How and why are subcutaneous fluids administered in an advanced illness population: a systematic review

Abstract

In the absence of sufficiently powered robust evidence, the mode of delivery of artificial hydration at end of life remains in the gloaming between evidence and unfounded habit.

Availability and perceived usefulness of guidelines and protocols for subcutaneous hydration in palliative care settings

“…Considering this perspective, the results on the availability of and adherence to hydration guidelines and protocols could be explained, first, by the scarce and controversial evidence in favour of assisted hydration in patients with palliative needs and end‐of‐life situations (Forbat et al, ). In addition, they could be a consequence of the need, according to the participants, to personalise patient care plans, as suggested by previous studies (Arts et al, ), or they could be because this type of intervention is considered a basic level of care and not a medical treatment.…”

“…In consonance with other authors, these tools are seen to facilitate decision-making processes and diminish variability in clinical practice and ongoing training, with the main disadvantages being the lack of potential for personalising care plans (Beghi et al, 1998;Fischer et al, 2016;Gundersen, 2000;Woolf, Grol, Hutchinson, Eccles, & Grimshaw, 1999) and the perception of such interventions as a basic level of care given the symbolic value of hydration (Cabañero-Martínez et al, 2016;Gent et al, 2015). Considering this perspective, the results on the availability of and adherence to hydration guidelines and protocols could be explained, first, by the scarce and controversial evidence in favour of assisted hydration in patients with palliative needs and end-of-life situations (Forbat et al, 2017). In addition, they could be a consequence of the need, according to the participants, to personalise patient care plans, as suggested by previous studies (Arts et al, 2016), or they could be because this type of intervention is considered a basic level of care and not a medical treatment.…”

Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews

“…Interestingly, another study of 100 terminally ill patients concluded that SC is useful and safe, with a maximum 1708 mL/24 h [41]. However, Forbat et al [42] concluded from their systematic review of 14 studies investigating subcutaneous hydration at end of life that there is a lack of empirical evidence to guide use of this therapy. Typical solutions in the elderly and palliative population were either sodium chloride (0.45% or 0.9%) or, more commonly, a dextrose/saline solution.…”

“…No studies compared the safety or efficacy of these specific hydration solutions. There is insufficient evidence to recommend Ringer [16,39,42]; upper extremities (deltoid region preferred) [16,39,42]; flank [26]; hips [26]; thighs d [39,42] Contraindicated: bony prominences [16]; joints [16]; previous surgical incision [16]; radiotherapy [16]; damaged skin [16]; intercostal space in cachectic patients (high risk of pneumothorax) [39]; near mastectomy, tumour, ascites, lymphedema [39]; inner thigh if urinary catheter [39]; thigh if peripheral vascular insufficiency [39] Cleanse skin with povidone-iodine or chlorhexidine 2%. Flush cannula with at least 0.…”

“…Duration of treatment ranged from a mean of four to 21 days for SC hydration in 1 review with an average of 10.5 days [46], and as long as three to six months in another review [16]. In the palliative population, durations ranged from three weeks to six months, or one to three days [42]. Table 4 provides a summary of the outcomes of the findings from the RCTs and prospective cohort studies included in the systematic reviews of subcutaneous hydration infusions (as detailed in S6 Table).…”