Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009 NOTTINGHAM UNIVERSITY HOSPITAL

AL NHS TRUST/NOTTINGHAMSHIRE COUNTY TEACHING PCT CLINICAL GUIDELINES Title of Guideline:

ADMINISTRATION OF SUBCUTANEOUS FLUIDS

Date First Issued: 2004 Version: NUH (1) Author and Job Title: Roz Bexon & Lindsay Hall Macmillan Nurse Specialists based on the version by Sharon Lane and Jean Patterson 2004 Document Derivation: See main references Latest Re-Issue Date: March 2009 Review Date: September 2009 Local Contact including job title and Ext. No. Roz Bexon & Lindsay Hall Macmillan Nurse Specialists ext 54977 Consultation Process: Ward Managers, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Ratification Group, Pain team, Palliative care team, Product Standardisation Group Distribution: Ward Managers, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Ratification Group Plans for audit of guideline:

Ratified by: Nursing Practice Guidelines Ratification Group

Plans for training on/implementing guideline: In local areas as required

Will be audited in individual speciality as appropriate

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using the guidelines after the review date.

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

NOTTINGHAM CITY HOSPITAL/QUEENS MEDICAL CENTRE/NOTTINGHAMSHIRE COUNTY TEACHING PCT NURSING PRACTICE GUIDELINES

ADMINISTRATION OF SUBCUTANEOUS FLUIDS

INTRODUCTION The infusion of a solution into the subcutaneous tissues is called hypodermoclysis. The subcutaneous compartment (hypodermis) is a layer of loose supporting tissue under the skin. Subcutaneous fluid absorption is possible due to the large number of capillaries ensuring complete and rapid absorption from the site. Hypodermoclysis has a number of advantages compared to the intravenous route. These include: ease of administration, low incidence of infection, little pain or discomfort, no need for prolonged immobilisation and minimal medical intervention therefore greater continuity of fluid provision.

INDICATIONS The main indication for hypodermoclysis is dehydration. This technique is particularly useful in the elderly. Clinical situations in which hypodermoclysis should be considered for fluid replacement rather than intravenous infusions are:

When adequate oral fluid intake is not feasible When there is no acute or specific indication requiring a direct intravenous line i.e. mild to moderate dehydration When the establishment or maintenance of an intravenous line presents problems (Khan & Younger 2007)

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

CONTRA-INDICATIONS Hypodermoclysis should not be used for patients who require more than 2-3 litres of fluid in 24 hours (Hypodermoclysis Working Group 1998; Sasson & Shvartzman 2001; Jackson 2004). It should never be regarded as an alternative to the intravenous route and should not be used to treat:

acute life threatening conditions i.e. major dehydration shock diabetic coma (Noble-Adams, 1995)

It should be used cautiously in patients with:

coagulation defects (Noble-Adams, 1995) possible tissue fibrosis resulting from previous radiotherapy, injury or surgery, since absorption will be decreased Pre-existing heart disease. Subcutaneous fluids (like intravenous fluids) can lead to fluid overload. Care needs to be taken with the volume and rate of the infusion as well as the total sodium load. Pre-existing Oedema Poor tissue perfusion i.e. Peripheral Vascular Disease

HAZARDS The main side effect of hypodermoclysis is subcutaneous oedema especially of the gluteal and genital regions (Rafael, Shen & SingerEdelstein, 1981).

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

SITE CHOICE When choosing a site for infusion factors, to consider include: patient mobility comfort access skin condition Any area with adequate subcutaneous tissue may be used. Potential sites include: abdomen anterior and lateral aspects of chest wall anterior thigh upper arm Scapula

(Chan 2001) Areas that should not be used for cannula placement include:

Lymphoedematous limbs: The rate of absorption would be adversely affected. A break in the skin integrity would increase the risk of infection in a limb that is already susceptible. Over bony prominences: The amount of subcutaneous tissue is diminished therefore impairing the rate of absorption. Previously irradiated skin areas: Radiotherapy can cause sclerosis of small blood vessels, thus reducing skin perfusion. Near a joint: Excessive movement may cause cannula displacement and patient discomfort. Near a surgical or chronic wound site. Sites of infection Areas of inflammation (Sasson & Shvartzman 2001; Dougherty & Lister 2007; RCN 2005)

To maximise absorption, rotate the infusion site and document accordingly. Indicators for the need for Rotation are:

pain at administration site localised inflammation skin surrounding insertion site becoming white and hard blood is present in giving set/butterfly dislodged needle localised oedema bleeding/bruising
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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

Best Practice When resiting or restarting an infusion, it is recommended that the site selected is rotated using a figure of eight principle to maximise site absorption. (Brown and Worobec 2000; RCN 2005)

TYPE OF INFUSION FLUID The type of infusion fluid administered depends on patient requirements. The solution must be isotonic e.g. 0.9% normal saline or 4% glucose in 0.18% saline. Non electrolyte containing isotonic solutions i.e. 5% glucose should alternate with 0.9% normal saline, as electrolyte free solutions can lead to fluid shift (Khan, Shah & White, 1996). Solutions containing up to 34 mmol potassium/litre fluid may be given however there is a risk of local ulceration with a higher concentration of potassium (Barua & Bhowmick 2005). If irritation occurs at the cannula site, infusion without potassium should be used instead.

Best Practice

CHOICE OF BUTTERFLY

There is evidence to suggest (Dawkins et al; 2000 Braua & Bhowmick 2005) that metal butterfly cannulae can be uncomfortable and cause small localised abscesses. Cannulae with removable inner metal inserts are favoured e.g. Teflon reduces insertion site complications and the need for frequent needle changes. (Ross et al 2002; Centre for Reviews & Dissemination 2005; Khan & Younger 2007) The Product Standardisation Group, NUH is currently reviewing products to standardise a device. For further advice contact NUH Palliative care or Pain team Ext.54977.

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

EQUIPMENT LIST Gloves Butterfly cannula (gauge 21or 25) (See Best Practice Box above) Semi-permeable occlusive dressing Choloprep swab Fluid for administration Intravenous infusion giving set Prescription chart See General Principles for All Procedures Best Practice Cleaning the Site

Alcohol combined with chlorhexidine is the cleaning agent of choice and the most suitable and practical option (Jackson 2004, RCN 2005)

ACTION 1. Site butterfly according to guidelines for Siting a Subcutaneous Infusion Device. Mark on film dressing date and time of insertion. 2. Check the patient details, on the prescription chart, with the patient. Check with the prescription chart that the type of fluid, route and rate is correct (refer to local drug administration policy). 3. Prime the giving set following the procedure for Setting Up an Intravenous Infusion. 4. Attach butterfly cannula to luer end of giving set and regulate the prescribed flow rate and monitor rate of infusion.

RATIONALE To ensure butterfly is correctly sited prior to administration of fluid. To facilitate site rotation.

To ensure correct fluid is administered to the correct patient.

To ensure no air is present in the giving set.

To ensure the patient receives the prescribed amount of fluid.

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

Best Practice

RATE OF INFUSION

The rate of administration is generally less than 125ml/hr provided that the total daily volume does not exceed 2-3 litres in 24 hours (Abdulla & Keast, 1997; Khan et al, 1996; Barua & Bhowmick 2005). Solutions should be infused by gravity rather than controller as this reduces the chance of local oedema formation (Noble-Adams, 1995).

Best Practice

CARE OF SITE

The site should be checked every 4 hours for bruising, reddening, oedema, leaking, pain, pooling or unresolved blanching. It is recommended that the insertion site should be rotated after infusion of a maximum of two litres of fluid at a rate of approximately 1ml per minute (Sasson & Shvartzman 2001) The Infection Control Team advise that the giving set should always be changed with each new butterfly insertion.

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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

REFERENCES Barua P, Bhowmick BK (2005) Hypoderclysis a victim of historical prejudice. Age and Aging 34, 3, 215-217 Brown MK, Worobec F (2000) Hypodermoclysis another way to replace fluids. Nursing 30, 5, 58-59 Centre for Reviews & Dissemination (2005) A prospective, within-patient comparison between metal butterfly needles & Teflon cannulae in subcutaneous infusion of drugs to terminally ill hospice patients. September, NHS Economic Evaluation Database Chan H (2001) Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin. Journal of Advanced Nursing. 35,6 882-892 Dawkins L, Britton D, Johnson I, Higgins B, Dean T (2000) A Randomised Trial of Winged Vialon Cannula and Metal Butterfly Needles International Journal of Palliative Nursing Vol. 6, No. 3 Dougherty L, Lister S (2007) (Eds) The Royal Marsden Hospital Manual of Clinical Procedures. Seventh edition Whiley-Blackwell Publishing, Oxford 202- 253 Hypodermoclysis Working Group (1998) Hypodermoclysis: Guidelines on the Technique. CP Pharmaceuticals Ltd, Wrexham Jackson A (2004) Subcutaneous fluid administration (hypodermoclysis). Unpublished internal policy document Khan I, Shah I , White A (1996) The use of subcutaneous fluids in elderly patients Reviews in Clinical Gerontology Vol. 6 No. 1 pp. 115-116. Khan M, Younger G (2007) Promoting safe administration of subcutaneous infusions. Nursing Standard. 21. 31, 50-56

Noble-Adams, R (1995) Dehydration: Subcutaneous Fluid Administration British Journal of Nursing Vol. 4 No 9 pp. 488-494 Rafael J, Shen M B, Singer-Edelstein M (1981) Subcutaneous Infusions in the Elderly Journal of the American Geriatrics Society Vol. 29 pp. 583-585
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Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

Royal College of Nursing (2005) Standards for Infusion Therapy. RCN, London Ross et al (2002) A prospective, within patient comparison between metal butterfly needles and Teflon cannulae in subcutaneous infusions of drugs to terminally ill hospice patients. Palliative Medicine 16: 13-18 Sasson M, Shvartzman P (2001) Hypodermoclysis an alternative infusion technique. American Family Physician 64, 9, 1575-1578

FURTHER READING Bavin L (2007) Artificial rehydration in the last days of life: is it beneficial? International Journal of Palliative Nursing Vol 13 No9 Challiner Y C, Jarrett D, Hayward M J, Al Jubouri M A, Julious S A (1994) A comparison of intravenous and subcutaneous hydration in elderly acute stroke patients Postgraduate Medical Journal Vol. 70 pp. 195-197 Mansfield S, Monaghan H, Hall J (1998) Subcutaneous Fluid Administration and Site Maintenance Nursing Standard Vol. 13 No 12 pp. 56-62 OKeeffe S T, Lavan J N (1996) Subcutaneous Fluids in Elderly Hospital Patients with Cognitive Impairment Gerontology Vol. 42 pp. 36-39 OKeeffe S T, Georghegan M (2000) Subcutaneous hydration in the Elderly Irish Medical Journal Vol. 93 No. 7 Remington R, Hultman T (2007) Hypodermoclysis to Treat Dehydration: A Review of the Evidence Reynolds A (2004) Changing practice in subcutaneous infusions of fluids to improve safety. Professional Nurse 20, 3 50-51 Slesak G, Schnurle JW, Kinzel E, Jakob J, Dietz K. (2003) Comparison of subcutaneous and intravenous hydration in Geriatric Patients Journal of the American Geriatric Society Vol. 51 No. 2 pp. 155-160 Walsh G (2005) Hypodermoclysis: An alternative method for rehydration in long-term care. Journal of Infusion Nursing 28, 123-129

SubCut Admin, 2009

Ratified March 2009 Trustwide standardisation of cannula currently in progress Further review September 2009

Authors: Roz Bexon & Lindsey Hall Macmillan Nurse Specialists based on Version 2004 by Sharon Lane & Jean Patterson NNPDG Member: Ellie Dring

For Review: September 2009

STANDARD AUDIT POINTS

1. 2.

Is there documented evidence of site rotation? Can you identify the date and time of current cannula insertion; is this documented? Was the site condition checked and is there documented evidence of this?

3.

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