Download Subcut Fluids Summary - Harrogate and Rural District CCG

Subcut fluids made simple in Primary Care
Background
The administration of subcutaneous fluids can provide a safe and effective way of
clinically assisting with hydration and symptom control for palliative care patients
who are unable to take, or absorb, adequate oral fluids.
For detailed protocol in place for community nursing team see the HDFT Clinically
Assisted Hydration in Palliative Care policy May 2016. This includes guidance for
clinicians on Indications for use of subcutaneous fluids and references to national
guidance. There is also GMC guidance which can be found here GMC - Treatment
and care towards the end of life.
Prescription should be by an appropriately qualified medical practitioner or registered
non-medical prescriber. If the patient is known to the Specialist Palliative Care team
a multi-disciplinary discussion and agreement that clinically assisted hydration is in
the patient's best interests should be held prior to these being commenced. The
Specialist Palliative Care Team are available for advice/consultation if required for
any palliative patient where you are considering subcut fluids.
A recent urea and electrolyte result may aid decision making regarding
appropriateness for CAH and whether IV fluids may be more appropriate.
If normal Urea and electrolyte results and patient is not clinically dehydrated then
explanations about the use and limitations of CAH may avoid false expectations for
patients and families.
Up to two litres of fluid a day may be administered subcutaneously. It is more likely
that problems will be fewer if one to two litres are given over 24 hours. If the patient
is able to take oral fluids, then one litre subcutaneously over 24 hours may be
sufficient.
Fluids can be administered continuously or over smaller periods of time if more
convenient for the patient.
Fluids cannot be prescribed on an FP10.
Equipment required:
GP
Subcutaneous Fluids Replacement Therapy Chart (WHZ066) available
via district nursing teams or will be supplied with patient if discharged
from HDFT on CAH. GP needs to prescribe on this.
District Nursing Teams
 Subcutaneous fluid site monitoring sheet also available via district nursing
teams or will be supplied with patient if discharged from HDFT on CAH.
 infusion fluid available via HDFT inpatient pharmacy department or the
vanguard hubs at Hornbeam park, Harrogate or Ripon hospital (awaiting
confirmation). Please call in advance to order and they will ensure the fluid is
available to collect. If the patient is being discharged from HDFT a box of fluid
will be supplied on discharge.
 Saf-T-Intima subcutaneous cannula
 Standard intravenous administration giving set as used by the service
available via HDFT or vanguard hubs.
 A semi-permeable transparent adhesive film dressing
 Sharps container
 Single use disposable non-sterile gloves
 Single use disposable apron
 Bionector
 Stand for the administration of fluids
 2% Chlorhexidine/70% alcohol impregnated wipe
 Water for injection
How to prescribe:
Prescribe on a Fluids Replacement Therapy Chart (WHZ066) on the fluid
replacement page stating that fluids should be administered subcutaneously. The
charts are available via district nursing teams, or will be supplied with patient if
discharged from HDFT on CAH (also see Appendix 1)
What to prescribe:
Current local guidance on what fluids to use is:
0.9% Sodium Chloride should be prescribed in either 500ml or 1000ml volumes.
Please discuss with Specialist Palliative Care team if unsure what to prescribe.
Parenteral fluids should be tailored to the clinical indication for which they are
required, the route they will be given via and the individual patient. If giving fluid
subcutaneously, potassium should not currently be given but other electrolytes
should be given e.g. 0.45% sodium chloride and 5% glucose.
If there are existing deficits or excesses, ongoing abnormal losses or abnormal fluid
distribution, these need to be taken into account in addition.
Fluids that should not be given via subcutaneous administration
• Colloids
• Blood or blood products
• Total parental nutrition ( TPN )
2
• Solutions with added medication
• Glucose solutions > 5%
• Solutions containing potassium
Volume of fluid:
Daily fluid volume requirements should be calculated using the guidance below
•
•
20-25ml/kg/day if older, frail, renal imp, cardiac failure, malnourished.
25-30 ml/kg/day normal population (obese patients use ideal body weight)*.
Palliative care patients will often be malnourished and frail. In addition they often
have low albumin levels and increased levels of ADH with a tendency to retain water.
Therefore, unless there is good reason, they should not usually be given more
than 20ml/kg/day including oral intake of fluid/medications etc. Lesser volumes are
acceptable if the aim of treatment is not simply replacing daily volume requirements
e.g. treatment of a dry mouth, or if there are signs of fluid overload and a more
cautious approach is required.
Preparing the patient and family:
Explain the procedure, indications and aims of subcutaneous fluids to the patient
and/or relatives. This is to remove any misconceptions around the use of
subcutaneous fluids, advising them that they are used only to alleviate symptoms
when the patient is unable to swallow oral fluids and IV fluids are inappropriate or
impractical. They should be informed that ongoing blood monitoring may be required
once fluids are commenced to monitor effects
This discussion and reasoning should be clearly documented.
Prescribing Hyalase:
If the site of subcut fluid infusion needs frequent changes, discuss with the specialist
palliative care team whether the infusion should continue or consider the addition of
Hyaluronidase to aid the absorption of the infusion.
Hyaluronidase is an enzyme that has a temporary and reversible depolymerising
effect on the polysaccharide hyaluronic acid, which is present in the intercellular
matrix of connective tissue.
3
Prescribe as 1500iu of Hyalase® dissolved in 1ml of water for injections, or normal
saline, injected into the site, before the infusion is set up, or injected into the tubing
of the infusion set. This should be prescribed on the community palliative care
medication chart (syringe driver chart) in the regular/prn medication section
(WHZ061)
An FP10 will be required to obtain this from a community pharmacy.1500iu is
sufficient for administration of 500-1000ml of most fluids.
Chris Ranson, HaRD CCG Senior Pharmacist
Dr Sarah Hay, GP Governing Body HaRD CCG
October 2016
Version 2.0
4