Monday, December 19, 2011

Dermoclysis - Subcutaneous Hydration for the Remote Medic

   Dermoclysis is the infusion of sterile saline fluids into the subcutaneous space in the belly of the casualty. For the Remote Medic, it is important to have the medical skills to deal with a hypovolemic casualty who needs rehydration fluids but who does not have an easily obtainable intravenous access. 

   Dermoclysis is also known as hypodermoclysis, proctoclysis, rectoclysis, interstitial infusion, subcutaneous infusion and Murphy's Drip, is the subcutaneous administration of fluids to the body. This would often be in the form of a saline or glucose solution.
   Hypodermoclysis can be used where a slow rate of fluid uptake is required compared to intravenous infusion. Typically, it is limited to 1 ml per minute, although it is possible to increase this by using two sites simultaneously. The chief advantages of hypodermoclysis over intravenous infusion is that it is cheap and can be administered by non-medical personnel with minimal supervision. It is therefore particularly suitable for home care.

   For the Remote Medic, this is a relatively safe option for those who are not up to their cannulation skills. It is the least preferable option for rehydration but it is better then nothing. The casualty should also be encouraged to drink fluids as well as tolerating the dermoclysis. 

   This technique was first documented for cholera patients in the 19th century.
The operation of hypodermoclysis was first employed by Cantani, at Naples, during the epidemic in 1865, and was again used by him with great success in1885. The operation was one of great simplicity, requiring for this purpose a small- sized aspirating needle and canula,which is attached to the rubber tube of an ordinary fountain syringe. The best point for the introduction of the needle is in the flanks between the ribs and the crest of the ileum; the inner surface of the thighs may also be used. 

    Currently there is plenty of research stating that dermoclysis is a viable source for rehydrating the geriatric casualty. 
As the world's population ages, chronic and degenerative diseases are rising. This scenario demands the development of new treatment techniques with lower costs, which are as efficient as the existing ones.Hypodermoclysis is the infusion of fluids into the subcutaneous tissue with a butterfly needle. This technique may be used for isotonic fluid replacement and to administer cytosine arabinoside, clodronate, antibiotics and narcotic analgesics.This review evaluates the evidence supporting the use of hypodermoclysis to treat elderly patients with dehydration and patients with terminal cancer, and discusses its indications, adverse effects and perspectives. A MEDLINE search of the last 30 years was done to recover all available literature.Hypodermoclysis therapy is a safe and effective method to provide fluids and narcotic analgesic therapy in elderly patients that are mild and moderate dehydrated and in patients with cancer. It seems a good option to provide antibiotics, but there is a need for more studies to evaluate this indication.

   The Remote medical professional should not overlook the rectal rehydration options as well. There will be other blog entries for rectal rehydration.

   The bottom line is this: We practise medicine in remote, austere and wilderness conditions. We don't always have easy access to medical kit or sterilisation options. We need to have a skill set that can address these issues while still providing scientifically based medical skills. 
   In remote areas, hydrating the trauma casualty can be challenging at best. The Remote EMT should be comfortable with their skill set to provide multiple options for rehydrating their casualty. Normal IV cannulation, drinking fluids, dermoclysis, and rectal rehydration should all be familiar for anyone practicing in austere conditions.

More information can be found at Remote Medicine Ireland.

1. Wikipedia
2. Remington, R. and Hultman, T. (2007), Hypodermoclysis to Treat Dehydration: A Review of the Evidence. Journal of the American Geriatrics Society, 55: 2051–2055. doi: 10.1111/j.1532-5415.2007.01437.x
3. Subcutaneous Hydration By Hypodermoclysis: A Practical and Low Cost Treatment for Elderly Patients
Authors: Frisoli A.J.1; de Paula A.P.2; Feldman D.2; Nasri F.1
Source: Drugs & Aging, Volume 16, Number 4, 1 April 2000 , pp. 313-319(7)

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