Using subcutaneous fluids to rehydrate older people: current practices and future challenges

Prolonged intravenous line access in a terminally ill patient, consequences and suggestions

Prolonged and neglected use of an intravenous (IV) line could be limb- and life-threatening. In many terminally sick cancer patients of rural India, pain management is a major concern. It is a very common practice by local practitioners to give IV fluids and pain medications in such patients. Where IV access is difficult, a secure venous cannula is kept in situ for long periods to administer pain medicines and fluids. This article tries to highlight the dangers a neglected IV line poses to limb and life and tries to stress on the importance of a subcutaneous route for pain medication administration in terminally ill palliative patients.

[Efficacy of the subcutaneous route compared to intravenous hydration in the elderly hospitalised patient: a randomised controlled study]

INTRODUCTION

The subcutaneous (SC) route has recently emerged as a rehydration method with potential advantages in the geriatric population. Nevertheless, little is known about its application during hospitalization. The objective of the present study is to evaluate the subcutaneous non-inferiority efficacy in hydration against the intravenous (IV) route in elderly patients with dehydration.

MATERIAL AND METHODS

A prospective, randomized and controlled interventional trial of patients 65 years and older admitted to an Acute Geriatric Unit with mild to moderate dehydration and oral intolerance, evaluating the non-inferiority of subcutaneous fluid therapy versus the intravenous route. The intervention consisted of the administration of up to 1.5 l/day/route for 72 hours subcutaneous vs. intravenous, evaluating the variations in biochemical parameters (urea, creatinine, osmolarity), clinical outcome, and route related complications.

RESULTS

Sixty seven patients completed the study (34 SC, age 86.4 ± 8.5 years, 41% women, vs. 33 IV, 84.3 ± 6.6, 54.5% women, with no significant differences). The amount of fluid administered per day by route was 1.320 ml ± 400 SC vs. 1.480 ml ± 340 IV, P = .092. During follow similar reductions were observed between groups without any statistical significance, with mean differences pre-postintervention of urea (49.6 ± 52.3 SC vs. 50.3 ± 52.3 IV, P=.96); creatinine (0.68 ± 0.66 SC vs. 0.60 ± 0.49 IV, P=.58), and osmolarity (15.6 ± 24.4 SC vs. 21.1 ± 31 IV, P=.43). Fewer catheter extraction episodes were observed in the SC group, which also was the group most prone to peri-clysis edema.

CONCLUSIONS

The efficacy of subcutaneous rehydration in elderly hospitalized patients with mild-moderate dehydration is not inferior to that obtained intravenously, and may even have additional advantages.

Use of hypodermoclysis in the treatment of elderly people in institutional care

Introduction: Hypodermoclysis is a way of administering fluids to the body by using a subcutaneous infusion. Research shows that this procedure is as effective as the more established intravenous infusion, posing no serious complications.Method: For this study, a descriptive quantitative method was used. The data were gathered through a structured survey questionnaire specifically designed for the purpose of the study. It consisted of 14 questions. The questionnaire was completed and returned by 40 nursing care managers in the old people’s homes. The questionnaire was designed and distributed by means of the 1ka web tool on February 10, 2013 and the answers were collected by February 26,  2013. The data analysis was performed using the software package 1ka, MS Office (Word, Excel) and SPSS 18.0.Results: With regard to geographical location of the old people’s homes inSlovenia, the familiarity with and the use of hypodermoclysis does not vary substantially (χ2 = 0.440, p = 0.507). Complications related to this procedure of administering fluids are rare when it is administered in conformity with accepted indications and guidelines. The risks of hypodermoclysis are not directly related to the rate of administration (χ2 = 0.000, p = 1.000). The research did not establish any correlation between the frequency of complications and the education level of the nursing staff (χ2 = 3.900, p = 0.420).Discussion and conclusion: The research shows that hypodermoclysis is an established and widely used procedure among the professionals who took part in the research. As hypodermoclysis is a safe, easy and financially accessible way of administering fluids, suitable for use both in institutions as well as in home care, the time has come for resurrection and evaluation of this alternative infusion technique for widespread future use.   

Artificial hydration in the terminally ill patient

Oral fluid intake is often reduced in dying patients. This article outlines the clinical assessment of the likely net benefit of artificial hydration, and the evidence relating to its use.

Subcutaneous hydration by hypodermoclysis

Subcutaneous 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.

Dysphagia treatment post stroke: a systematic review of randomised controlled trials

BACKGROUND

dysphagia is common following stroke and is associated with the development of pneumonia. Many dysphagia treatment options are available, some still experimental and others already rooted in common practice. Previous reviews of these treatments were limited due to a dearth of available studies. Recently, more trials have been published warranting a re-examination of the evidence.

OBJECTIVE

a systematic review of all randomised controlled trials (RCTs), updating previous work and evaluating a broader range of therapeutic interventions intended for use in adults recovering from stroke and dysphagia.

METHODS

using multiple databases, we identified RCTs published between the years 1966 and August 2007 examining the efficacy of dysphagia therapies following stroke. Across studies, results of similar treatments and outcomes were compared and evaluated.

RESULTS

fifteen articles were retrieved assessing a broad range of treatments that included texture-modified diets, general dysphagia therapy programmes, non-oral (enteral) feeding, medications, and physical and olfactory stimulation. Across the studies there was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. Descriptively these findings present emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes; and general dysphagia therapy programmes are associated with a reduced risk of pneumonia in the acute stage of stroke.

CONCLUSIONS

dysphagia is known to be a common and potentially serious complication of stroke. Despite the recent newly published RCTs, few utilise the same treatment and outcomes thereby limiting the evidence to support the medical effectiveness of common dysphagia treatments used for patients recovering from stroke.