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Hypodermoclysis Joshua Plants, RN, BSN.

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Presentation on theme: "Hypodermoclysis Joshua Plants, RN, BSN."— Presentation transcript:

1 Hypodermoclysis Joshua Plants, RN, BSN

2 OBJECTIVES Define Hypodermoclysis
At the completion of this presentation you should be able to: Define Hypodermoclysis State the indications and contraindications for this therapy Identify acceptable infusion sites

3 OBJECTIVES Relate the types of solutions used
State the potential complications of therapy Understand monitoring parameters and documentation responsibilities

4 Age Related Changes Contributing factors to dehydration Kidney
Reduction in size and nephron function Decreased GFR—decreased ability to concentrate urine, balance H20, K and Na Homonal changes ADH, ANP, Aldosterone Regulate fluids and electrolytes Atrial natriuretic peptide

5 Age Related Changes Contributing factors to dehydration
Body fluid content Young adult 60%--older adult 40% Decreased sensation of thirst (Scales, 2011) Atrial natriuretic peptide

6 Dehydration Increased morbidity and mortality Mental function
Increased irritation, behaviors, cognition problems, confusion Infection Renal stones Falls Constipation Thrombosis (Scales, 2011)

7 Dehydration Compounding factors: Fears of incontinence
Inability to obtain drinks/liquids Lack of access to fluids of choice Temperature (Remington & Hultman, 2007)


9 What is Hypodermoclysis?
Treatment /Prevention of mild to moderate dehydration ‘Clysis’ for short Administration of fluids to the hypodermis “Subcutaneous infusion” Between skin and fascia Latin—hypo—below; dermo—skin; Greek—hypo—under; derma—skin; klyster—washout

10 Epidermis composed of 5 different “strata”

11 Epidermis( distal) & Dermis (proximal) compose skin

12 Route of Administration
SUBCUTANEOUS INTRAVENOUS Easy to initiate and maintain Minimal complications Edema Insertion site issues Inadvertent IV access Can be difficult for staff to initiate or maintain Missed doses Precise locations Therapeutic levels Multitude of potential complications Phlebitis Infiltration Sepsis Fluid Overload Catheter related issues

13 Maine State Board of Nursing
Go to Maine State Board of Nursing Website At the far right select the hyperlink entitled ‘Practice Questions’ Select the link entitled ‘Scope of Practice Decision Tree’ Use tree to determine SOP

14 Advantages Ease of access with subcutaneous administration
Easy for nurses to insert and maintain Minimal number of complications when compared to intravenous therapy Minor complications with SC versus IV

15 Advantages Reduced levels of patient discomfort
Size of needles Number of rotations required Care provider technique Reduces potential for hospitalization $1 billion annual US cost of avoidable hospitalizations for dehydration (Lybarger, 2009) Re-hospitalization Nosocomial infection

16 Advantages Cost effective
Subcutaneous fluid group cost “much lower” than IV group (Sasson and Shvartzman, 2001) Per kit price $13.74; case of five $68.70 Nursing time costs; education Admission/Re-admission MSD

17 Disadvantages Limited volume of administration
Localized edema is created Isotonic or near isotonic fluids only No medications Gravity versus pump Sub-Q versus IV Reimbursement rates

18 Indications Mild to moderate dehydration
Adults, Children, Geriatrics Alternative to the intravenous route When intravenous access cannot be achieved or reliably maintained

19 Contraindications Emergency situations Severe electrolyte imbalance
Shock Circulatory failure Severe dehydration Severe electrolyte imbalance Coagulopathy/blood dyscrasia Fluid overload Congestive heart failure Marked edema Ascites

20 Contraindications Need for additional intravenous medications or antibiotics Renal dialysis Need for precise control of fluid balance Lack of sufficient subcutaneous tissue to safely perform the therapy (cachectic)

21 Hypodermoclysis Fluids
The preferred solution is 0.9% sodium chloride (normal saline) Other solutions include: Lactated ringers (LR) D5 ½ NS D5 NS D5 LR D5 ¼ NS D2.5 in ½ NS

22 Fluids D5W and D10W solutions are not recommended as the dextrose component is quickly metabolized. The remaining free water is hypotonic and causes a subsequent osmotic draw in the reverse direction of that which is desired. Increased edema and secondary discomfort is likely to result. Glucose pH (acidic); no greater than 5% Osmolality less than 280 mOs/kg (Medicines Information, 2001)

23 Fluids Note: No medications should be added to subcutaneous hydration solutions. Exception: hyaluronidase—Hydase, Amphadase, Wydase Used to enhance fluid absorption by decreasing viscosity of subcutaneous tissue Dose: 150 units (Clinical Pharmacology, 2013) NOTE: SUB-q bolus, DO NOT add to solution bag

24 Sub-Q Devices Rates of infusion are based on gauge size and device type. Manufacturer’s recommendations should be followed. Norfolk Medical MarCal Medical Churchhill Medical Systems Smiths Medical pages/promotions/md/cleo-home.html

25 Rates of Infusion Lumens Single—80 ml/hour
Double—62 ml/hour at each of two sites Total Rate: 124 ml/hour Multiple—used for non-hydration sub-q therapies

26 Rates of Infusion Sizes 6-20 mm lengths 21-29 gauge
Shortest possible size based on subcutaneous tissue Cleo—6mm Marcal—6mm Aqua-C—9mm 21-29 gauge Cleo—29 ga Marcal—27 ga Aqua-C—25 ga

27 Site Selection Abdomen Anterior or lateral thigh Posterior upper arms
Note: area within two inch radius of umbilicus excluded Anterior or lateral thigh Note: avoid in ambulatory patients Posterior upper arms Anterior chest wall Subscapular Lower back

28 Site Selection AVOID: Scarred tissue, bruised areas, areas of impaired skin integrity Areas prone to mechanical friction from clothes, equipment or patient movement Edematous areas Painful or infected areas Hard or bony areas, near the breast(s), perineum or waistline Dependent areas Poorly vascularized

29 Site Rotation After: 1500-2000 ml/24 hours at single site
3000 ml/24 hours for double site Q24-48 hours New site proximity When complications are noted PRN Positional

30 Monitoring Parameters
Site surveillance/monitoring should occur a minimum of every two hours: Erythema Gross swelling/edema Leakage Pain/discomfort Overall patient tolerance of therapy

31 Complications Risks are minimal when indications, guidelines and P&P are followed. Adverse effects are rare and related to: Solution type Volume administered Rate of infusion

32 Complications Edema Most common Massage Redness, swelling and inflammation at infusion site 5% of 46 patients with clysis versus 25% of 18 patients IV (Sasson and Shvartzman, 2001) 2.3 vs 4.5

33 Complications Cellulitis Pain/discomfort Technique Rotation Rate
Infection Oversaturation

34 Complications Inadvertent IV access Pulmonary edema
Check for blood return (INS, 2011) Pulmonary edema 0.6% of 600+ patients (Sasson and Shvartzman, 2001) 36

35 Care Plan Problem Patient requires short term hydration for mild to moderate dehydration. Potential for leakage, prominent swelling and localized infection

36 Care Plan Goal/Outcome Patient will return to baseline hydration level
Patient will not develop erythema, prominent swelling, pain, drainage or elevated temperature for duration of therapy Access will remain patent

37 Care Plan Interventions
Ensure clean/aseptic technique is maintained for all clysis procedures Including during needle rotation Administer the correct solutions for the type of therapy Select appropriate sites for subcutaneous infusion Avoid aforementioned site selection locations

38 Care Plan Interventions Monitor site Q2 hours during therapy
At least once per shift Change dressings PRN Ensure ordered rates are maintained 80 ml/hour at single site 62 ml/hour at double site (total 124 ml/hour)

39 Care Plan Interventions
Rotate needle sites Q hours during therapy After liters at single site After 3 liters at double site PRN Provide staff with safety needle technology Needle-stick prevention Non-metal devices preferred (INS, 2011) Needle-stick Increased dwell Rates of 3-5ml/h reported INS Standards

40 Care Plan Interventions
Use administration sets with rate flow controller or electronic infusion device (INS, 2011) CAUTION: Pumping fluids into subcutaneous tissue may mask oversaturation Increased edema and pain/discomfort Notify physician/LIP with complications Rates of 3-5ml/h reported INS Standards

41 Documentation Parameters
Follow local/institutional policy and procedures Valid prescriber order for therapy Use MAR/TAR/POS specific to therapy as indicated

42 Documentation Parameters
Specific data to be documented by the nurse in the medical record include: Date and time Medications/solutions to be infused Rate of infusion and start/stop times Device specific information

43 Documentation Parameters
Site selection/assessment Complications noted during therapy Interventions and inter-disciplinary communication Patient/family teaching Patient response to therapy

44 References Medicines Information Centre at Calderdale Royal Hospital. (2001). Hypodermoclysis-subcutaneous administration of fluids. Pharmacy news, 7(4). Omnicare. (2012). Hypodermoclysis. Sasson, M., & Shvartzman, P. (2oo1). Hypodermoclysis: An alternative infusion technique. American Family Physician, 64(9), Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1S), S84-85.

45 References Lybarger, E. (2009) Hypodermoclysis in the home and long-term care settings. Journal of Infusion Nursing, 32(1), p Clinical Pharmacology. (2013). Wydase. Retrieved from: Scales, K. (2011). Use of hypodermoclysis to manage dehydration. Nursing Older People, 23(5), Remington, R., & Hultman, T. (2007). Hypodermoclysis to treat dehydration: a review of the evidence. Journal Of The American Geriatrics Society, 55(12),

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