous group. Patients in the intravenous group were more likely to develop a local infection and phlebitis, but were less likely to develop erythema, oedema or swelling than those in the subcutaneous group. A larger volume of fluids was infused into patients via the intravenous route. There was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine if the risk of insertion failure differed between the saphenous vein cutdown (SVC) and intraosseous method (RR 4.00, 95% CI 0.51 to 31.13; GRADE rating: low). Insertion using SVC took longer than the intraosseous method (MD 219.60 seconds, 95% CI 135.44 to 303.76; GRADE rating: moderate). There were no data and therefore there was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine the relative effects of intraperitoneal or central intravenous access relative to any other parenteral access method.

AUTHORS' CONCLUSIONS

There are several different ways of achieving parenteral access in patients who are unable meet their fluid requirements with oral intake alone. The quality of the evidence, as assessed using the GRADE criteria, is somewhat limited because of the lack of adequately powered trials at low risk of bias. However, we believe that there is sufficient evidence to draw the following conclusions: if peripheral intravenous access can be achieved easily, this allows infusion of larger volumes of fluid than other routes; but if this is not possible, the intraosseous and subcutaneous routes are viable alternatives. The subcutaneous route may be suitable for patients who are not severely dehydrated but in whom ongoing fluid losses cannot be met by oral intake.A film to accompany this review can be viewed here (http://youtu.be/ArVPzkf93ng).