Hypodermoclysis:
`An Alternative Infusion Technique
`
`MENAHEM SASSON, M.D., and PESACH SI-IVARTZMAN, M.D.
`Ben-Gurion University of the Negev, Be’er Sheva, Israel
`
`Hypodermoclysis, the subcutaneous infusion of fluids, is a useful and easy hydration tech-
`nique suitable for mildly to moderately dehydrated adult patients, especially the elderly.
`The method is considered safe and does not pose any serious complications. The most fre-
`quent adverse effect is mild subcutaneous edema that can be treated by local massage or
`systemic diuretics. Approximately 3 L can be given in a 24-hour period at two separate
`sites. Common infusion sites are the chest, abdomen, thighs and upper arms. The preferred
`solution is normal saline, but other solutions, such as half-normal saline, glucose with
`saline or 5 percent glucose, can also be used. Potassium chloride can be added to the solu-
`tion bag if needed. Hyaluronidase can also be added to enhance fluid absorption. Hypo-
`dermoclysis can be administered at home by family members or a nurse; the technique
`should be familiar to every family physician. (Am Fam Physician 2001;64:1575-8.)
`
`0 A patient informa-
`tion handout on
`hypodermoc/ysis, writ-
`ten by the authors of
`this article, is provided
`on the AFP Web site.
`
`
`See editorial
`
`on page 1516.
`
`ypotlerinoclysis is a method
`of infusing lluid into subcu-
`taneotls tissue that requires
`only Iniliimal equipment.
`"I1:-cimically,
`it
`is easier
`to
`administer fluids subcutaneously than intra-
`venously. During the past two decades, many
`articles advocating this method have been
`published in the geriatric and palliative med-
`ical literature. ' '2 However, hypodermoclysis is
`suitable for use in many hospital and home-
`care situations regardless of the patient’s age.’
`The advantages and disadvantages of this
`technique are presented in Table 1.
`
`Efficacy
`
`A 1991 study‘ demonstrated the efficacy of
`fluid absorption in hypodermoclysis. Healthy
`elderly volunteers were infused with normal
`saline either intravenously or subcutaneously,
`using radioisotopic triated water and tech-
`netium pertechnetate. The infusion included
`750 IU of hyaluronidase, and the saline infu-
`sion rate was 167 mL per hour. The absorp-
`tion of fluid via the intravenous route was
`almost identical to that with the subcutaneous
`
`route in all subjects. Radioactivity could not
`be demonstrated at the subcutaneous site 75
`
`minutes after completion of the infusion.
`In an uncontrolled study,-" hypodermo-
`clysis was used in 36 instances in nursing-
`
`home residents with a mean age of 85 years
`and was associated with a return to clinical or
`
`functional baseline in 71 percent of subjects
`one week after the end of clysis. In a further
`study,‘ 60 patients (mean age: 80 years) with
`cognitive impairment who required par-
`enteral fluids for at least 48 hours were ran-
`
`domly chosen to receive either intravenous or
`subcutaneous fluids. After adjusting for base-
`line differences, no differences in serum urea
`or creatinine levels were found between the
`
`two groups 48 hours later. The cost was much
`lower in the subcutaneous fluid group, and
`agitation related to the infusion was more
`prevalent in the intravenous fluid group.
`
`Indications
`
`Subcutaneous fluids are indicated for
`
`maintaining adequate hydration in patients
`who are unable to take adequate fluids orally,
`who are mildly to moderately dehydrated and
`in whom it is difficult or impractical to insert
`an intravenous line.’ Theimain use of subcu-
`
`taneous fluids has been in geriatric and pal-
`liative medicine settings."5"
`Oral hydration is often difficult in the pres-
`ence of cognitive impairment, vomiting and
`nausea,
`infection, abdominal obstruction
`related to cancer, or cerebrovascular accident,
`
`especially in elderly patients.‘-3"° Home use of
`intravenous infusion entails serious risks and
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`TABLE 1
`Advantages and Disadvantages of Hypodermoclysis
`
`Advantages
`Low cost
`More comfortable than IV administration
`Less likely than IV administration to cause pulmonary edema or fluid overload
`Simple insertion, less distressing than IV; easier reinsertion at new site
`More suitable for home care than IV line, with less staff supervision and less
`need for hospitalization
`Can be set up and administered by nurses in almost any setting
`Does not cause thrombophlebitis
`Has not been shown to cause septicemia or systemic infection
`Can be started and stopped at any time by opening and closing the clamp on
`clysis tubing; no danger of clot formation
`Disadvantages
`Usual rate only 1 mL per minute; only 3,000 mL (at two sites) can be given in 24 hours
`Limitations on administration of electrolytes, nutrition additives and medications
`Edema at infusion site is common
`Possibility of local reactions
`
`IV = intravenous.
`
`requires close supervision by skilled medical
`staff. However, hospitalization is inconvenient
`for patients and families, and many patients
`wish to stay at home. The cost of hospitaliza-
`tion and the danger of nosocomial infections
`are further disadvantages of admitting a
`patient for hydration. Because of its safety and
`ease of administration, hypodermoclysis is a
`useful alternative to intravenous hydration.11
`Terminal cancer patients usually stop eating
`and drinking near the end of life. The use of
`fluids in this situation is subject to debate,
`because nutrition and hydration have not
`been proved to prolong life or improve
`patients’ well-being.12,13 Several authors claim
`that hypodermoclysis (at a rate of 500 to 1,500
`mL per 24 hours) circumvents many of the
`objections to other methods of hydration.14,15
`Clinical studies suggest that terminally ill
`
`The Authors
`MENAHEM SASSON, M.D., is a family physician in an urban clinic in Be’er Sheva, Israel,
`and assists in the home-care unit for terminal patients, also in Be’er Sheva. He is a lec-
`turer and medical student clerkship coordinator in the Department of Family Medicine
`and Palliative Medicine at Ben-Gurion University of the Negev, Be’er Sheva, Israel.
`PESACH SHVARTZMAN, M.D., is professor in the Department of Family Medicine and
`Palliative Medicine and chairman of the Division of Community Health at Ben-Gurion
`University of the Negev. He is also head of the Israeli Palliative Care Association.
`Address correspondence to Pesach Shvartzman, M.D., Division of Community Health,
`Ben Gurion University of the Negev, P.O.Box 653, Be’er Sheva, 84105, Israel (e-mail:
`spesah@bgumail.bgu.ac.il). Reprints are not available from the authors.
`
`patients with cancer may achieve adequate
`hydration with much lower fluid volumes
`than recommended for the average medical
`and surgical patient.16 Also, patients and fam-
`ilies can be disturbed by low fluid intake, par-
`ticularly when there is active fluid loss from
`diarrhea, vomiting, bowel obstruction or pro-
`found sweating. In these situations the physi-
`cian should discuss hypodermoclysis with the
`patient and/or caregivers.
`
`Contraindications
`There are few contraindications to hypo-
`dermoclysis. It should not be used when flu-
`ids must be administered rapidly and in large
`amounts, such as in patients with collapse,
`shock, severe electrolyte disturbance or major
`dehydration. It is also contraindicated when
`the patient may be at increased risk of pul-
`monary congestion or edema, such as severe
`congestive heart failure. Because of bleeding
`at the injection site, clotting disorders are
`another contraindication.
`
`Technique
`SITE
`In ambulatory patients, hypodermoclysis
`sites include the abdomen, upper chest, above
`the breast, over an intercostal space and the
`scapular area. In bedridden patients, preferred
`sites are the thighs, the abdomen and the outer
`aspect of the upper arm.3,17 After one to four
`days, the needle and tubing should be changed,
`although infusion sets have been left in place
`for much longer periods without complica-
`tions.2 The reported duration of any one site in
`a palliative care unit was 4.7 days. Total hypo-
`dermoclysis duration was an average of
`14 days.14 In another study18 using a Teflon
`cannula, the site duration was 11.9 ± 1.7 days
`versus 5.3 ± 0.5 days using a butterfly needle.
`
`VOLUME AND RATE
`Fluid can be delivered subcutaneously by
`gravity at a rate of 1 mL per minute at one site;
`thus, about 1.5 L can be delivered at one site and
`3 L at two separate sites over 24 hours.2 In a
`
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`TABLE 2
`Technique of Hypodermoclysis
`
`Preparation
`1. Explain the procedure to the patient.
`2. Select the infusion site.
`3. Wash hands.
`Procedure
`1. Assemble fluid and tubing. Prime line with selected fluid and hyaluronidase,
`using lidocaine if required.
`2. Swab the site with povidone-iodine skin preparation solution using a circular
`motion, beginning at the center of the site. Allow at least one minute
`contact time. Do not touch prepared site again with fingers.
`3. Insert needle, bevel up, into subcutaneous tissue at a 45- to 60-degree angle.
`4. Secure needle and tubing with occlusive dressing.
`5. Adjust fluid drip rate as prescribed.
`Post-procedure
`1. Do not set drip rate to deliver more than 1 L in two hours.
`2. Date and initial dressing; date and initial intravenous tubing.
`3. Document infusion fluid on medication chart.
`4. Check patient and infusion after one hour to ensure that the infusion site is
`correct, that there are no signs of edema, leakage, disconnection or fluid
`collection distal to the site, and that patient does not show signs of fluid
`overload.
`5. If necessary, the infusion site can be massaged to enhance edema absorption.
`
`(1,500 U) and 1 to 2 mL of lidocaine.3 Usually
`150 U per L is an effective dose of hyalu-
`ronidase.7 However, this dosage can cause dis-
`comfort and local reaction.3 Many reports sug-
`gest that the addition of hyaluronidase is not
`necessary to prevent edema.5,6,20-23 There are
`reports of the safe addition of 20 to 40 mmol
`of potassium chloride per L to the infused
`solution in cases where potassium replacement
`is needed (i.e., diarrhea, vomiting).2,3,7,24
`No data have been reported on the absorp-
`tion of morphine and other medications
`added to the fluid bag or given as a bolus,
`although concomitant subcutaneous infusion
`of such medications warrants investigation.
`The technique for hypodermoclysis is sum-
`marized in Table 2.
`
`Adverse Effects
`The risks of hypodermoclysis are minimal
`when it is administered in conformity with
`accepted indications and guidelines. Adverse
`effects, which are rare and easily avoidable,
`depend mainly on the choice of solution, the
`volume and the infusion flow rate7 (Table 3).
`In a 1981 experiment,21 4,500 infusions of
`normal saline and 5 percent glucose solutions
`were administered to 634 patients, of whom
`the majority were older than 80 years. Few
`adverse effects were noted. The most common
`
`prospective study14 in a palliative care unit, 100
`consecutive patients received an average volume
`of 1,203 ± 505 mL per day. One to 2 L can be
`given overnight to allow freedom from tubes
`during the day.3 Another method involves
`administration of 500-mL boluses over one or
`two hours three times a day, with 150 U of
`hyaluronidase (Wydase) given at the subcuta-
`neous site before the first morning infusion.1
`
`EQUIPMENT
`The equipment consists of a solution bag, a
`tube with a drip chamber, a 21- or 23-gauge
`long-tube butterfly needle, povidone-iodine
`solution or alcohol skin preparation, and a
`sterile occlusive dressing.
`
`FLUID AND ADDITIVES
`Usually, normal saline (0.9 percent) is
`infused,2,19 but 0.45 percent saline, one third
`saline with two thirds glucose 5 percent, or 5
`percent glucose alone or with normal or half-
`normal saline have been administered in clini-
`cal practice.1,2,5-7,19 Past reports warned of the
`danger of rapidly infusing electrolyte-free solu-
`tions such as 5 percent glucose. More recently,
`reports have been published on the use of
`5 percent dextrose with no attendant risk.7
`Hyaluronidase, an enzyme obtained from
`bull testes, has been used to enhance fluid
`absorption from subcutaneous tissue. Hyalu-
`ronidase temporarily lyses the normal inter-
`stitial barrier, which consists mainly of
`hyaluronic acid, a polysaccharide found in
`the intercellular ground substance of connec-
`tive tissue.1 Hyaluronidase decreases the vis-
`cosity of the connective tissue, thus increasing
`diffusion of the fluid administered subcuta-
`neously for about 24 to 48 hours.5
`When hyaluronidase is used to increase fluid
`absorption, one method of doing so is to add
`150 U per L to a fluid infusion bag and to inject
`75 U of hyaluronidase into each clysis site
`through the short latex tubing near the nee-
`dle.2 Some physicians have used 10 times
`this dose for hypodermoclysis by priming the
`needle and infusion set with hyaluronidase
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`NOVEMBER 1, 2001 / VOLUME 64, NUMBER 9
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`TABLE 3
`Adverse Effects of Hypodermoclysis
`
`Effect
`
`Comment
`
`Local edema
`Local catheter
`reactions*
`
`Most common adverse effect; can be resolved by massage
`Occurred in 5% of 46 patients per day who were hydrated
`by hypodermoclysis compared with 25% of 18 patients
`hydrated by intravenous fluid.22
`Pain or discomfort Rare; can be related to insertion of needle into underlying
`at infusion site
`muscle or to increase in infusion rate
`Cellulitis
`Risk is minimal when aseptic technique is used and needle
`site is changed daily.
`Risk is minimal; subcutaneous infusion should not be
`Puncture of
`performed if blood appears when needle is inserted.
`blood vessels
`Pulmonary edema Rare; reported in 0.6% of more than 600 patients
`hydrated by hypodermolysis11
`Changes in plasma Rare; less common than with intravenous infusion
`concentrations
`of electrolyte
`Side effects of
`hyaluronidase†
`
`Rare
`
`Information from Schen R. Administration of fluid by subcutaneous infusion.
`Harefuah 1997;132:716-7, and Dasgupta M, Binns MA, Rochon PA. Subcuta-
`neous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000;48:795-9.
`*—Redness, obstruction, swelling.
`†—Local edema or urticaria, erythema, chills, nausea, vomiting, dizziness, tachy-
`cardia and hypotension are listed in the package insert for Wydase (Wyeth Lab-
`oratories), 1993.
`
`problem was fluid overloading, which caused
`either subcutaneous edema or heart failure in
`nine patients. Four of five patients with subcu-
`taneous edema in the pelvic and genital
`regions rapidly responded to diuretics. Local
`infection occurred in only one patient, who
`developed cellulitis at the infusion site in the
`thigh. Two patients had ecchymoses, one of
`them with probable disseminated intravascu-
`lar coagulation. The investigators concluded
`that hypodermoclysis is safe in older patients
`with mild to moderate dehydration.
`
`The authors indicate that they do not have any con-
`flicts of interest. Sources of funding: none reported.
`
`REFERENCES
`
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