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Initiation and administration of the infusion
Patients do not require routine referral to specialist palliative care teams solely due to commencing subcutaneous fluids. However, there may be situations where this is helpful, including where decision making about fluid administration is complex, or where discussion occurs about transfer of a patient to an alternative care setting with subcutaneous fluids in place.
Once referred, the Specialist Palliative Care team may be involved in the ongoing review of care for patients receiving subcutaneous fluids.
Administration of subcutaneous fluids can be commenced by any registered nurse who is competent to administer subcutaneous injections and insertion of a subcutaneous needle. No formal training is required as the skills required to site a subcutaneous needle and to care for an infusion set are covered in current syringe driver training. However, it is recognised that this may be a new area of practice for staff so individual organisations may wish to develop a competency framework for this intervention.
The fluid of choice is sodium chloride 0.9% or dextrose saline (glucose 4% and sodium chloride 0.18%), which can be given as an infusion or in boluses up to a maximum of 2 litres per 24-hour period (see below). Other fluids or medications should not be administered via this route
Infusion Regimen
Maximum continuous infusion rate: up to 100ml/hour
Maximum infusion volume: usually two litres over 24 hours with a maximum of 1.5 litres at any one site 1,6
Maximum bolus dose: 500ml over one hour
The infusion may be given:
- Continuously
- Overnight
- In boluses of 500ml per hour, two to three times each day with or without hyaluronidase
The following equipment will be required:
- standard intravenous infusion set, for example solution set orange Y-site luer lock (Codan- 370001)
- sodium chloride 0.9% or dextrose saline one litre infusion bags
- Hyaluronidase 1,500units ampoules (if required)
- Drip stand
- Cannula with a safety system (the use of Teflon or Vialon cannula instead of metal needles reduces insertion site complications and the need for frequent needle changes)
- A clear adhesive dressing
- Appropriate skin cleansing apparatus
- Label to date the intravenous infusion set
The required consumables are all available from NHS supply chain.
Sodium Chloride 0.9% and glucose 4% & sodium chloride 0.18% are classed as medicines and can therefore both be prescribed on FP10 prescription. Where prescribers have difficulty locating this on an electronic system they can handwrite a prescription.
Sodium Chloride 0.9% and glucose 4% & sodium chloride 0.18% are available through all wholesalers in 500ml and 1000ml infusion bags, therefore, Community Pharmacies are able to supply both products. There may be a short delay whilst these are ordered. Please see the Specialist Palliative Care Drugs Supply Scheme for details of Pharmacies on the scheme who are commissioned to hold agreed fluids for infusion at all times. Community Pharmacies may claim broken bulk on supplies of individual bags for infusion made against a single prescription.
When choosing the site for infusion placement the following should be considered:
- Patient comfort and safety
- Loose subcutaneous tissue allows ease of larger volume of fluid
- Whether the patient is mobile
The abdomen, chest and lateral aspects of the upper arm or thigh are recommended sites. The following should be avoided:
- Lymphoedematous / oedematous tissue as absorption will be restricted and problems with skin integrity could increase risk of infection
- Bony prominences
- Areas of skin with a rash, broken skin, areas of inflammation or infection
- Sites of tumour
- Peripheral limbs (distal to knees or elbows)
- Recently irradiated skin sites
The subcutaneous needle should be inserted using standard precautions and aseptic technique. A sterile, transparent, occlusive dressing should be used to cover the administration site.
Subcutaneous fluids should only be infused via gravity and calculating the drip rate, using a drip stand and standard IV giving set connected to a long tube butterfly needle, or preferably a Teflon catheter i.e. softset via luer lock connections. The needle should be of the smallest gauge and shortest length necessary to obtain subcutaneous access.
SC fluids should not be infused using a pump. This is because forcing fluid into subcutaneous tissue can increase the risk of local reactions. The drip rate should be as per fluid prescription chart, though adherence to exact flow rate is not imperative (see 6.4). The following formula may be used to calculate the required drops per minute, but the number of drops per ml for the particular giving set being used must be known (on the giving set pack)
Number of drops per minute = Volume of fluid (mls) x Number of drops per ml
Duration of Infusion (minutes)
The number of drops per ml for the giving set can usually be found on the packet.
Administering an infusion in the home
When administering an infusion in the home it is important to:
- Ensure that the carers are not responsible for the ongoing monitoring and adjustment of the infusion unless they have been given specific training and there is an agreement that this is appropriate
- Give advice to the carer about what to do if the infusion finishes early
- Give advice to the carer about what to do if the infusion becomes dislodged
Patients undergoing subcutaneous fluid infusion should undergo a clinical assessment every 24 hours. This may be done by a member of the hospital team, primary care team or specialist palliative care team. The infusion should be checked at each visit for flow rate, site integrity and leakage.
An assessment of the ongoing benefits or harms of subcutaneous fluids should take place at each clinical assessment. Continue subcutaneous fluids if they are giving symptomatic benefit. Stop subcutaneous fluid infusions if they are causing harm to the dying patient or they no longer wish to continue. Document the rationale for the decision.
Administration of subcutaneous fluids should be recorded in the patient’s care plan in accordance with local Medicines Management Policy.
In addition to the date and time of commencement of infusion, the following should be recorded:
- Insertion site, including whether cannula has been re-sited and condition of surrounding skin
- Type of cannula and giving set used
- Expected time of end of infusion and actual time infusion ended, plus reasons for any variance
- Patient’s response to therapy and any adverse effects observed
The giving set should be changed every 72 hours or more frequently if the site is changed.
For more details of the procedure associated with the administration of subcutaneous fluids see The Royal Marsden Hospital Manual of Clinical Nursing Procedures (look for hypodermoclysis) 4.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.