Subcutaneous infusion or hypodermoclysis: a practical approach

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).

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

INTRODUCTION

The subcutaneous (SC) route has recently emerged as a rehydration method with potential advantages in the geriatric population. Nevertheless, little is known about its application during hospitalization. The objective of the present study is to evaluate the subcutaneous non-inferiority efficacy in hydration against the intravenous (IV) route in elderly patients with dehydration.

MATERIAL AND METHODS

A prospective, randomized and controlled interventional trial of patients 65 years and older admitted to an Acute Geriatric Unit with mild to moderate dehydration and oral intolerance, evaluating the non-inferiority of subcutaneous fluid therapy versus the intravenous route. The intervention consisted of the administration of up to 1.5 l/day/route for 72 hours subcutaneous vs. intravenous, evaluating the variations in biochemical parameters (urea, creatinine, osmolarity), clinical outcome, and route related complications.

RESULTS

Sixty seven patients completed the study (34 SC, age 86.4 ± 8.5 years, 41% women, vs. 33 IV, 84.3 ± 6.6, 54.5% women, with no significant differences). The amount of fluid administered per day by route was 1.320 ml ± 400 SC vs. 1.480 ml ± 340 IV, P = .092. During follow similar reductions were observed between groups without any statistical significance, with mean differences pre-postintervention of urea (49.6 ± 52.3 SC vs. 50.3 ± 52.3 IV, P=.96); creatinine (0.68 ± 0.66 SC vs. 0.60 ± 0.49 IV, P=.58), and osmolarity (15.6 ± 24.4 SC vs. 21.1 ± 31 IV, P=.43). Fewer catheter extraction episodes were observed in the SC group, which also was the group most prone to peri-clysis edema.

CONCLUSIONS

The efficacy of subcutaneous rehydration in elderly hospitalized patients with mild-moderate dehydration is not inferior to that obtained intravenously, and may even have additional advantages.

Safety and pharmacokinetics of subcutaneous ceftriaxone administered with or without recombinant human hyaluronidase (rHuPH20) versus intravenous ceftriaxone administration in adult volunteers

OBJECTIVE

To compare pharmacokinetics and safety of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous (SC) ceftriaxone administration versus SC ceftriaxone preceded by SC saline placebo or intravenous (IV) ceftriaxone administration.

RESEARCH DESIGN AND METHODS

This Phase I, two-part, placebo-controlled, crossover study was conducted in 54 healthy volunteers. In Part 1 (N = 24), subjects received 1 mL rHuPH20 (150 USP units) or placebo (0.9% sodium chloride) SC, followed by 1 or 2 g ceftriaxone (10-350 mg/mL). In Part 2 (N = 30), subjects received 1 g ceftriaxone at the Part 1 maximum tolerated concentration (MTC) administered either SC - preceded by SC rHuPH20 or placebo - or IV. Subjects were monitored for adverse events (AEs); blood samples were obtained (Part 2 only) during 48 hours post-dosing for ceftriaxone bioanalysis.

MAIN OUTCOME MEASURES

Part 1 primary endpoint was the SC ceftriaxone (with or without rHuPH20) MTC. Pharmacokinetic parameters were determined in Part 2. Bioequivalence was based on maximum concentration (C(max)) and area under plasma concentration-time curve (AUC).

RESULTS

The highest SC ceftriaxone concentration tested in Part 1 (350 mg/mL) was selected as the Part 2 MTC. In Part 2, median time to maximum concentration (t(max)) was 1 hour earlier (P < 0.0001), and C(max) was 12% higher (P < 0.0001) for ceftriaxone (350 mg/mL) administered via rHuPH20-facilitated SC versus SC preceded by placebo. IV ceftriaxone led to higher C(max) and shorter t(max) values than either SC treatment. Ceftriaxone exposure (AUC) was comparable among all three treatments. At least 1 AE was experienced by 100% of subjects after SC ceftriaxone and 76% after IV; most commonly reported AEs were infusion-site reactions.

CONCLUSIONS

Ceftriaxone AUC did not differ significantly between the three administration routes. C(max) was higher and t(max) shorter with rHuPH20-facilitated SC than SC preceded by placebo. rHuPH20-facilitated SC ceftriaxone was generally well tolerated. This study is limited by evaluation of healthy adults and absence of repeated-dose groups.

Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration

OBJECTIVES

The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age.

METHODS

Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration.

RESULTS

Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied.

CONCLUSIONS

rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

Scientific basis for the use of hypotonic solutions with ultrasonic liposuction

BACKGROUND

A number of plastic surgeons have advocated using hypotonic solution in ultrasound lipoplasty, theorizing that induced adipocyte swelling increases membrane susceptibility to ultrasonic disruption. Additionally, it has been theorized that potassium increases membrane permeability. This study aimed to determine the effect of solution osmolality on adipocyte diameter, the time course of hypotonic solution action, and the effect of potassium addition on adipocyte diameter.

METHODS

Base solutions with three different osmolalities were prepared: normal saline (NS) (154 mOsm/l), 1/2NS (77 mOsm/l), and 1/4NS (38.5 mOsm/l). Each solution was modified to contain 0, 5, and 10 mEq/l of potassium and adjusted to starting osmolality. Adipocytes of six patients were suspended in the nine solutions, and diameters were determined at 0, 15, 30, and 45 min. Diameters were measured using imaging software (Kodak ID 3.6).

RESULTS

At time 0, the average adipocyte diameter was 79 +/- 8 microm, and no difference was seen in any of the solutions. Cells in the NS group showed no significant increase in diameter over 45 min. The 1/2NS group achieved an 8% +/- 1.9% increase in diameter at 45 min (p < 0.05). The 1/4NS group showed an increase by 14% +/- 2.4% (p < 0.01) at 15 min, and 15% +/- 2.3% (p < 0.01) at 45 min. Potassium had no independent effect on cell diameter.

CONCLUSIONS

Hypotonic solution can significantly increase human adipocyte diameter. The findings showed that 1/2NS had a significant effect within 15 min. Tumescent solutions with an osmolality of 1/4NS may be useful in facilitating ultrasonic lipoplasty.

L'hypodermoclyse : intérêts et indications en gériatrie

PURPOSE

Older people are at high risk of dehydration. Oral intakes are often inadequate routinely. Intravenous infusion may be difficult in these patients and harmful. Subcutaneous infusion or hypodermoclysis is a useful technique for the cure of a moderate dehydration in elderly patients and especially for its prevention. Moreover, this technique is of great interest in end-life patients.

CURRENT KNOWLEDGE AND KEY POINTS

When it is used correctly and when its contraindications are respected (emergency situations), hypodermoclysis is a simple, safe, sure, effective and comfortable technique. It does not need trained supervision and can be used both in an institution and at home, thus avoiding hospitalization of older subjects and reducing health costs. This technique has considerable benefits both psychologically and financially.

FUTURE PROSPECTS AND PROJECTS

The numerous advantages of hypodermoclysis should encourage its wider use in older patients at home as well as in institutions. Moreover, new indications need to be evaluated. In this way, subcutaneous infusion of therapeutics or prevention of protein-energy malnutrition by hypodermoclysis of amino acids need further investigations.

Strategies for Ensuring Good Hydration in the Elderly

Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary.

Subcutaneous administration of drugs in the elderly: survey of practice and systematic literature review

OBJECTIVES AND METHOD

Survey of subcutaneous drug use and hypodermoclysis with a standardized questionnaire to 27 nursing teams and 52 physicians in a geriatric hospital department (404 beds). Evaluation of license status (CH, F, D and UK) and systematic literature review of 34 drugs used in the geriatric setting.

RESULTS

Subcutaneous route is used daily with drugs and fluids mostly for patients in palliative care (83%) or who are dehydrated (54%) when oral or IV administration is impossible (73%, 68% respectively). Morphine (98%), haloperidol (90%), furosemide (69%) and hydromorphone (56%) by bolus (36%) or slow injection over 5 min (82%) are the main drugs used and NaCI 0.9% (95%), and glucose 5%/NaCI 0.9% (31 %) are commonly used for rehydration. Among the 34 drugs reviewed, only 13 (38%) are licensed for subcutaneous use in CH, UK, F or D, and only, morphine (14 articles of 68) and rehydration (six articles) are evaluated in high level studies. Haloperidol and furosemide are used off-label and there are no well-designed studies supporting their subcutaneous use.

CONCLUSION

There is a lack of information on drugs widely used by subcutaneous route in the elderly. In that context, physicians carry responsibility for the prescription.

Hypodermoclysis (subcutaneous infusion) effective mode of treatment of dehydration in long-term care patients

Dehydration is associated with morbidity and mortality in frail elderly patients. Intravenous fluid administration in these patients is sometimes hard, especially in agitated patients. The purpose of this study was to review of 57 long-termed care patients received hypodermoclysis infusion on 118 different occasions during the 9 months. Data collection included: demographic data, functional and mental status, indication hypodermoclysis, duration of the infusion, type of solution, laboratory data, adverse effects, and outcome. The main reasons for initiation of the hypodermoclysis were either dehydration (64%) or febrile illness (21%). The average duration of infusions was 15.9 days and average daily volume was 1161 ml per day. After hydration by hypodermoclysis, in 77% of the patients, clinical improvement occurred manifested as general improvement (88%), cognitive status improvement (84%), and improved oral intake (81%). During the course of the study, failure of the treatment was observed in 12% of the patients, mortality of 11% was observed. Nobody developed signs of fluid overload. Local complications were reported in 12% of patients: local swelling (6/57), complain of local pain at site (3/57) and local inflammation (2/57). Hypodermoclysis is a safe, effective and suitable alternative to intravenous re-hydration in long-term care patients.

Continuous subcutaneous infusion practices of United States hospices

In hospice organizations, continuous subcutaneous infusion (CSI) is a common medication delivery modality for pain management. Nonetheless, little is known regarding the practices of hospice organizations in their utilization of this technique. We surveyed 3,930 hospice organizations to describe indication, diluents, medications, and other variable factors associated with CSI utilization. Of the 3,930 surveys sent, 907 were returned, yielding a response rate of 24%. Seventy-three percent of hospice organizations surveyed indicated they utilized CSI. The average daily census (ADC) of these hospices was 38.6 +/- 61.0. The most common indication for CSI use was palliative management (95%). The most common medication used in CSI was morphine sulfate (97%). These results indicate that CSI utilization may be widespread in hospices and further study regarding this delivery system is warranted.

Hypodermoclysis for rehydration in the community

During 1999 and 2000 the practice development unit of Greater Glasgow Primary Care Trust received an increasing number of requests from community staff for guidance in caring for patients receiving subcutaneous fluids for rehydration. This article describes the process of developing guidelines in order to address the issue. Hypodermoclysis is a relatively safe, simple and cost-effective technique, suitable for use in the community with a range of client groups, e.g. older people or those recovering from recent cardiovascular accidents. Its use in palliative care, however, raises problems in terms of clinical evidence and ethical issues which need to be addressed. Various factors, i.e. products not being licensed for this specific use, staff requests for clinical guidance and the anticipated increasing use of hypodermoclysis for rehydration, all indicated the need for a collaborative approach, address the complexity of issues in the decision-making process and provide clinical guidance with the aim of improving nursing practice and patient outcomes.

Subcutaneous fluid infusion in a long-term care setting

OBJECTIVE

To study the use of hypodermoclysis in a long-term care setting for chronic fluid supplementation and to compare it to intravenous (IV) fluid in the treatment of acute mild to moderate dehydration.

DESIGN

A prospective observational study.

PARTICIPANTS

Fifty-five residents of a long-term care facility treated with fluid therapy during a 5-week period.

MAIN OUTCOME MEASURES

Efficacy of hydration and adverse effects were obtained from detailed chart review, interviews with healthcare providers, and investigators' observations.

RESULTS

The study subjects were frail older people. Hypodermoclysis was used for maintenance fluid needs in 24 residents; none of these residents required any additional fluid therapy for dehydration. In addition, 37 residents received fluids for acute dehydration. In these residents, hypodermoclysis was associated with clinical improvement in 57% and no clinical change in 25%. Recipients of IV fluids improved 81% of the time and the remainder were unchanged. Hypodermoclysis was associated with fewer fluid therapy-related complications relative to IV therapy (P = .04).

CONCLUSIONS

Hypodermoclysis is an effective procedure for providing fluids for both chronic maintenance needs and acute situations associated with mild to moderate dehydration in a long-term care setting. Hypodermoclysis appears safer and can avoid transfers to hospital for rehydration.