What is the recommended protocol for subcutaneous hydration in patients with dehydration?

Subcutaneous Hydration Protocol for Dehydration

Subcutaneous fluid administration (hypodermoclysis) is recommended as an effective and safe hydration technique for patients with mild to moderate dehydration, offering similar effectiveness to intravenous hydration with fewer complications and lower costs. 1

Assessment of Dehydration

• Dehydration should be diagnosed using measured serum or plasma osmolality >300 mOsm/kg (or calculated osmolarity >295 mmol/L) 1
• For volume depletion assessment in older adults, look for at least four of these seven signs: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, and sunken eyes 1
• In cases of blood loss, assess for postural pulse change (30 beats per minute) or severe postural dizziness resulting in inability to stand 1

Indications for Subcutaneous Hydration

• Mild to moderate dehydration in patients who appear unwell 1
• When oral intake is insufficient but intravenous access is difficult, not tolerated, or undesirable 2
• Particularly beneficial for older adults and patients receiving palliative care 1, 3
• Can be administered in multiple settings including hospitals, nursing homes, and home care 2

Subcutaneous Hydration Protocol

Solution Selection

• Use isotonic fluids for rehydration 1
• Recommended solutions include:
  • Half-normal saline-glucose 5% (40 g/L dextrose and 30 mmol/L NaCl) 1
  • 5% dextrose solution with 4 g/L NaCl 1
  • Two-thirds 5% glucose and one-third normal saline 1
• Potassium chloride can be added if needed 3

Administration Technique

• Insert small-gauge needles into subcutaneous tissue 2
• Common infusion sites: chest, abdomen, thighs, and upper arms 3
• Maximum volume: approximately 3L in 24 hours using two separate sites 3
• Hyaluronidase can be added to enhance fluid absorption if needed 3

Monitoring and Complications

• Monitor for local edema, which can be treated with local massage or systemic diuretics 3
• Re-siting of infusion may be required (13% of cases compared to 23% for IV) 1
• Agitation related to fluid provision is significantly less common with subcutaneous (37%) than with intravenous (80%) administration 1

Special Considerations

• For severe dehydration or when greater fluid volumes are needed, intravenous fluid administration should be considered 1
• Continue to encourage oral fluid intake in parallel with subcutaneous hydration when possible 1
• Subcutaneous hydration can be administered at home by family members or nurses with proper training 3
• Contraindications include coagulation disorders, dermatological problems at the infusion site, and severe malnutrition with lack of subcutaneous tissue 1

Advantages Over Intravenous Hydration

• Easier application with lower cost 2
• Fewer serious complications, particularly infections 2
• Lower rates of agitation in older adults 1
• Can be administered in home settings with minimal training 3, 4
• Similar effectiveness in correcting dehydration compared to IV route 2

Transitioning From Subcutaneous Hydration

• Reassess hydration status regularly until corrected 1
• Once dehydration is resolved, transition to oral hydration with preferred beverages when possible 1
• For older adults in institutions, implement multicomponent strategies to support adequate fluid intake 1