Prescribing staff should consider any ethical implications of the administration of subcutaneous fluid which should be discussed with the patient and / or next of kin and consent to treat obtained. Prescribers will be responsible for ensuring that their instructions are clear and prescribed on a fluid administration chart.

All staff involved must be aware that Intravenous fluids are licensed but prescribed ‘off label’ for subcutaneous route and the implications of this. Refer to the NHS Borders code of Practice for the Control of Medicines (2019).

According to NMC guidelines on record keeping (2009) it is the nurse’s role to ensure that:

• The use of subcutaneous fluids is indicated
• Patients do not have any contraindications for its use
• That fluids prescribed are suitable for subcutaneous administration
• The administration site is individually assessed
• Infusion is documented and monitored
• Infusion will be administered at prescribed rate and completed on time

All registered nurses and assistant practitioners will be required to undertake subcutaneous fluid administration training. Cascade trainers will be identified when staff attend the Subcutaneous training Programme. Cascade trainers will then give training to staff in ward areas. Competency will be recorded on the Competency Assessment Recording System (CARS).

This procedure should be read in conjunction with:

• The National Infection Prevention and Control Manual, page10,
• Personal Protective Equipment
• Zero Tolerance Hand Hygiene Policy
• BodyGuard T Syringe Pump Protocol
• The Consent to Treatment Policy
• NHS Borders code of Practice for the Control of Medicines NMC guidelines on record keeping

Patients with any of the following:

• Patients who are unable to maintain their optimum level of fluid intake
• Vomiting and/or diarrhoea
• Mild to moderate dehydration
• With poor venous access

• Patients requiring large amounts of fluids infused i.e. more than 2 litres in

24hours

• Severe dehydration
• Oedema
• Coagulation disorders
• Where precise rate of infusion is required
• Low platelets
• Fluid overload
• Poor tissue perfusion

        Advantages

• No need to find a vein
• BD Saf-T- Intima can be inserted by any trained nurse
• BD Saf-T- Intima can remain in situ for 7 days
• Very little discomfort or pain
• Incidence of infection is low and localised
• Eliminates the risk of thrombosis
• More cost effective
• No clot formation
• Can be used intermittently

       Disadvantages

• Cannot be used in an emergency
• Cannot be used in a hypotensive patient or a patient in shock
• Cannot be used in patients who require large amounts of fluids
• Only electrolyte solutions can be used
• Has limitations on administration of electrolytes and additives
• Leakage at insertion site
• Poor absorption of fluids in some patients

Localised infection

Medically assisted hydration via subcutaneous infusion in palliative care is provided with the intent of improving quality of life. Some indications when considering subcutaneous fluids are irreversible dysphasia, irreversible bowel obstruction, and symptomatic dehydration secondary to high GI output, or myoclonic jerks and sedation secondary to opioid toxicity. The literature does point to the burdens of subcutaneous infusion treatment such as oedema, site inflammation, ascites and effusions and this should be taken into account when taking the decision around subcutaneous infusion. Good mouth hygiene is paramount and should be the primary management before considering any assessment for subcutaneous fluids.

The Scottish Palliative Care Guidelines (2019) provides a flowchart when assessing for the potential benefits and burdens on an individual basis. https://www.palliativecareguidelines.scot.nhs.uk/media/71354/20-2019-subcutaneousfluids.pdf

The decision to initiate or discontinue subcutaneous infusion at end of life should be taken by the clinician in charge of the patients care and must be based on consideration of the needs and circumstances of the particular individual. Decisions should be promptly communicated and carefully explained to family and loved ones, and decisions should be reviewed regularly.

Hydration is often an emotional topic for families and patients when approaching end of life. There is a necessity for ongoing sensitive discussions about goals of care and realistic expectations of treatment. The views of the patient and any advanced care planning should be considered throughout, and support for the carers when these decisions are being made is essential (Scottish Palliative Care guidelines 2019).

This guideline can support the use of SC fluids in the community only where the patient is thought to be in the last days to weeks of life and hospital admission is not clinically indicated or not wished by the patient. If the clinical assessment is that hospital admission is indicated for parenteral hydration then this should be discussed with the patient. This should not be used to delay an indicated hospital admission. If the patient has made an informed decision not to be admitted to hospital then the option of SC fluids should be considered by the clinician. SC fluids are not appropriate for all patients and will not reverse established dehydration/ acute kidney injury (Guideline for the Administration of Subcutaneous Fluids in a Community Setting During the Last Weeks or Days of Life, 2017). 

All prescriptions should be recorded on NHS Borders Intravenous / Subcutaneous Fluid Prescription chart.

Administration of Fluids

• Infusion will be by gravity only, no infusion pumps to be used
• All fluids must be prescribed on a fluid prescription chart
• All fluids must be recorded on fluid prescription chart
• Any fluid not infused within 24 hours must be removed
• This Cannula is for subcutaneous fluids only, not to be used for other medications
• Administration set should be labelled with date

Fluids which can be safely administered

Isotonic or hypotonic solutions only should be used (for example 0.9% NaCl)  (Scottish Palliative Care Guidelines, 2019)

Suitable infusion sites

Choose a healthy, intact, clean oedema free area. This should have a sufficient fat layer and be suitable for the individual patients comfort and convenience. The most appropriate sites are:

• Lower abdominal wall
• Anterior lateral aspect of the upper arms and thighs
• Anterior chest wall below the clavicle
• Occasionally, the back

For cannula placement and insertion refer to the BodyGuard TSyringe pump Protocol. Please note that upper arms are only appropriate for the administration of small volumes of subcutaneous fluids (less than 30 mls). Do not use on skin that is

• Discoloured
• Over breast tissue
• Near joint
• Oedematous

Refer to the BodyGaurd T Syringe pump guidance for sites to be avoided.

The insertion site should be wiped with a 2% chlorhexidine in 70% alcohol skin cleansings wipe for a minimum of 30 seconds then allowed to air dry  prior  to inserting BD Saf-T- Intima cannula. This is to prevent skin contaminants entering the subcutaneous space.

The dressing should have a semi permeable membrane and should be transparent   to allow staff to observe the insertion site and surrounding skin. The date and time should be documented on the dressing and/or in the patient’s notes.

Once subcutaneous fluid administration is started the following should be documented in the patients notes.

• Position and date of BD Saf-T- Intima cannula insertion
• Which fluids are being administered, batch number, time commenced and the rate the fluids are running. Sign chart for accountability.

The insertion site and flow rate should be monitored 15 minutes after commencement then at 4 hourly intervals or at medicine rounds and documented. Drop rate can be adjusted as required.

• Observe for signs of leakage from insertion site
• Observe for oedema
• Observe for local irritation, infection, bruising and pain
• Change infusion site every 7days or when contraindications occur
• If infusion is continuous infusion, administration set should be changed every 48 hours and documented in notes
• If infusion is intermittent, administration set should be changed with every new bag of fluid
• If complication occurs stop infusion and remove BD Saf-T- Intima cannula

Explain procedure to patient. Obtain consent from the patient and document this in notes. If the patient is unable to consent, ensure Adult with incapacity form has been completed before commencing procedure. Refer to the Consent to Treatment Policy.

• Signed prescription chart
• 24g cannula BD Saf-T- Intima with removable needle Intrafix SafeSet Gravity Giving set
• 9% Sodium chloride 50 mls to prime the Intrafix SafeSet Gravity Giving set
• 2% chlorhexidine in 70% alcohol skin cleansings wipes
• Occlusive dressing
• PPE
• Fluids prescribed, check expiry date
• Sharps container
• Drip stand

PROCEDURE FOR THE ADMINISTRATION OF

SUBCUTANEOUS FLUIDS