1
|
Volkert D, Beck AM, Faxén-Irving G, Frühwald T, Hooper L, Keller H, Porter J, Rothenberg E, Suominen M, Wirth R, Chourdakis M. ESPEN guideline on nutrition and hydration in dementia - Update 2024. Clin Nutr 2024; 43:1599-1626. [PMID: 38772068 DOI: 10.1016/j.clnu.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.
Collapse
Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Germany.
| | - Anne Marie Beck
- Dietetic and Nutritional Research Unit, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Gerd Faxén-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Hietzing Municipal Hospital, Vienna, Austria
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Heather Keller
- Department of Kinesiology & Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Canada; Schlegel-UW Research Institute for Aging, Waterloo, Canada
| | - Judi Porter
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Elisabet Rothenberg
- Department of Nursing and Integrated Health Sciences, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Merja Suominen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| |
Collapse
|
2
|
Broadhurst D, Cooke M, Sriram D, Barber L, Caccialanza R, Danielsen MB, Ebersold SL, Gorski L, Hirsch D, Lynch G, Neo SHS, Roubaud-Baudron C, Gray B. International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration and Medication in Adults: An e-Delphi Consensus Study. JOURNAL OF INFUSION NURSING 2023; 46:199-209. [PMID: 37406334 PMCID: PMC10306332 DOI: 10.1097/nan.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Infusion of fluids and medications is traditionally performed intravenously. However, venous depletion in patients has led to the quest for vessel health preservation. A safe, effective, acceptable, and efficient alternative is the subcutaneous route. A lack of organizational policies may contribute to the slow uptake of this practice. This modified e-Delphi (electronic) study aimed to derive international consensus on practice recommendations for subcutaneous infusions of fluids and medications. A panel of 11 international clinicians, with expertise in subcutaneous infusion research and/or clinical practice, rated and edited subcutaneous infusion practice recommendations from evidence, clinical practice guidelines, and clinical expertise within an Assessment, Best Practice, and Competency (ABC) domain guideline model. The ABC Model for Subcutaneous Infusion Therapy provides a systematic guideline of 42 practice recommendations for the safe delivery of subcutaneous infusions of fluids and medications in the adult population in all care settings. These consensus recommendations provide a guideline for health care providers, organizations, and policy makers to optimize use of the subcutaneous access route.
Collapse
Affiliation(s)
- Daphne Broadhurst
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Marie Cooke
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Deepa Sriram
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Lauren Barber
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Riccardo Caccialanza
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Mathias Brix Danielsen
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Stacie Lynne Ebersold
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Lisa Gorski
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - David Hirsch
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Gerardine Lynch
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Shirlyn Hui-Shan Neo
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Claire Roubaud-Baudron
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| | - Brenda Gray
- Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Gold Coast, Queensland, Australia (Mss Broadhurst, Cooke, and Sriram); Infusion Excellence Consulting, Ottawa, Ontario, Canada (Ms Broadhurst); School of Nursing and Midwifery, Nathan Campus, Griffith University, Nathan, Queensland, Australia (Ms Cooke); Needle Calm Pty, Melbourne, Victoria, Australia (Ms Barber); Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (Mr Caccialanza); Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark [ORCID https://orcid.org/0000-0001-7431-5257] (Mr Danielsen); Optum Complex Care Management, Horsham, Pennsylvania (Ms Ebersold); Ascension at Home, Indianapolis, Indiana (Ms Gorski); The Johns Hopkins Home Care Group, Baltimore, Maryland (Mr Hirsch); Centre for Nurse Education, Cork University Hospital, Cork, Ireland (Ms Lynch); FAMS Institution: Division of Supportive and Palliative Care, National Cancer Centre, Singapore (Ms Neo); Roubaud CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France (Ms Roubaud-Baudron); Clinical Pharmacy Partners, Tampa, Florida (Ms Gray)
| |
Collapse
|
3
|
Chanthong P, Siriwattanakul S, Srion C. Comparison of feasibility between hypodermoclysis and intravenous hydration among palliative care patients in Thailand. Int J Palliat Nurs 2022; 28:308-312. [PMID: 35861446 DOI: 10.12968/ijpn.2022.28.7.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Pratamaporn Chanthong
- Palliative Physician, Siriraj Palliative Care Center, Faculty of Medicine Siriraj Hospital, Thailand
| | - Suphawan Siriwattanakul
- Medicine Physician and Rheumatologist, Golden Jubilee Medical Center, Mahidol University, Thailand
| | - Chawalee Srion
- Clinical Nurse Manager, Golden Jubilee Medical Center, Mahidol University, Thailand
| |
Collapse
|
4
|
ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr 2022; 41:958-989. [DOI: 10.1016/j.clnu.2022.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/15/2022]
|
5
|
Adem S, ALMouaalamy N. Effectiveness and Safety of Hypodermoclysis Patients With Cancer: A Single-Center Experience From Saudi Arabia. Cureus 2021; 13:e13785. [PMID: 33728227 PMCID: PMC7946612 DOI: 10.7759/cureus.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Decreased intake of food or fluid causes dehydration in hospitalized adult patients. This has led to a negative impact on patients and increased the morbidity and mortality rate at the Princess Noorah Oncology Center, where patients with advanced cancer who suffer from dehydration have been treated with parenteral fluids until the date of discharge from the hospital. Objective: The objective of this pilot study is to assess the effectiveness and safety of hypodermoclysis (HDC) to close the gap of treatment for home-based palliative patients with cancer. Method: During home visits, the home health care (HHC) nurse assessed these patients through history and physical examination for dehydration. Our team also incorporated the Edmonton Symptom Assessment System revised (ESAS-r) Scale in the assessment of these patients' symptoms. Informed consent has been obtained from the patient and the caregiver. The trained nurses initiated the subcutaneous infusion. The caregivers monitored it and disconnected it when completed. The study population consists of palliative patients with advanced cancer under the services of palliative care. Effectiveness and safety have been assessed using the ESAS-r scale. Results: A total of 25 (92.6%) HDC treatments were successfully completed for nine patients (seven males and two females). One female patient had only one session because her health had deteriorated for reasons other than dehydration and was transferred to the hospital. No serious side effects were observed. One (3.6%) patient developed redness at the site of cannula insertion. The mean duration of the infusions was 8.44 hours. The median age was 70 years. Conclusion: This study has concluded that HDC is effective, safe, and can enhance the patient’s comfort level without the need for hospitalization. The fact that HDC can be administered at home with minimum equipment and technical support makes it an ideal option in several countries with varied income settings.
Collapse
Affiliation(s)
- Sittelbenat Adem
- Nursing, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah, SAU
| | - Nabil ALMouaalamy
- Oncology Department/Palliative, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah, SAU.,Research, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| |
Collapse
|
6
|
Broadhurst D, Cooke M, Sriram D, Gray B. Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews. PLoS One 2020; 15:e0237572. [PMID: 32833979 PMCID: PMC7446806 DOI: 10.1371/journal.pone.0237572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 07/29/2020] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Daphne Broadhurst
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- Infusion Excellence Consulting, Ottawa, Canada
| | - Marie Cooke
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- School of Nursing and Midwifery, Nathan Campus, Griffith University, Queensland, Australia
| | - Deepa Sriram
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
| | - Brenda Gray
- Clinical Pharmacy Partners, Tampa, Florida, United States of America
| |
Collapse
|
7
|
Coelho TA, Wainstein AJA, Drummond-Lage AP. Hypodermoclysis as a Strategy for Patients With End-of-Life Cancer in Home Care Settings. Am J Hosp Palliat Care 2020; 37:675-682. [DOI: 10.1177/1049909119897401] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background:The increase in the elderly population associated with a higher incidence of cancer strongly endorses palliative care (PC). Hypodermoclysis (HDC) is a feasible technique for drugs and fluids delivery at the home care setting.Objectives:To assess the use and benefits of HDC in patients with end-of-life cancer assisted by a single home-based palliative care program (HPCP) in Belo Horizonte, Brazil.Methods:This was a retrospective study that analyzed medical charts from patients with end-of-life cancer who were assisted by an HPCP in a 1-year period of time.Results:A total of 333 patients, 81.7% with advanced cancer, were included. The most frequent symptoms were fatigue (44.4%) and pain (43.2%). Hypodermoclysis was used in 77.5% of the patients for the administration of fluids or medicines. Continuous palliative sedation was applied to 70.5% of patients. The place of death was home for 90.2% of the patients.Conclusion:Receiving home care assistance with palliative intention may decrease the need for dying patients with cancer to visit emergency units, as their symptoms were well controlled. Hypodermoclysis was a safe and effective alternative for hydration and drug delivery when provided and supervised by an experienced team. The place of death is a reliable indicator of the quality of death, and, in this study, the HPCP allowed patients to die at home with their families. It is essential for PC professionals to understand the impact of HDC use at home care setting for patients with end-of-life cancer allowing the increase of quality of death indicators.
Collapse
Affiliation(s)
- Tatiana A. Coelho
- Post Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | | | - Ana P. Drummond-Lage
- Post Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| |
Collapse
|
8
|
ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 2018; 38:10-47. [PMID: 30005900 DOI: 10.1016/j.clnu.2018.05.024] [Citation(s) in RCA: 642] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. AIM To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. METHODS This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. RESULTS We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. CONCLUSION A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.
Collapse
|
9
|
Caccialanza R, Constans T, Cotogni P, Zaloga GP, Pontes-Arruda A. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. JPEN J Parenter Enteral Nutr 2018; 42:296-307. [PMID: 29443395 DOI: 10.1177/0148607116676593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/04/2016] [Indexed: 11/17/2022]
Abstract
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).
Collapse
Affiliation(s)
- Riccardo Caccialanza
- Servizio di Dietetica e Nutrizione Clinica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thierry Constans
- Service de Médecine Gériatrique, Centre Hospitalier Régional Universitaire and Université François Rabelais, Tours, France
| | - Paolo Cotogni
- Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
| | | | | |
Collapse
|
10
|
Forbat L, Kunicki N, Chapman M, Lovell C. How and why are subcutaneous fluids administered in an advanced illness population: a systematic review. J Clin Nurs 2017; 26:1204-1216. [PMID: 27982484 DOI: 10.1111/jocn.13683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To identify the mechanisms of subcutaneous fluid administration in advanced illness. BACKGROUND Hydration at end of life is a fundamental issue in quality care internationally. Decision-making regarding the provision of artificial hydration in advanced illness is complicated by a paucity of evidence-based guidance. Despite considerable attention given to the topic including two recent Cochrane reviews, there has been no focus in systematically identifying papers that report the mechanisms for delivering hydration subcutaneously. Consequently, there is a need to produce guidance on the site, mode, volume and rate of infusion, based on empirical evidence. DESIGN Systematic review of papers reporting empirical research data. METHODS Key databases (CENTRAL, Medline, EMBASE, Web of Science, CINAHL) were searched in September 2015, with no date limitations. Inclusion criteria focused on hypodermoclysis in adults within an advanced illness population. Selected studies were reviewed for quality and a risk-of-bias assessment was conducted for the included studies. RESULTS Fourteen papers were included in the analysis; most (n = 8) were conducted in hospices with others (n = 6) in long-stay units with a population affected by chronic conditions associated with ageing. Studies were of moderate or high quality. The site and mode of infusion were not well described in these papers, and rates of infusion varied widely allowing for little clear consensus to guide clinical practice in the administration of subcutaneous fluids. CONCLUSIONS Studies under-report the mechanisms by which artificial hydration is provided, creating a paucity of evidence-based guidance by which to practice. There is a need for evidence generated from nonmalignant populations to ensure applicability to the large number of people with other advanced illness. RELEVANCE TO CLINICAL PRACTICE In the absence of sufficiently powered robust evidence, the mode of delivery of artificial hydration at end of life remains in the gloaming between evidence and unfounded habit.
Collapse
Affiliation(s)
- Liz Forbat
- Centre of Palliative Care Research, Calvary Health Care and Australian Catholic University, Canberra, ACT, Australia
| | | | | | | |
Collapse
|
11
|
Roubaud-Baudron C, Forestier E, Fraisse T, Gaillat J, de Wazières B, Pagani L, Ingrand I, Bernard L, Gavazzi G, Paccalin M. Tolerance of subcutaneously administered antibiotics: a French national prospective study. Age Ageing 2017; 46:151-155. [PMID: 28181635 DOI: 10.1093/ageing/afw143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 06/15/2016] [Indexed: 11/12/2022] Open
Abstract
Background/ Objective Although poorly documented, subcutaneous (SC) administration of antibiotics is common practice in France especially in Geriatrics Departments. The aim of this study was to determine the tolerance of such a practice. Design Prospective observational multicentre study. Methods Sixty-six physicians accepted to participate from 50 French Infectious Diseases and Geriatrics Departments. From May to September 2014, patients treated at least one day with SC antibiotics could be included. Modalities of subcutaneous administration, occurrence of local and systemic adverse effects (AE) and clinical course were collected until the end of the treatment. Results Two hundred-nineteen patients (83.0 [19–104] yo) were included. Ceftriaxone (n = 163, 74.4%), and ertapenem (n = 30, 13.7%) were the most often prescribed antibiotics. The SC route was mainly used because of poor venous access (65.3%) and/or palliative care (32.4%). Fifty patients (22.8%) experienced at least one local AE that led to an increased hospital stay for two patients (4.0%) and a discontinuation of the SC infusion in six patients (12.0%). A binary logistic regression for multivariate analysis identified the class of antibiotic (p = 0.002) especially teicoplanin and the use of rigid catheter (p = 0.009) as factors independently associated with AE. In over 80% of cases, SC antibiotics were well tolerated and associated with clinical recovery. Conclusions SC administration of antibiotics leads to frequent but local and mild AE. Use of non-rigid catheter appears to be protective against AE. As it appears to be a safe alternative to the intravenous route, more studies are needed regarding efficacy and pharmacokinetics.
Collapse
Affiliation(s)
- Claire Roubaud-Baudron
- Pôle de Gérontologie Clinique, Centre Hospitalier Universitaire - Hôpitaux de Bordeaux, Université de Bordeaux, F-33000 Bordeaux, France
| | - Emmanuel Forestier
- Service de Maladies Infectieuses, Centre Hospitalier Métropole Savoie, F-73000 Chambéry, France
| | - Thibaut Fraisse
- Court Séjour Gériatrique Aigu, Centre Hospitalier Alès-Cévennes, F-30100 Alès, France
| | - Jacques Gaillat
- Service de Maladies Infectieuses, Centre Hospitalier Annecy Genevois, F-74000 Annecy, France
| | - Benoit de Wazières
- Médecine Interne Gériatrique, Centre Hospitalier Universitaire de Nîmes, F-30000 Nimes, France
| | - Leonardo Pagani
- Service de Maladies Infectieuses, Centre Hospitalier Annecy Genevois, F-74000 Annecy, France
| | - Isabelle Ingrand
- Pôle Biologie, Pharmacie et Santé Publique, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, F-86000 Poitiers, France
- INSERM, CIC 1402, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, F-86000 Poitiers, France
| | - Louis Bernard
- Service de Maladies Infectieuses, Centre Hospitalier Régional Universitaire Bretonneau, F-37000 Tours, France
| | - Gaëtan Gavazzi
- Clinique Universitaire de Médecine Gériatrique, Centre Hospitalier Universitaire de Grenoble, F-38000 Grenoble, France
| | - Marc Paccalin
- Pôle de Gériatrie, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, F-86000 Poitiers, France
- Intergroupe SPILF-SFGG
| |
Collapse
|
12
|
Vidal M, Hui D, Williams J, Bruera E. A Prospective Study of Hypodermoclysis Performed by Caregivers in the Home Setting. J Pain Symptom Manage 2016; 52:570-574.e9. [PMID: 27640727 DOI: 10.1016/j.jpainsymman.2016.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 02/01/2016] [Accepted: 04/29/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Decreased oral intake is very common at the end of life. Dehydration can aggravate symptoms, such as fatigue, myoclonus, and confusion. Intravenous hydration at home can be logistically difficult and expensive. Hypodermoclysis is easy to provide and inexpensive; however, it is rarely used to provide hydration at the end of life in the home setting. OBJECTIVES The purpose of this study was to determine if caregivers were capable of administering hypodermoclysis in the home hospice setting. METHODS All caregivers underwent a 45-minute training session on hypodermoclysis administration and assessment of infusion site delivered by a specially trained nurse. Caregivers received daily calls and on-site evaluation on Day 8. RESULTS A total of 21 patient/caregivers dyads were admitted to this preliminary study: 10 (48%) female patients and 16 (76%) female caregivers. All patients had advanced cancer, receiving hospice care at home. All caregivers who received training were able to start the infusion. The infusion was facilitated by gravity or weight. Side effects were minimal with one (5%) because of the care of the needle and leakage. CONCLUSION This preliminary study suggests that subcutaneous hydration could be administered by caregivers at home with minimal burden, equipment, and technical support.
Collapse
Affiliation(s)
- Marieberta Vidal
- University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - David Hui
- University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
13
|
Forestier E, Fraisse T, Roubaud-Baudron C, Selton-Suty C, Pagani L. Managing infective endocarditis in the elderly: new issues for an old disease. Clin Interv Aging 2016; 11:1199-206. [PMID: 27621607 PMCID: PMC5015881 DOI: 10.2147/cia.s101902] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.
Collapse
Affiliation(s)
- Emmanuel Forestier
- Infectious Diseases Department, Centre Hospitalier Métropole Savoie, Chambéry, France
- Correspondence: Emmanuel Forestier, Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, BP 1125, 73011 Chambery Cedex, France, Tel +33 4 7996 5847, Fax +33 4 7996 5171, Email
| | - Thibaut Fraisse
- Acute Geriatric Department, Centre Hospitalier, Alès, France
| | | | | | - Leonardo Pagani
- Infectious Diseases Department, Centre Hospitalier Annecy-Genevois, Annecy, France
| |
Collapse
|
14
|
Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, Vandewoude M, Wirth R, Schneider SM. ESPEN guidelines on nutrition in dementia. Clin Nutr 2015; 34:1052-73. [PMID: 26522922 DOI: 10.1016/j.clnu.2015.09.004] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 09/10/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.
Collapse
Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany.
| | - Michael Chourdakis
- Department of Medicine, Aristotle University of Thessaloniki (AUTH), Greece
| | - Gerd Faxen-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Krankenhaus Hietzing, Vienna, Austria
| | - Francesco Landi
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Merja H Suominen
- Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
| | - Maurits Vandewoude
- Department of Geriatrics, Medical School, University of Antwerp, Belgium
| | - Rainer Wirth
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany; St. Marien-Hospital Borken, Department for Internal Medicine and Geriatrics, Borken, Germany
| | - Stéphane M Schneider
- Nutritional Support Unit, Centre Hospitalier Universitaire de Nice, Nice, France
| |
Collapse
|
15
|
Abstract
SummaryPatients 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.
Collapse
|
16
|
Abstract
Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.
Collapse
Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
| |
Collapse
|
17
|
Abstract
Subcutaneous (SC) rehydration therapy (SCRT), originally referred to as "hypodermoclysis," shows promise as an alternative to intravenous (IV) fluid administration for treatment of dehydration. A simple, safe, and effective technique, SCRT is indicated for treatment of mild-to-moderate dehydration. Augmentation of SCRT with administration of a recombinant human formulation of the hyaluronidase enzyme at the infusion site gives rise to SC fluid administration rates up to 5-fold faster than those achieved without the enzyme, making the technique more clinically practical. Unlike older, animal-derived forms of hyaluronidase, recombinant human hyaluronidase has a lower chance of allergic reactions with repeated dosing. Clinical trials have demonstrated that recombinant human hyaluronidase effectively and safely facilitates fluid delivery in adults and children and is well accepted by parents and clinicians. In the emergency department setting, SCRT may be an appropriate alternative to IV fluid administration in certain situations because it is less invasive and generally less painful, while still permitting administration of appropriate volumes of rehydration fluids. Subcutaneous rehydration therapy appears to be particularly useful in patients who present with mild-to-moderate dehydration and have had failed attempts at oral rehydration. The SC route also provides benefits in patients with small, collapsed, or difficult-to-visualize veins or in those who may be agitated or distressed by IV catheterization. Continued research will further clarify the role of recombinant human hyaluronidase-facilitated SCRT in the rehydration treatment algorithm.
Collapse
|
18
|
Abstract
SummarySubcutaneous hydration, or hypodermoclysis (HDC), is a very simple technique that should be practised more often by doctors and nurses who care for older patients. It involves less discomfort, generates less cost and has fewer adverse effects than the intravenous route and may reduce the need for admission to the emergency department. The main indication is the management of mild to moderate dehydration, and prevention of dehydration in patients who are intolerant of oral intake. It should not be administered in situations of severe dehydration, in emergency situations, or in patients with fluid overload. Isotonic or hypotonic solutions must be used with appropriate electrolytes. Certain medicines can be given simultaneously by HDC and this may be especially valuable in palliative care settings. In most cases there is no need to add hyaluronidase.
Collapse
|
19
|
Pershad J. A systematic data review of the cost of rehydration therapy. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2010; 8:203-214. [PMID: 20205481 DOI: 10.2165/11534500-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Dehydration secondary to acute gastroenteritis is a commonly encountered condition among patients presenting to physicians' offices and hospital EDs. Treatment options consist of oral rehydration therapy (ORT), intravenous rehydration therapy (IVRT) and subcutaneous rehydration therapy (SCRT). Although most patients with dehydration can be effectively treated in an outpatient setting, hospitalization is frequently warranted, with estimated annual inpatient costs for dehydration therapy exceeding $US1 billion in the US in 1999 for elderly patients alone. Although most treatment guidelines recommend ORT as first-line treatment for mild to moderate dehydration, IVRT remains the predominant route of administration for rehydration fluids in the acute care setting in the US. To evaluate the current state of the literature examining costs associated with dehydration therapy, a systematic review of articles published on MEDLINE from 2000 to 2009 was conducted. A total of 20 reports containing pharmacoeconomic data on rehydration therapy were evaluated. Findings suggest that ORT and SCRT may be less costly than IVRT in the treatment of mild to moderate dehydration; however, variability in cost parameters examined or data collection methods described in the literature precluded a comprehensive comparative cost-effectiveness analysis of treatment options. Future pharmacoeconomic analyses of rehydration therapy should incorporate time-motion analyses comprising a consistent set of variables to determine the most cost-effective treatment modality for patients with mild to moderate dehydration.
Collapse
Affiliation(s)
- Jay Pershad
- University of Tennessee Health Sciences Center, Le Bonheur Children's Medical Center, Memphis, Tennessee 38103, USA.
| |
Collapse
|
20
|
Dychter SS, Ebel D, Mead TR, Yocum RC. Comparison of the tolerability of recombinant human hyaluronidase + normal saline and recombinant human hyaluronidase + lactated ringer's solution administered subcutaneously: A phase IV, double-blind, randomized pilot study in healthy volunteers. CURRENT THERAPEUTIC RESEARCH 2009; 70:421-38. [PMID: 24692835 PMCID: PMC3969977 DOI: 10.1016/j.curtheres.2009.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/04/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recombinant human hyaluronidase (rHuPH20) (150 U) is approved by the US Food and Drug Administration to facilitate subcutaneous fluid administration in adults and children. OBJECTIVE This Phase IV, double-blind, randomized pilot study was designed to compare the tolerability, flow rate, and safety profile of subcutaneous infusions of normal saline (NS) and lactated Ringer's (LR) solutions following subcutaneous administration of rHuPH20. METHODS Healthy volunteers received 1 mL rHuPH20 (150 U) in each thigh, followed by simultaneous gravity-driven subcutaneous infusions of 500 mL of LR solution into 1 thigh and NS solution into the contralateral thigh. Subjects rated infusion-site discomfort in each thigh using a 100-mm (0 = no pain to 100 = most severe pain) visual analog scale (VAS) at baseline (ie, after catheter placement/ rHuPH20 injection and just prior to the start of the infusions) and at the following times: after infusion of 250 mL, after infusion of 500 mL (end of infusion), and when thigh circumference returned to within 5% of baseline. Adverse events (AEs) were recorded throughout the study. The primary tolerability end point was the maximal increase from baseline in infusion-site discomfort on the VAS. Secondary end points included infusion flow rate, change in thigh circumference, subject preference for leftversus right-thigh infusion, and safety profile measures. RESULTS Fifteen subjects (14 women, 1 man; mean age, 41 years [range, 20-60 years]) were included in the study. Mean (SD) maximal increase from baseline VAS pain score was significantly greater with NS solution than with LR solution (20.0 [19.4] vs 9.4 [18.3] mm, respectively; P = 0.005). Mean infusion flow rate was not significantly different between the NS and LR solutions (384.1 [118.1] vs 395.8 [132.8] mL/h). No significant differences between solutions were observed in mean maximal change in thigh circumference (5.2% [1.6%] vs 5.3% [1.5%]). All subjects expressed global preference for LR infusion over NS infusion. All subjects experienced ≥1 AE; the majority of AEs were mild, localized infusion-site reactions. Of all AEs (regardless of their relationship to study drug or procedure), 81% were mild injectionsite reactions that were similar in nature for the NS and LR solutions. Although the types of mild local AEs were similar for the 2 infusions, they were numerically more common with NS infusions (15 subjects [100%]) than with LR infusions (9 subjects [60%]). For the NS and LR solutions, the most frequent infusion-site AEs were pain (67% vs 40%, respectively), erythema (47% vs 13%), and irritation (27% vs 20%). CONCLUSIONS This small pilot study found that the mean maximal increase from baseline in self-assessed pain VAS scores was statistically significantly higher with NS solution than LR solution. In addition, all subjects preferred LR solution to NS solution, and the incidence of some infusion-site AEs was numerically greater with NS solution. Although the VAS score indicated a statistically significant difference in tolerability favoring LR, the modest changes from baseline suggest both solutions were generally well tolerated and support the use of both NS and LR, as appropriate, for rHuPH20-facilitated subcutaneous isotonic fluid infusion in healthy adults. These results need to be confirmed in larger, controlled clinical studies.
Collapse
|
21
|
Hernández Palacios R. [Usefulness of the subcutaneous route in the care of patients with advanced dementia]. Rev Esp Geriatr Gerontol 2009; 44 Suppl 2:37-42. [PMID: 19765863 DOI: 10.1016/j.regg.2009.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 05/20/2009] [Indexed: 05/28/2023]
Abstract
In advanced dementia, the therapeutic goals should be patient comfort, adequate symptom control, and the prevention of suffering due to futile, intrusive or disproportionate procedures. To attain these goals, the subcutaneous route is a useful tool, since it allows fluid administration and the delivery of many drugs. Because it is well tolerated and easy to apply, this route can be safely used in non-hospital settings, allowing patients to stay in their environment and avoiding the risks resulting from hospitalization. Although subcutaneous administration is outside the approved label of many drugs, clinical experience and the medical literature have produced sound evidence that has been incorporated into a number of practice guidelines in palliative care. The recent regulations simplify the implementation of these standards of clinical practice.
Collapse
|
22
|
ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009; 28:461-6. [PMID: 19464090 DOI: 10.1016/j.clnu.2009.04.004] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/12/2022]
Abstract
When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or - for limited period of time and with limitation in the osmolarity and composition of the solution - through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or - if planned for an extended or unlimited time - long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.
Collapse
|
23
|
Schols JMGA, De Groot CPGM, van der Cammen TJM, Olde Rikkert MGM. Preventing and treating dehydration in the elderly during periods of illness and warm weather. J Nutr Health Aging 2009; 13:150-7. [PMID: 19214345 DOI: 10.1007/s12603-009-0023-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Translate the available knowledge on ageing and dehydration into main messages for clinical practice. MAIN POINTS Older people are more susceptible to dehydration than younger people. This is partly due to lack of thirst sensation and changes in the water and sodium balance that naturally occur as people age. It is also, to some degree, attributable to the fact that elderly people, both those living at home and those living in institutions, often have various impairments, disabilities and/or handicaps (comorbidity). They also tend to use numerous drugs and medication for these illnesses (polypharmacy). Multimorbidity and polypharmacy often overstress the normal age-related physiological changes in the water and sodium balance and therefore increase elderly people's risk of dehydration,especially during intercurrent infections or warm weather. Elderly people, whether they are living on their own or in an institution, and especially elderly people that can no longer take care of themselves because of cognitive, sensory, motor and/or ADL impairments, need extra help to stay hydrated. The most important strategy is simply a matter of ensuring that elderly people consume a sufficient amount of fluids (at least 1.7 liters every 24 hours). Additional strategies include making healthy drinks and water easily available and accessible at all times and reminding and encouraging the elderly to consume these fluids. Elderly people should not be encouraged to consume large amounts of fluids at once but rather small amounts throughout the day. When the recommended fluid intake cannot, for whatever reason, be realized, fluids can be administered via catheter or by hypodermoclysis. In more specific and severe cases, fluids can be administered intravenously. CONCLUSION The prevention, signaling and treatment of dehydration in the elderly is an important multidisciplinary endeavor. Formal and informal care providers need to continuously be aware of the risk factors and signs of dehydration in the elderly, especially during periods of very warm weather and when older people are ill. Standard professional care for high risk patients is imperative.
Collapse
Affiliation(s)
- J M G A Schols
- Nursing Home Medicine, Department of General Practice, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | | | | |
Collapse
|
24
|
O'Hanlon S, Sheahan P, McEneaney R. Severe hemorrhage from a hypodermoclysis site. Am J Hosp Palliat Care 2009; 26:135-6. [PMID: 19136643 DOI: 10.1177/1049909108330033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypodermoclysis, or subcutaneous infusion of fluids, is an alternative means of administration of fluid. It is sometimes used in older patients in whom there is difficulty achieving intravenous access, or who are entering the terminal stage. It is considered a relatively low-risk procedure. We report a case where a patient's death may have resulted from its use.
Collapse
|
25
|
Schmidlin E. Artificial hydration: the role of the nurse in addressing patient and family needs. Int J Palliat Nurs 2008; 14:485-9. [DOI: 10.12968/ijpn.2008.14.10.31492] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Esther Schmidlin
- Communication and Ethics at the End of Life, Institute Universitaire Kurt Boesch, Sion, Switzerland
| |
Collapse
|
26
|
Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. J Palliat Med 2008; 10:1312-20. [PMID: 18095810 DOI: 10.1089/jpm.2007.0126] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subcutaneous hydration has potential advantages over intravenous. Despite studies supporting the efficacy and safety of subcutaneous hydration it has not been studied extensively to date either with or without hyaluronidase. OBJECTIVES To compare flow rate, tolerability, and safety of gravity-driven subcutaneous fluid administration with and without recombinant human hyaluronidase (rHuPH20) in healthy volunteers. DESIGN Randomized, double-blind, placebo-controlled, within-subject trial. SETTING Contract research organization. PARTICIPANTS Fifty-four volunteers. INTERVENTION 24-gauge angiocatheters were placed subcutaneously in both upper arms. Each arm received rHuPH20 (150 U, 750 U, or 1500 U) or equal volume saline placebo. Immediately, 400 mL Lactated Ringer's (LR) solution was gravity-infused from a 100 cm height. In the pilot stage, 5 subjects also received a similar intravenous infusion. MEASUREMENTS Primary outcome was time to infuse 400 mL LR. Secondary outcomes included discomfort assessments, edema, arm circumference, time to recover to baseline arm circumference, subject and investigator global preference, and adverse events. RESULTS rHuPH20 150 U, 750 U, and 1500 U yielded mean flow rates of 383 +/- 119 mL/hr, 518 +/- 154 mL/hr, and 494 +/- 136 mL/hr, respectively, compared to their respective placebo rates of 82 +/- 30 mL/hr, 148 +/- 57 mL/hr, and 124 +/- 50 mL/hr. rHuPH20 was well tolerated. CONCLUSIONS In volunteers, clinically relevant fluid volumes can be rapidly delivered subcutaneously with rHuPH20 in a well-tolerated manner without a pump. These findings suggest that this method of hydration could potentially replace intravenous infusions in many clinical settings; further studies with rHuPH20, in patients, are warranted.
Collapse
Affiliation(s)
- Jay R Thomas
- San Diego Hospice & Palliative Care, San Diego, California
| | | | | | | |
Collapse
|
27
|
Dardaine-Giraud V, Lamandé M, Constans T. L'hypodermoclyse : intérêts et indications en gériatrie. Rev Med Interne 2005; 26:643-50. [PMID: 16023267 DOI: 10.1016/j.revmed.2005.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 03/01/2005] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- V Dardaine-Giraud
- Service de soins de suite et réadaptation, hôpital de l'Ermitage, CHU de Tours, 2, allée Gaston-Pagès, 37081 Tours cedex 2, France.
| | | | | |
Collapse
|
28
|
Martínez-Riquelme A, Rawlings J, Morley S, Kendall J, Hosking D, Allison S. Self-administered subcutaneous fluid infusion at home in the management of fluid depletion and hypomagnesaemia in gastro-intestinal disease. Clin Nutr 2005; 24:158-63. [PMID: 15681114 DOI: 10.1016/j.clnu.2004.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2003] [Accepted: 09/27/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS In short bowel fistula and some other gastrointestinal (GI) diseases, salt, water and magnesium (Mg) balance may continue negative despite oral treatment, even in patients with adequate nutritional status. This study describes the use of self-administered subcutaneous fluid infusions (HSCF) to treat this problem. PATIENTS & METHODS HSCF was administered to patients with GI failure and adequate macro-nutrient status (BMI) when GI salt, water and magnesium balance continued negative despite optimal diet, drug and supplemental treatment. Mg depletion was confirmed using the Mg load test. Patients were taught to self-administer 0.5-1.0 l 0.9% saline +/-0.5 l 5% dextrose +/-2-4 mmol MgSO4 subcutaneously by gravity drip during 6-12 h overnight, 3-7 days/week. Water and Na balance were assessed (weight, serum creatinine, urea, Na) at baseline and at 1 and 3 months of treatment, but also monitored carefully during the first few days of treatment. Serum Mg was measured at baseline and at 2 and 4 weeks. RESULTS In 10 patients (mean age 65.3+/-13.5 years) Na and water balance was rapidly restored. At baseline, 1 and 3 months, serum biochemical results were: Eight patients received 8-28 mmol MgSO4/week in the infused fluid. Serum Mg [0.7-1.0 mmol] at baseline, 2 and 4 weeks was 0.49+/-0.06, 0.79+/-0.18, 0.83+/-0.10 mmol/l (P=0.002). Tolerance was good; transient oedema developed in 2 patients, resolved by reducing infusion dose. No patient developed hypokalaemia. CONCLUSIONS Subcutaneous self-administered fluid infusion at home (HSCF) is an easily managed, safe and effective method of restoring and maintaining water, salt and Mg balance in patients with large GI fluid losses but adequate macronutrient status, particularly in the frail or elderly in whom home parenteral nutrition may be difficult.
Collapse
Affiliation(s)
- Amparo Martínez-Riquelme
- Clinical Nutrition and Investigation Unit, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
| | | | | | | | | | | |
Collapse
|
29
|
Fonzo-Christe C, Vukasovic C, Wasilewski-Rasca AF, Bonnabry P. Subcutaneous administration of drugs in the elderly: survey of practice and systematic literature review. Palliat Med 2005; 19:208-19. [PMID: 15920935 DOI: 10.1191/0269216304pm1006oa] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
Collapse
|
30
|
Mion LC, O'Connell A. Parenteral hydration and nutrition in the geriatric patient: clinical and ethical issues. JOURNAL OF INFUSION NURSING 2003; 26:144-52. [PMID: 12792372 DOI: 10.1097/00129804-200305000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A common ethical and legal issue in elder care involves the decision to withhold or withdraw parenteral hydration and nutrition (PHN) at the end of life and in the terminal stage of dementia. The aging of the population will impact the frequency with which nurses face this situation in their practices and with their families. The ethical, legal, and clinical issues involving PHN discussed in this article will assist the nurse in his or her practice.
Collapse
Affiliation(s)
- Lorraine C Mion
- Division of Nursing, The Cleveland Clinic Foundation, OH 44195, USA.
| | | |
Collapse
|
31
|
Abstract
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.
Collapse
Affiliation(s)
- C M Herndon
- Department of Clinical Affairs, Ortho McNeil Pharmaceutical, Inc., O'Fallon, IL 62269, USA
| | | |
Collapse
|