Author: Robin Fainsinger
The decision to use or withhold non-oral hydration near the end-of-life is complex (see FF #133). This Fast Fact reviews the technical aspects of providing non-oral hydration.
The use of enteral feeding tubes to provide nutrition is beyond the scope of this Fast Fact (see FF #10, 84). If already in place, enteral feeding tubes provide easy access for supplemental hydration. Placement of enteral tubes solely for hydration management in the last few weeks of life is generally not indicated, as other methods of hydration can be provided (see below).
This method includes hydration via peripheral or central catheters. For short-term use, especially as a time-limited trial, intravenous hydration is a reasonable step. However, both peripheral and central catheters are plagued with problems of site selection/placement/maintenance, clot formation, local skin irritation and local or systemic bacterial infections.
Hypodermoclysis offers a number of advantages compared to the intravenous route due to greater ease of site access, the possibility of temporary disconnection to facilitate patient mobility, and ease and suitability for home administration. Thrombocytopenia may be a relative contraindication. Solutions with electrolytes should be used (e.g. 0.9% sodium chloride), as non-electrolyte solutions (e.g. 5% dextrose) can draw fluid into the interstitial space. Continuous infusion rates up to 120 cc/hr have been reported; patients can tolerate boluses of up to 500 cc/hr two to three times per day. Traditionally the use of hyaluronidase to promote absorption was recommended. More recent experience has demonstrated that most patients will achieve good absorption of SQ fluids without hyaluronidase. Winged infusion sets with 25 – 27 G needles are recommended. Check the site frequently for redness, irritation, excessive edema, or a dislodged needle. If there is a problem with absorption it recommended to a) s low the infusion rate and consider using an infusion pump or b) consider dividing the total volume into two separate SQ sites.
Rectal hydration is an alternative only when other resources are not available. A 22 French nasogastric catheter can be inserted approximately 40 cm into the rectum. The patient can be positioned as for any rectal procedure. Tap water can be used, and the rectal infusion increased from 100 cc to a maximum of 400 cc per hour, unless fluid leakage occurs before the maximum volume is achieved. The majority of patients can successfully tolerate this approach at a volume of 100 to 200 cc per hour.
For all routes, a reasonable goal is 1.0-1.5 L/day in fluid volume.
Fast Facts were edited by David Weissman MD,
Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fainsinger R . Non-oral hydration in palliative care. Fast Facts and Concepts #134: April 2005. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.
Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
Creation Date: 4/2005
Purpose: Self-Study Guide, Teaching
Audience(s)
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Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice |
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Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery |
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Non-Physician: Nurses |
ACGME Competencies: Medical Knowledge, Patient Care, Systems Based Practice
Keyword(s): Non pain symptoms & syndromes