Journal of Gerontological Nursing

Your Turn

Abstract

When patients are nearing the end of life and no longer are able to swallow, this is an excellent method to provide supportive hydration without overloading a system that is trying to shut down. Hypodermoclysis, using normal saline (approximately 1 to 1.5 liters per 24 hours), is a low-tech, comfortable, simple, safe, minimally invasive procedure. Fluid is administered using a 25-gauge butterfly needle inserted at a 45° angle or one of the newer needles attached to a disk and inserted at a 90° degree angle which lies flush against the skin, secured with a transparent dressing. Usually the thighs are the most convenient site, especially for bedridden patients, but the abdomen, upper chest, or upper arms also may be used.

I have administered fluids this way to a patient with amyotrophic lateral sclerosis (ALS) who became dysphagic but wanted to receive supportive hydration. It was a comfortable procedure, no pumps or machines, and she was able to maintain her cognitive status until she died a few days later. Hypodermoclysis was also the choice of a family trying to cope with the terminal suffering of an elderly woman with a bowel obstruction and intractable vomiting where surgery was not an option. She received subcutaneous fluids and pain medication, while her family sat with her and knew that "something was being done." In both of these instances, 1,000 mL of fluid per day was sufficient to maintain mental alertness and physical comfort with no sensation of thirst.

Some of the other benefits of hypodermoclysis include:

* Low cost.

* Does not require intravenous skills.

* Comfort for patient.

* No danger of infiltration or fluid overload.

* Can be given only at night if desired.

Over the years, patient, family, and staff satisfaction always have been high with this procedure. It's a winwin situation.

Virginia A. Lindes, MSN, RN

Assistant Administrator for Nursing Services

Little Brook Nursing & Convalescent Home

Calif on, New Jersey

I have had little experience over the past few years. I have seen it with frail elderly patients who are mildly dehydrated. Hypodermoclysis was used for short periods of time with no ill effect. It is better than having to put in a peripherally inserted central catheter/central lines.

Alina M. Holmes, CNS, C, MSN, CS, CNAA

Senior Vice President

Quality and Professional Services

Post Acute Care, LLC

Baltimore, Maryland

No experience with clysis in the past 10 years. Even 10 years ago it was unsatisfactory because it was ordered as a last-ditch effort, and absorption was very poor.

Nancy Dressier, RN

Assistant Director of Nursing

Canton Christian Home

Canton, Ohio

I have no experience in humans but have used it in my cat with effect.

Dianne Acheson, RN, C

Day Charge Nurse

Caritas Norwood Intensive Care Unit

Norwood, Massachusetts

I have not yet implemented hypodermoclysis in our facility. Our Medical Director has requested this procedure be implemented. I am very interested in any information you could provide.

Lony L. Edwards, RN, CDON

CDON

Life Care Center of LaCenter

Paducah, Kentucky

We have not had an opportunity to care for a resident who needed this type of therapy in our facility.

Nancy Curry, RN

Director of Nursing

St. Joseph Manor - Holy Redeemer

Long-Term Care and Elder Services

Meadowbrook, Pennsylvania

This question was submitted by Helen Wood, RN, MS, Lead Nurse, On Lok SeniorHealth by IOA/UCSF, Goldman Institute on Aging, San Francisco, California. Her commentary follows:

Concerns about using clysis seem to arise from its potential to further complicate decisions that are already difficult in gerontologie care - decisions about how intensively to treat a person near the end…

The following question was asked of the readers of the Journal of Gerontological Nursing:

What has been your experience with hypodermoclysis? What have been the burdens and benefits to your clients for whom it was used?

Editor's Note: This Your Turn question stemmed from dialogue on a gerontology listserv. The first three responses are from the listserv. The responses that follow are responses to the above question.

I am working in a geriatric clinic setting where we have a limited number of hours in the day for infusing but would like to be able to use clysis on occasion. From the literature, I gather that the usual rate of infusion is 75 cc per hour (Worobec & Brown, 1997). However, one practitioner reports using boluses of 500 cc per hour. Comments?

REFERENCE

Worobec, E, & Brown, M.K. (1997). Hypodermoclysis therapy in a chronic care hospital setting. Journal of Gerontological Nursing, 23(6), 23-28.

Helen Wood, RN, MS

Lead Nurse

On Lok SeniorHealth by IOA/UCSF

Goldman Institute on Aging

San Francisco, California

I am a Clinical Nurse Specialist in palliative care/gerontology and recently suggested hypodermoclysis (HDC) as a means to address a chronic oliguria. The treating physician was not eager to sign off on the suggestion and it took another 3 weeks until the resident deteriorated into acute renal failure that another doctor on the same service decided a fluid challenge may arrest the renal failure. As it turned out, this is exactly what happened. The resident brightened up immediately, serum creatinine decreased, urinary output increased, and the resident's mentation also returned to baseline. Anecdotally, we are seeing that the use of HDC as a primary treatment for dehydration has merit, both from a physiological and a costbenefit point of view.

Hypodermoclysis (usually 2/31/3 in the geriatric population) by continuous infusion or alternatively by bolus are standards of parenteral hydration used in palliative care. Clearance of morphine's active metabolites that cause neurotoxicity is facilitated by adequate renal function. In other words, providing the kidneys with an adequate fluid challenge helps ensure the clearance of these metabolites. Similarly, given that polypharmacy is an issue in the geriatric population, inadequate clearance of the plethora of medications this population has been exposed to has been linked in the literature to changes in mentation, diminished activities of daily living, deceased quality of life, falls, incontinence, etc.

The following is how HDC hydration would be ordered in the palliative care population (Pereira & Bruera, 1997). For rehydration, fluid type: normal saline; rate: 70 to 100 mL/hour by continuous infusion. For augmenting or maintaining fluid intake, fluid type: 2/3-1/3; rate: 40 to 80 mL/hour (if by continuous infusion), 1 liter overnight (if by overnight clysis). This can be done by gravity, especially in the home. If by boluses, boluses of 500 mL each can be given twice daily. Each 500 mL can run in over 1 hour.

In our recent experience, hyaluronidase (Wydase) is not universally required to effectively administer fluid subcutaneously. Most HDCs can be given without hyaluronidase. However, if the site leaks significantly, hyaluronidase can be added to the fluid. One hundred fifty units in each liter of fluid usually is adequate. Reactions to hyaluronidase are uncommon (Pereira & Bruera, 1997).

REFERENCE

Pereira, J., & Bruera, E. (1997). Hydration. In The Edmonton aid to palliative care (pp. 59-61). Edmonton, Alberta: Division of Palliative Care, University of Alberta.

Gregg Trueman, RN, MN

Clinical Nurse Specialist

Youville Home

St Albert Alberta, Canada

We currently are conducting an evaluative study examining the impact of a hydration management intervention with delirium (acute confusion) and urinary tract infections as outcomes. We have a control group and an experimental group (these groups are in different long-term care facilities in Iowa). We would advocate the accurate assessment of hydration status in elderly long-term care residents so it does not progress to the point of initiating the therapies described by Mr. Trueman, but by the same token, I recognize there are limitations to this.

Kennith CuIp, PhD, RN

Assistant Professor

College of Nursing

The University of Iowa

Iowa City, Iowa

I have had very limited experience with this procedure, but we have discussed expanding our use of it in our long-term care population. We are trying to manage more acute illnesses in the long-term care facility to avoid hospital transfer. Dehydration is often an integral part of the problem we are managing. Maintaining a peripheral intravenous is a challenge, both from difficulties associated with the resident (e.g., small veins, confusion) and with staff (e.g., inexperience with intravenous). We are investigating the willingness of the long-term care facilities to establish this procedure.

Janice Locke, BSN, MS, RN, CS

Nurse Practitioner - Gerontology

St Joseph Mercy Health System

Ann Arbor, Michigan

What's old is new again" or "what goes around comes around" seems to describe the current revived interest in hypodermoclysis. Having worked in the palliative care arena for 16 years afforded me the opportunity to use the subcutaneous route for fluid administration in selective situations.

When patients are nearing the end of life and no longer are able to swallow, this is an excellent method to provide supportive hydration without overloading a system that is trying to shut down. Hypodermoclysis, using normal saline (approximately 1 to 1.5 liters per 24 hours), is a low-tech, comfortable, simple, safe, minimally invasive procedure. Fluid is administered using a 25-gauge butterfly needle inserted at a 45° angle or one of the newer needles attached to a disk and inserted at a 90° degree angle which lies flush against the skin, secured with a transparent dressing. Usually the thighs are the most convenient site, especially for bedridden patients, but the abdomen, upper chest, or upper arms also may be used.

I have administered fluids this way to a patient with amyotrophic lateral sclerosis (ALS) who became dysphagic but wanted to receive supportive hydration. It was a comfortable procedure, no pumps or machines, and she was able to maintain her cognitive status until she died a few days later. Hypodermoclysis was also the choice of a family trying to cope with the terminal suffering of an elderly woman with a bowel obstruction and intractable vomiting where surgery was not an option. She received subcutaneous fluids and pain medication, while her family sat with her and knew that "something was being done." In both of these instances, 1,000 mL of fluid per day was sufficient to maintain mental alertness and physical comfort with no sensation of thirst.

Some of the other benefits of hypodermoclysis include:

* Low cost.

* Does not require intravenous skills.

* Comfort for patient.

* No danger of infiltration or fluid overload.

* Can be given only at night if desired.

Over the years, patient, family, and staff satisfaction always have been high with this procedure. It's a winwin situation.

Virginia A. Lindes, MSN, RN

Assistant Administrator for Nursing Services

Little Brook Nursing & Convalescent Home

Calif on, New Jersey

I have had little experience over the past few years. I have seen it with frail elderly patients who are mildly dehydrated. Hypodermoclysis was used for short periods of time with no ill effect. It is better than having to put in a peripherally inserted central catheter/central lines.

Alina M. Holmes, CNS, C, MSN, CS, CNAA

Senior Vice President

Quality and Professional Services

Post Acute Care, LLC

Baltimore, Maryland

No experience with clysis in the past 10 years. Even 10 years ago it was unsatisfactory because it was ordered as a last-ditch effort, and absorption was very poor.

Nancy Dressier, RN

Assistant Director of Nursing

Canton Christian Home

Canton, Ohio

I have no experience in humans but have used it in my cat with effect.

Dianne Acheson, RN, C

Day Charge Nurse

Caritas Norwood Intensive Care Unit

Norwood, Massachusetts

I have not yet implemented hypodermoclysis in our facility. Our Medical Director has requested this procedure be implemented. I am very interested in any information you could provide.

Lony L. Edwards, RN, CDON

CDON

Life Care Center of LaCenter

Paducah, Kentucky

We have not had an opportunity to care for a resident who needed this type of therapy in our facility.

Nancy Curry, RN

Director of Nursing

St. Joseph Manor - Holy Redeemer

Long-Term Care and Elder Services

Meadowbrook, Pennsylvania

This question was submitted by Helen Wood, RN, MS, Lead Nurse, On Lok SeniorHealth by IOA/UCSF, Goldman Institute on Aging, San Francisco, California. Her commentary follows:

Concerns about using clysis seem to arise from its potential to further complicate decisions that are already difficult in gerontologie care - decisions about how intensively to treat a person near the end of life and about when artificial hydration is ethical or comfortable. We don't have a reliable way of predicting end of life for patients with multiple medical conditions, nor of distinguishing episodic need for hydration from the terminal stage of dying. Under the circumstances, it is understandable that patients and nurses experience ambivalence about hydration. The availability of clysis lowers the barriers to hydration, and may sometimes heighten discomfort about not choosing it.

The lower cost of clysis also decreases the barriers to choosing hydration. Low cost raises the specter of using a second-rate treatment mainly because it is cheaper, or because it is more convenient for staff to maintain the skill of subcutaneous injection than of intravenous. Responses by both Janice Locke and Virginia Lindes refer to the difficulty of maintaining the skill to start intravenous infusions in elderly individuals who are already dehydrated. Low cost and convenience are fine, as long as we don't choose a less effective treatment over a more effective one simply for those reasons.

But the nurses who use clysis find that it is technically straightforward, effective, and of little burden to the patient. As Gregg Trueman points out, there are many times when the dehydration of an acute episode or exacerbation of illness can be treated successfully. Hospitalization may be avoided by clysis in a facility, clinic, or possibly even in the home. It does seem to me that clysis is used less often than its practical limitations would require. It may be a valuable technology that raises difficult judgment questions.

10.3928/0098-9134-20000501-15

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