Wydase

By opting for this effective alternative to I.V. therapy, you can spare your elderly patients the stress of venipuncture.

ROBERT ALVAREZ, 82, was admitted to our chronic care facility following a debilitating stroke. When he developed a urinary tract infection, he became increasingly confused and stopped drinking adequate fluids. Despite the nursing staff's attempt to push fluids, he became dehydrated. Eventually, he was transferred to an acute care facility for intravenous (LV ) fluid replacement. When he returned to us, bruised from several unsuccessful venipuncture attempts on his fragile veins, he required intensive physical therapy to reverse the deconditioning he experienced from prolonged immobilization.

If Mr. Alvarez developed a similar problem today, we'd probably treat him in a less invasive, less costly way-with hypodermoclysis, or rehydration via subcutaneous infusion. A therapy that can be provided in various subacute settings, hypodermoclysis can often correct fluid deficits without the stress of LV therapy or enteral tubes. It's particularly beneficial for elderly patients, who may not tolerate the stress of hospitalization and more invasive treatments well.

In this article we'll explain when it's indicated and offer guidelines for managing therapy.

Short-farm option

Consider hypodermoclysis as a treatment for short-term, reversible fluid deficits if the patient:

doesn't need rapid or emergency LV fluid replacement

needs less than 3,000 ml of fluid per 24 hours

has no bleeding or coagulation disorders

has intact skin sites available for insertion of a wingedtip needle.

For ethical reasons, hypodermoclysis may not be appropriate for patients who are near death and those whose fluid deficit isn't caused by a reversible condition.

Fluids infused subcutaneously must be isotonic; for example, either 0.9% sodium chloride or a mixture of 5% dextrose (twothirds) and 0.9% sodium chloride (one-third). Don't use dextrose 5% or 10% solutions alone. Although 5% dextrose is isotonic, it becomes hypotonic in the body because it metabolizes so quickly.

To facilitate fluid absorption from subcutaneous tissue, we add the enzyme hyaluronidase (Wydase) to the infusion (150 ml per 1,000 ml of infusion fluid). Because hyaluronidase can cause allergic responses, inject a test dose of the fluid and hyaluronidase solution subcutaneously before initiating therapy. (Avoid sites that are inflamed, infected, or cancerous.) A positive reaction includes a wheat within 5 minutes and persisting, with itching, for 20 to 30 minutes. Although you can infuse fluid subcutaneously without hyaluronidase, fluid may not be well absorbed and redness at the site is more likely. If you decide to proceed with hypodermoclysis, the infusion may have to run slower and the site may need to be changed more often; check it frequently for proper absorption.

Choosing an infusion site

The best infusion sites include the anterior and lateral aspects of the thighs and hips, upper abdominal wall, and intraclavicular areas. Avoid sites on the arms because fluids are absorbed better from central sites with large stores of adipose tissue.

Don't use sites that are edematous, painful, hard, bruised, or scarred. Also avoid sites near breast tissue (fluid may drain into the axillary lymph glands) or the perineum (fluid may drain into the scrotum or labia).

Initiating therapy

Follow your facility's protocol for initiating hypodermoclysis therapy. After completing the test dose of hyaluronidase, our facility's protocol includes the following steps:

If the test dose was negative, inject the ordered dose of hyaluronidase into the bag of isotonic solution and shake the bag to distribute the medication. If the test dose was positive, withhold hyaluronidase and try to administer the infusion without it. Watch the patient closely for signs of fluid pooling.

Attach the infusion tubing to the bag and a 25-gauge winged-tip needle and prime the tubing and needle.

Clean the insertion site.

Insert the needle into the subcutaneous insertion site and tape securely.

Begin the infusion at 30 ml/hour and monitor the patient's response. If he tolerates this rate well for 1 hour, increase the rate as ordered, to a maximum of 80 ml/hour. In our facility, a typical infusion rate is 75 ml/hour to a maximum of 2,000 ml/24 hours.

Monitor the patient's response to treatment. Watch for respiratory distress and other signs of fluid overload.

Check the site every hour for redness, swelling, pain, or leakage. Change the site at least once every 72 hours or at the first sign of a local complication.

Troubleshooting tips

Most problems associated with hypodermoclysis are minor and easily remedied by changing the infusion site. Here are the most common complications and the appropriate interventions:

redness at the insertion site. Remove the needle and restart the infusion at another site.

pooling of the fluid at the infusion site. This problem is caused by poor absorption by tissue and possibly infusing at a rate too fast for optimal absorption. It can be handled by restarting the infusion at another site or by increasing the dose of hyaluronidase, as ordered.

sporadic drip rate. Try adjusting the height of the I.V. bag. You can also use an infusion pump to control the flow rate.

adverse reaction to hyaluronidase. Signs and symptoms include local edema or urticaria, erythema, chills, nausea, vomiting, dizziness, tachycardia, and hypotension. The test dose should prevent an adverse reaction; should it occur, stop the infusion immediately and notify a physician.

fluid overload. This is unlikely if you limit the infusion rate to no more than 80 ml/hour (2,000 ml/ 24 hours). Patients should be monitored closely. If it occurs, however, stop the infusion immediately and notify a physician.

A better way

Now let's consider how you could use hypodermoclysis to Mr. Alvarez's benefit. Instead of arranging for his transfer to an acute care facility, you obtain an order for hypodermoclysis therapy at 75 ml/hour for 7 days and initiate therapy in his left lateral thigh. The staff continues to push fluids (100 ml/hour PO.) and administers an oral antibiotic to treat the urinary tract infection, as ordered.

Somewhat confused and restless, Mr. Alvarez dislodges the subcutaneous needle several times. However, the nursing staff easily restarts the infusion at another site.

After 3 days, Mr. Alvarez is less confused and drinking well. His dry mouth disappears and his skin turgor returns to its baseline state. When his oral fluid intake exceeds 1,000 ml/day, the physician discontinues the order for hypodermoclysis.

Thanks to hypodermoclysis, Mr. Alvarez is successfully treated for dehydration in a familiar environment, without the stress and expense of hospitalization and LV therapy. By following the guidelines we've outlined here, you can offer your elderly patients the same benefits.

SELECTED REFERENCES

Constans, T., et al.: "Hypodermoclysis in Dehydrated Elderly Patients: Local Effects with and without Hyaluronidase," Journal of Palliative Care. 7(2):10-12, Summer 1991,

Hussain, N., and Warshaw, G.: "Utility of Clysis for Hydration in Nursing Home Residents," Journal of the American Geriatrics Society. 44:969-973, August 1996.

Worobec, F, and Brown, M.: "Hypodermoclysis Therapy in a Chronic Care Hospital Setting," Journal of Gerontological Nursing. 23(6):23-28, June 1997.

BY MARY K. BROWN, RN, PhD

Professor Department of Nursing Mohawk College of Applied Arts and Technology Hamilton, Ontario, Canada

FRAN WOROBEC, RN, MHSc

Clinical Nurse Specialist St. Peter's Hospital Hamilton, Ontario, Canada

Copyright Springhouse Corporation May 2000
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