Hypodermoclysis Administration

When and how to administer, appropriate solutions, procedure for administering.

1. Hypodermo clysis Subcutaneous Infusion an Alternative Infusion Route for hydration & certain medications and solutions in selected patient situations

2. H ypo d ermo clysis Known As: Clysis, HDC, Subcutaneous Hydration No Flushing Required “ H ypo d ermo clysis ” literally means “ A Washing Out Beneath the Skin”

3. H ypo d ermo clysis Objective To Provide Fluids to PATIENTS Whose Oral Intake is Not Adequate and are AT RISK FOR DEHYDRATION

4. H ypo d ermo clysis POPULAR TECHNIQUE USED TO ADMINISTER FLUIDS & SOME MEDICATIONS UNTIL THE LATE 1950’S WHEN THERE WAS A DECLINE IN SUBCUTANEOUS HYDRATION. Decline was a result of NUMEROUS COMPLICATIONS DUE TO: IMPROPER USE POOR PATIENT SELECTION INCORRECT RATES OF ADMINISTRATION POOR CHOICES OF FLUIDS IN IV Therapies IN Clysis Therapy

5. Hypodermoclysis: Indications Prevention from or treatment of patients with mild to moderate dehydration resulting from: an Inability to take adequate amounts of fluids orally, ( e.g. dysphagia) Have had a Fluid loss due to vomiting, diarrhea, diuretics, etc. Difficult or impractical IVF access

6. HYPODERMCLYCIS Safer Route than IVF Administration ; No thrombophlebitis, thrombosed catheters or veins, air and/or catheter emboli, septicemia. Reduced Distress for Patients ; Especially the cognitively impaired Less Discomfort with insertion & maintenance Less Complicated , easier to maintain than IVF administration. Night Infusions allow for Daytime Mobility . Fewer Hospital Admissions with potential cost savings. ADVANTAGES

7. Hypodermo clysis: Contraindications CONTRAINDICATED FOR THE FOLLOWING PATIENT POPULATION OR CONDITION(S): Shock Circulatory Failure Severe electrolyte imbalance Severe dehydration Patients with bleeding disorders Patients with skin conditions Edema d/t hypoalbumenia

8. HYPODERMO CLYCIS: Potential Complications Itching or burning at site Erythema Leaking at site/bleeding Edema Cellulitis

9. HYPODERMO CLYSIS: Prior to Procedure Verify physician order and appropriateness of order Assess patient’s medical history including potential contraindications f or hypodermoclysis Gather all equipment/fluids Explain , to the patient, the procedure and rationale for procedure

10. APPROPRIATENESS OF THE ORDER MEDICATION ORDER

11. H YPODERMOCLYSIS PROTOCOL Isotonic or Near-Isotonic Fluids Including: 0.45% Sodium Chloride 0.9% Sodium Chloride(most commonly used) NaCl solutions with glucose may be used LR may also be used KCI, 20 to 40 mmol /L may be added DEXTROSE 5% WITHOUT SODIUM AND D10 SHOULD NOT BE USED

12. HYPODERMO CLYSIS: SITE SELECTION Access site should have intact skin be away from umbilicus and bony prominences Lateral Abdominal Wall – most common site Anterior or Lateral thighs Sub-Clavicular Region INTER or Subscapular Regions – useful for confused patients who attempt to dislodge device

13. HYPODERMO CLYSIS: SITE SELECTION

14. Hypodermo clysis: Procedure Use Aseptic Technique and Standard Precautions Accessing, Maintaining, and Removing device. Site should have Adequate Subcutaneous Tissue ; A fat fold of at least one (1) inch or 2.5 cm. between thumb and forefinger. Site Prep with Single-Dose Antiseptic Solution ; Chlorhexidine preferred Alcohol, if allergy or sensitivity to chlorhexidine.

15. Hypodermo clysis: Procedure INS Standard Practice Criteria Aspirate Device Prior to fluid administration for Absence of blood Access site should have intact skin and be away from umbilicus and bony prominences Site should be assessed frequently and rotated based upon: volume of fluid given , patient comfort , appearance of site , and/or Time Duration of indwelling needle.

16. Hypodermo clysis: Procedure Gather Equipment: IV Start Kit(s) (All-in-one kit recommended; contains TSM Dressing, Antiseptic Wipe, Gloves, Sterile Tape) SQ Needle Set(s) 0.9% Sodium Chloride Prefilled Flush Syringe(s) Needleless Access Device/Connector(s) IV Gravity Tubing / Flow Regulator Tubing(s)

17. Hypodermo clysis: Procedure Explain Procedure to Patient Clean Work Area Perform Hand Hygiene Don Gloves Set Up/Prepare Equipment Open supplies, Attach Needleless access device/connector to SQ Needle set and prime with 0.9% Sodium Chloride, Leave Syringe and SQ Needle Set Attached..

18. Hypodermo clysis: Procedure Clean Selected Skin Site With Antimicrobial Solution for at least 30 seconds , using friction, and let dry completely. Preferred antimicrobial is chlorhexidine

19. Needle insertion Remove Protective Cover from SQ Needle, being careful not to contaminate. Grasp skin at around the selected site with thumb and forefinger and insert SQ needle ( do not touch the actual anticipated site without sterile gloves)

20. Hypodermoclysis: Procedure Pull Back on the Attached Syringe to ASSESS for Blood Return. IF BLOOD IS OBTAINED (ASPIRATED), REMOVE NEEDLE AND BEGIN NEW PROCEDURE

21. Hypodermo clysis: Procedure Cover Insertion Site with Transparent (TSM) Dressing Coil SQ Tubing and Secure Label Site/Dressing Label Tubing “ SUBCUTANEOUS INFUSION ” Connect IV Administration Tubing and Begin Infusion

22. Hypodermo clysis : SITE ROTATION PROTOCOL ROTATE SITE based upon : volume of fluid given patient comfort appearance of site Time Duration of indwelling needle AND/OR Every 48 hours (OR SOONER IF S/SX OF COMPLICATIONS) * Insert new site at least 2 -3 inches away from previous site

23. INFUSION RATES AND VOLUME PROTOCOL

24. Hyaluronidase ? What is it? & How does it work an enzyme that increases the absorption and dispersion of subcutaneous solutions and other injected drugs . It Modifies connective tissue permeability , causing rapid spread of subcutaneous fluid. How is it administered ? . Can be administered locally (subcutaneously) or added to the infusion solution. If Subcutaneously, administered before the 1 st dose.

25. Monitoring avoid edema by watching for signs of fluid accumulation in tissues around injection site; change site if this occurs Observe for redness or irritation at the infusion site when hyaluronidase is used, as there is a possibility of allergic reactions. Observe for signs of fluid volume overload due to rapid absorption of fluid when hyaluronidase is used. Observe for signs of infection at injection site . Always use sterile technique when inserting or removing needle Watch for dislodgement of needle and disconnection of tubing. If surrounding tissues show signs of inflammation, change site immediately. Observe as for IV site.

26. Documentation Date/Time Needle gauge/length Site/type of dressing Solution, rate and route of administration Reason for administration Patient’s response to procedure

27. TEST YOUR KNOWLEDGE Which of the following site(s) are recommended for Hypodermoclysis Infusion? Abdominal Wall Lateral aspect of Thighs Sub-Clavicular Region Lateral aspect of Calves.

28. TEST YOUR KNOWLEDGE 2. Your patient has an order for Hypodermoclysis for mild dehydration. You have inserted your subcutaneous needle into your selected site. When you assessed for a blood return, you were unable to obtain a blood return . YOU

29. TEST YOUR KNOWLEDGE 3. Which of the following is NOT an indication for Hypodermoclysis? Patient is unable to take adequate fluids orally. Patient has fluid loss due to vomiting or diarrhea. Patient has difficult/limited venous access. Patient is septic and at risk for shock.

30. 4. which of the following do you consider WHEN DETERMINING WHETHER OR NOT YOU NEED TO ROTATE YOUR PATIENT’S SUBCUTANEOUS Needle site ? The amount of fluid that has been administered into “ that” site The Appearance of the Site It is Friday and you are off the next day The patient’s comfort The length of time the site has been used .

31. TEST YOUR KNOWLEDGE For safety purposes, Hypodermoclysis infusions are administered on an electronic pump. True or False Studies show that Hypodermoclysis infusions are an acceptable way of hydrating a patient but the absorption of the fluid is not as good as hydration through an IV. True or False It is acceptable to bolus a patient 500-ml over 1-2 hours up to 3 times per day with the use of Hyaluronidase. True or False

32. TEST YOUR KNOWLEDGE What is the recommended maximum amount of volume to administer per site per day? 3 liters 1.5 liters 500-ml 1 Liter

33. TEST YOUR KNOWLEDGE Why is Hyaluronidase is sometimes used for subcutaneous administrations? To prevent skin breakdown When larger volumes are administered at faster rates To make sure the patient isn’t going to react to the subcutaneous administration.

34. TEST YOUR KNOWLEDGE What would you do? A patient is have a hypoglycemic event and has passed out. The provider has order D10 IV Stat but IV access was not successful. The provider orders the nurse to administer D10 through a subcutaneous infusion . Would you do it? Why or Why not?

35. QUESTIONS? THANK YOU