Hypodermoclysis: trust in the old ways

Sometimes the simple ways are the best. In a world that prizes sophistication, it is tempting to use the latest techniques and technologies in the belief that they are intrinsically better than more straightforward or older methods. It often pays, however, to question such assumptions and the case of hypodermoclysis is one such example.

A type of subcutaneous or interstitial infusion, hypodermoclysis is a process for the subcutaneous administration of fluids to the body. When used, it is often in situations where a relatively slow rate of fluid uptake is required and, in this application, it offers a number of advantages. Firstly, it is a relatively simple technique. Secondly, it is commonly agreed to be cheaper than alternatives such as intravenous infusion.

Involving only minimal equipment, infusions via the subcutaneous route make it relatively easy to administer fluids to patients, and it is most frequently used in palliative and geriatric care. Some advocates, however, feel that it could be used much more widely in hospital and home care settings, even if patients are not of advanced age or nearing the end of their lives.

Hypodermoclysis and palliative care

One such advocate who works in the palliative care setting has experienced the benefits of using hypodermoclysis, as her work centres on relieving and preventing the suffering of patients.

"Since 1982, I have held many different roles in various hospitals across oncology and palliative care functions, but there has always been one common aspect - the death of patients," explains Cathy Mouchebeuf, a nurse in the mobile palliative care team of a cancer care department. "I have sometimes observed poor quality of care, and in many cases this was because the clinicians did not know how to manage the pain experienced by these patients.

"After working in palliative care, I studied it at university. I am now a nurse working in a mobile team alongside doctors and psychologists, visiting patients when they are referred by clinicians, or when families ask us to come and help. I get requests for advice on how to treat symptoms, particularly pain, and deal with ethical questions such as caring for patients who are mentally ill or who have refused treatment. As a result, I see patients who are very ill, at the end of life or in great pain, and who feel vulnerable, tired or afraid," she says.

Mouchebeuf is devoted to treating pain in a way that supports patient dignity while, at the same time, not adding to their suffering. This is why she views hypodermoclysis as an extremely important technique.

"Subcutaneous infusion allows us to administer treatments in a way that is less invasive and yet achieves similarly good results," she states. "This is an important point because patients often have complex conditions with different symptoms, and this technique is an ideal way of delivering a range of effective treatments.

"The main benefit is that we can place a patient's catheter at their bedside, avoiding the need for patients who are fragile or at the end of their lives to travel to an operating room, as would be required for a more complex technique. Also, hypodermoclysis is much less painful for the patient, which in turn can be less anxiety provoking," she adds.

Dedicated followers of fashion

It is easy to see the benefits of subcutaneous infusion, so one is compelled to ask: why has such a simple, cost-effective and relatively painless method of administering fluids been overlooked?

"I work in a centre where we use state-of-the-art techniques that focus on the comfort of the patient, but in many places hypodermoclysis has fallen out of use," says Mouchebeuf. "Doctors and anaesthetists tend to forget the subcutaneous route as it is an older technique for administering drugs or hydration solutions, but we use it frequently in palliative care.

"Often, we see patients after they have been in the care of other teams and doctors who refuse the help of mobile teams like ours. They prefer more modern techniques and newer technologies, which is why hypodermoclysis may be going out of fashion. In general, medicine prefers progress and favours new techniques. I don't understand the lack of interest in a technique that works so well," she adds.

According to Mouchebeuf - and detailed in 'Competing infusion techniques' - the fashionable techniques that have become most popular are peripherally inserted central catheters (PICC lines) and central venous catheters (CVC lines), although these have their limitations. For instance, PICC and CVC placement are very expensive and require surgical support - a far cry from subcutaneous infusion. When using these techniques, complications can be serious and costly.

Promoting subcutaneous infusion

"The subcutaneous technique has generally been reserved for use in geriatric care; it is not used widely in other services where an IV route is usually preferred," she explains.

"The use of hypodermoclysis could be promoted further through nursing recommendations. As countries see populations age, I believe we may see its use increase, especially in geriatric care, and I hope that it will be better understood as an option at the end-of-life palliative care stage - but it could also see applications in many other settings," she opines.

While subcutaneous infusion could be used more widely than at present, it is through consistent use in palliative care that this technique is likely to increase its prevalence within clinical settings. At least, says Mouchebeuf, this may prove to be the case in France, where government initiatives are pushing for palliative care to become a required element in the training of doctors. Through this, she hopes that more clinicians will understand the benefits of options such as hypodermoclysis - in terms of cost and simplicity of management.

"If it becomes more widely prescribed, doctors will become more aware of the technique and may come to realise that, for patients at the end of life, there is a further benefit - it could be an important way of administering drugs at home, rather than admitting patients to hospital. Subcutaneous infusion is much simpler, requires less medical supervision and has a lower risk of infection than other techniques," Mouchebeuf stresses.