今日の臨床サポート

輸液と中心静脈栄養(在宅医療)

著者: 小野沢滋 みその生活支援クリニック

監修: 和田忠志 いらはら診療所 在宅医療部

著者校正/監修レビュー済:2022/10/12
患者向け説明資料

概要・推奨   

  1. 在宅で補液をおこなう場合、患者の快適さや安全性などから、高齢者の場合には皮下輸液を第一選択と考えて良い。
  1. 悪性腫瘍終末期の中心静脈栄養は症状増悪および生命予後を短縮するのリスクとなり得る。中止を考慮すべきである。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小野沢滋 : 特に申告事項無し[2022年]
監修:和田忠志 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 皮下補液についての項目を改定した。薬剤投与経路としての皮下注射についても可能な限り記載を行った。

まとめ

まとめ  
  1. 在宅医療の輸液は①経口摂取不十分時の脱水予防、②経口摂取不可能時の家族希望の充足、③中心静脈栄養――の3つの目的で行われることが多い。 >詳細情報 
  1. アクセスルートとしては、末梢血管、中心静脈に加え、皮下注射の経路が用いられる。
  1. 持続大量皮下注射は経口摂取不十分時の脱水予防や、少量補液で1日量が1,000ml以下、等浸透圧補液で賄える場合に用いることができる。
  1. 終末期患者に対しての末梢からの少量補液が症状改善につながるという根拠は薄弱である[1]。多くの場合、家族や本人の心理的要因の緩和のために行うと考えたほうがよい。
  1. 在宅中心静脈栄養法(Home Parenteral Nutrition、HPN)には、Hohn カテーテル、埋込み型中心静脈ポート(<図表>)、トンネル型カテーテル、PICCカテーテル(<図表>)、が用いられており、留置期間によって使い分ける。 >詳細情報 
  1. 長期的なHPN、特に短腸症候群が原疾患のHPNでは脂肪肝から肝硬変を来すことがある。頻度は報告によりさまざまであるが、報告によっては長期例の42%が重症化するという報告もある[2]
  1. HPNによる肝疾患の予防には、ウルソデオキシコール酸[3]や、積極的な経口摂取の併用[4]などがある程度有効といわれているが、確立された方法はない。
  1. HPNを余命が短い(例えば週単位など)悪性腫瘍の患者に行う場合、適応外と考えられていること[1][5][6][7]をきちんと認識したうえで、患者に利益があると個別に判断した症例にのみ行うべきである。
  1. 終末期の患者で中心静脈栄養がなされ、倦怠感や気持ちの悪さを訴えている場合、経験上、高カロリー輸液の中止で症状が改善することが多い。
  1. 悪性腫瘍におけるHPNの最もよい適応は、上部消化管狭窄で長期予後が推測される場合である[5]
  1. HPNは経腸栄養などと比較して合併症の発生頻度が高く、catheter related bloodstream infection(CRBSI)を常に念頭に置く必要がある。HPNのルート閉塞は比較的頻回に起きる。閉塞時の対処としてはウロキナーゼ6,000~1万単位/mLとしたものをルート内に注入し、2~3時間ほど放置する方法が有効である[8]。改善しない場合には画像診断を考慮する。

問診、診察のポイント

問診、診察のポイント  
  1. 終末期悪性腫瘍の場合には、TPN施行によって、患者に不利益がもたらされていないかをきちんと検証する。
  1. 短腸症候群など長期にHPNを行う症例では、肝機能には特段の注意を払う必要があり、定期的な採血を行う。
  1. カテーテル関連の感染には注意する。埋込み型ポートの場合、ポート埋め込み部の発赤、腫脹、圧痛を観察。トンネル型の場合、入口部の発赤、腫脹、膿の流出、圧痛の確認を行う。
  1. 発熱した場合にはCRBSIを疑い、2セット血液培養を採る。そのうち1つは末梢血管から採ることが望ましい[9]
  1. 血栓症に注意する。特に骨盤内悪性腫瘍などに対して、下肢にルートがある場合、PICCカテーテルが用いられている場合は、挿入側の肢の浮腫には特段の注意を払い、片側性浮腫が認められた場合には血栓を疑う[8]
  1. 中心静脈栄養を長期間行った場合、高率(1年で21%、2年で38.7%)に胆石を合併する[10]ことが知られており、腹痛を訴える場合には胆石発作を念頭に置いて診察を行う。

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文献 

Eduardo Bruera, David Hui, Shalini Dalal, Isabel Torres-Vigil, Joseph Trumble, Joseph Roosth, Susan Krauter, Carol Strickland, Kenneth Unger, J Lynn Palmer, Julio Allo, Susan Frisbee-Hume, Kenneth Tarleton
Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial.
J Clin Oncol. 2013 Jan 1;31(1):111-8. doi: 10.1200/JCO.2012.44.6518. Epub 2012 Nov 19.
Abstract/Text PURPOSE: The vast majority of patients with cancer at the end of life receive parenteral hydration in hospitals and no hydration in hospice, with limited evidence supporting either practice. In this randomized controlled trial, we determined the effect of hydration on symptoms associated with dehydration, quality of life, and survival in patients with advanced cancer.
PATIENTS AND METHODS: We randomly assigned 129 patients with cancer from six hospices to receive parenteral hydration (normal saline 1 L per day) or placebo (normal saline 100 mL per day) daily over 4 hours. The primary outcome was change in the sum of four dehydration symptoms (fatigue, myoclonus, sedation and hallucinations, 0 = best and 40 = worst possible) between day 4 and baseline. Secondary outcomes included Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Nursing Delirium Screening Scale (NuDESC), Unified Myoclonus Rating Scale (UMRS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Dehydration Assessment Scale, creatinine, urea, and overall survival. Intention-to-treat analysis was conducted to examine the change by day 4 ± 2 and day 7 ± 2 between groups.
RESULTS: The hydration (n = 63) and placebo (n = 66) groups had similar baseline characteristics. We found no significant differences between the two groups for change in the sum of four dehydration symptoms (-3.3 v -2.8, P = .77), ESAS (all nonsignificant), MDAS (1 v 3.5, P = .084), NuDESC (0 v 0, P = .13), and UMRS (0 v 0, P = .54) by day 4. Results for day 7, including FACIT-F, were similar. Overall survival did not differ between the two groups (median, 21 v 15 days, P = .83).
CONCLUSION: Hydration at 1 L per day did not improve symptoms, quality of life, or survival compared with placebo.

PMID 23169523
M Cavicchi, P Beau, P Crenn, C Degott, B Messing
Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure.
Ann Intern Med. 2000 Apr 4;132(7):525-32. doi: 10.7326/0003-4819-132-7-200004040-00003.
Abstract/Text BACKGROUND: Liver cholestasis can be a life-threatening complication during home parenteral nutrition and may lead to combined liver-intestinal transplantation.
OBJECTIVE: To assess the prevalence of home parenteral nutrition-related liver disease and its contributing factors in patients with permanent intestinal failure.
DESIGN: Prospective cohort study.
SETTING: Two approved home parenteral nutrition centers.
PATIENTS: 90 patients with permanent intestinal failure who were receiving home parenteral nutrition were enrolled from 1985 to 1996.
INTERVENTION: Clinical, biological, endoscopic, and ultrasonographic follow-up. Histologic examination of the liver was done in 57 patients (112 liver biopsies).
MEASUREMENTS: The Kaplan-Meier method was used to determine the actuarial occurrence of chronic cholestasis and complicated home parenteral nutrition-related liver disease (bilirubin level > or =60 micromol/L [3.5 mg/dL], factor V level < or =50%, portal hypertension, encephalopathy, ascites, gastrointestinal bleeding, or histologically proven extensive fibrosis or cirrhosis). Contributing factors were assessed by using univariate and multivariate (Cox model) analysis.
RESULTS: 58 patients (65%) developed chronic cholestasis after a median of 6 months (range, 3 to 132 months), and 37 (41.5%) developed complicated home parenteral nutrition-related liver disease after a median of 17 months (range, 2 to 155 months). Of these patients, 17 showed extensive fibrosis after 26 months (range, 2 to 148 months) and 5 had cirrhosis after 37 months (range, 26 to 77 months). The prevalence of complicated home parenteral nutrition-related liver disease was 26%+/-9% at 2 years and 50%+/-13% at 6 years. Six patients died of liver disease (22% of all deaths). In multivariate analysis, chronic cholestasis was significantly associated with a parenteral nutrition-independent risk for liver disease, a bowel remnant shorter than 50 cm in length, and a parenteral lipid intake of 1 g/kg of body weight per day or more (omega-6-rich long-chain triglycerides), whereas complicated home parenteral nutrition-related liver disease was significantly associated with chronic cholestasis and lipid parenteral intake of 1 g/kg per day or more.
CONCLUSION: The prevalence of complicated home parenteral nutrition-related liver disease increased with longer duration of parenteral nutrition. This condition was one of the main causes of death in patients with permanent intestinal failure. Parenteral intake of omega-6-rich long-chain triglycerides lipid emulsion consisting of less than 1 g/kg per day is recommended in these patients.

PMID 10744588
M I Spagnuolo, R Iorio, A Vegnente, A Guarino
Ursodeoxycholic acid for treatment of cholestasis in children on long-term total parenteral nutrition: a pilot study.
Gastroenterology. 1996 Sep;111(3):716-9. doi: 10.1053/gast.1996.v111.pm8780577.
Abstract/Text BACKGROUND & AIMS: Cholestatic liver disease (CLD) is a frequent and sometimes fatal complication of total parenteral nutrition (TPN) that may require withdrawal of TPN. The aim of this pilot study was to evaluate ursodeoxycholic acid (UDCA) as treatment of TPN-associated CLD.
METHODS: Seven children (4 boys and 3 girls) undergoing long-term TPN because of intractable diarrhea syndrome developed cholestasis and were treated with UDCA. Treatment efficacy was evaluated by monitoring clinical and biochemical markers of CLD, including gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), conjugated bilirubin, and alanine aminotransferase (ALT).
RESULTS: In all children, UDCA was associated with the disappearance of signs of CLD and with normalization of biochemical markers of cholestasis within 4-8 weeks. A rebound increase of GGT, ALP, and ALT serum levels was observed in 3 children in whom UDCA was temporarily discontinued while they were still undergoing TPN. However, after reinstitution of UDCA, markers of cholestasis normalized in all cases. UDCA was withdrawn on reinstitution of full oral feeding; there was no relapse of cholestasis. Six children fully recovered. One child died because of the lack of vascular access.
CONCLUSIONS: UDCA appears to be an effective treatment for TPN-related cholestasis in children.

PMID 8780577
Clarivet Torres, Debra Sudan, Jon Vanderhoof, Wendy Grant, Jean Botha, Stephen Raynor, Alan Langnas
Role of an intestinal rehabilitation program in the treatment of advanced intestinal failure.
J Pediatr Gastroenterol Nutr. 2007 Aug;45(2):204-12. doi: 10.1097/MPG.0b013e31805905f9.
Abstract/Text OBJECTIVE: To analyze outcomes in children with intestinal failure treated by our Intestinal Rehabilitation Program (IRP) in a 4-year period.
PATIENTS AND METHODS: A total of 51 parenteral nutrition (PN)-dependent patients (20 male) were enrolled in the IRP. Median age was 1.7 years, with the primary diagnoses being gastroschisis, necrotizing enterocolitis, volvulus, and congenital atresia. Median small bowel intestinal length was 35 cm, with the majority of patients having only jejunum as remaining bowel anatomy. Thirty-six of the 51 patients had liver disease characterized by cirrhosis, advance bridging fibrosis, and portal and periportal fibrosis. Height, weight z score, platelet count, albumin, and bilirubin levels were measured at the beginning and end of the study.
RESULTS: Of the 51 patients, 29 had 46 different surgical intestinal repairs. Twenty-nine of the 36 patients with hyperbilirubinemia had normalized serum bilirubin with treatment. Ten patients required transplantation. Five patients died of sepsis, influenza, or complications after intestinal transplantation. Of the remaining 37 patients in the IRP, 31 were weaned from parenteral nutrition (5 with cirrhosis); 6 patients are in the process of weaning. Survival rate of the patients in the IRP was 90%. Growth has continued along the same curve, and some patients have exhibited significant catch-up.
CONCLUSIONS: With an aggressive medical/surgical approach, even patients with intestinal failure and advanced liver disease can avoid transplantation. Patients in the IRP showed improved liver function and nutritional parameters with the ability to discontinue PN while maintaining growth. Early referral of these patients to specialized centers before the development of advanced liver disease is recommended.

PMID 17667717
F Bozzetti, J Arends, K Lundholm, A Micklewright, G Zurcher, M Muscaritoli, ESPEN
ESPEN Guidelines on Parenteral Nutrition: non-surgical oncology.
Clin Nutr. 2009 Aug;28(4):445-54. doi: 10.1016/j.clnu.2009.04.011. Epub 2009 May 23.
Abstract/Text Parenteral nutrition offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake is inadequate and enteral nutrition is not feasible, is contraindicated or is not accepted by the patient. These guidelines are intended to provide evidence-based recommendations for the use of parenteral nutrition in cancer patients. They were developed by an interdisciplinary expert group in accordance with accepted standards, are based on the most relevant publications of the last 30 years and share many of the conclusions of the ESPEN guidelines on enteral nutrition in oncology. Under-nutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis and, per se, responsible for excess morbidity and mortality. Many indications for parenteral nutrition parallel those for enteral nutrition (weight loss or reduction in food intake for more than 7-10 days), but only those who, for whatever reason cannot be fed orally or enterally, are candidates to receive parenteral nutrition. A standard nutritional regimen may be recommended for short-term parenteral nutrition, while in cachectic patients receiving intravenous feeding for several weeks a high fat-to-glucose ratio may be advised because these patients maintain a high capacity to metabolize fats. The limited nutritional response to the parenteral nutrition reflects more the presence of metabolic derangements which are characteristic of the cachexia syndrome (or merely the short duration of the nutritional support) rather than the inadequacy of the nutritional regimen. Perioperative parenteral nutrition is only recommended in malnourished patients if enteral nutrition is not feasible. In non-surgical well-nourished oncologic patients routine parenteral nutrition is not recommended because it has proved to offer no advantage and is associated with increased morbidity. A benefit, however, is reported in patients undergoing hematopoietic stem cell transplantation. Short-term parenteral nutrition is however commonly accepted in patients with acute gastrointestinal complications from chemotherapy and radiotherapy, and long-term (home) parenteral nutrition will sometimes be a life-saving maneuver in patients with sub acute/chronic radiation enteropathy. In incurable cancer patients home parenteral nutrition may be recommended in hypophagic/(sub)obstructed patients (if there is an acceptable performance status) if they are expected to die from starvation/under nutrition prior to tumor spread.

PMID 19477052
Federico Bozzetti
Nutritional support in oncologic patients: where we are and where we are going.
Clin Nutr. 2011 Dec;30(6):714-7. doi: 10.1016/j.clnu.2011.06.011. Epub 2011 Jul 29.
Abstract/Text The use of nutritional support in cancer patients has evolved since its introduction in the clinical practice 40 years ago. Both parenteral and enteral nutrition are now increasingly integrated within the main oncologic strategy with the aim of making surgery, chemotherapy and radiation therapy more safe and effective. This requires a better awareness of the inherent risk of starvation and undernutrition by the surgeons, medical oncologists and radiologists, the ability to implement a policy of nutritional screening of cancer patients and to propose them the nutritional support in a single bundle together with the oncologic drugs. Four different areas of nutritional intervention are now recognized which parallel the evolutionary trajectory of patients with tumour: the perioperative nutrition in surgical patients, the permissive nutrition in patients receiving chemotherapy and/or radiation therapy and the home parenteral nutrition which may be total (in aphagic-obstructed-incurable patients) or supplemental (in advanced weight-losing anorectic patients). Since cancer is a common disease and the continuous progress in medical therapy is changing its natural history, with more and more patients entering in a chronic and finally incurable phase where nutrition is determinant for survival, we can expect an increased demand for nutritional support in the next future.

2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
PMID 21802801
L Bishop, L Dougherty, A Bodenham, J Mansi, P Crowe, C Kibbler, M Shannon, J Treleaven
Guidelines on the insertion and management of central venous access devices in adults.
Int J Lab Hematol. 2007 Aug;29(4):261-78. doi: 10.1111/j.1751-553X.2007.00931.x.
Abstract/Text Central venous access devices are used in many branched of medicine where venous access is required for either long-term or a short-term care. These guidelines review the types of access devices available and make a number of major recommendations. Their respective advantages and disadvantages in various clinical settings are outlined. Patient care prior to, and immediately following insertion is discussed in the context of possible complications and how these are best avoided. There is a section addressing long-term care of in-dwelling devices. Techniques of insertion and removal are reviewed and management of the problems which are most likely to occur following insertion including infection, misplacement and thrombosis are discussed. Care of patients with coagulopathies is addressed and there is a section addressing catheter-related problems.

PMID 17617077
Leonard A Mermel, Michael Allon, Emilio Bouza, Donald E Craven, Patricia Flynn, Naomi P O'Grady, Issam I Raad, Bart J A Rijnders, Robert J Sherertz, David K Warren
Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2009 Jul 1;49(1):1-45. doi: 10.1086/599376.
Abstract/Text
PMID 19489710
Michael Staun, Loris Pironi, Federico Bozzetti, Janet Baxter, Alastair Forbes, Francesca Joly, Palle Jeppesen, Jose Moreno, Xavier Hébuterne, Marek Pertkiewicz, Stefan Mühlebach, Alan Shenkin, André Van Gossum, ESPEN
ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients.
Clin Nutr. 2009 Aug;28(4):467-79. doi: 10.1016/j.clnu.2009.04.001. Epub 2009 May 22.
Abstract/Text Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.

PMID 19464089
Carole Bouleuc, Amélie Anota, Cécile Cornet, Ghislain Grodard, Antoine Thiery-Vuillemin, Olivier Dubroeucq, Nathalie Crétineau, Véronique Frasie, Vincent Gamblin, Gisèle Chvetzoff, Laure Favier, Christophe Tournigand, Marie-Christine Grach, Bruno Raynard, Sébastien Salas, Géraldine Capodano, Lionel Pazart, Régis Aubry
Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial.
Oncologist. 2020 May;25(5):e843-e851. doi: 10.1634/theoncologist.2019-0856. Epub 2020 Mar 25.
Abstract/Text BACKGROUND: Malnutrition worsens health-related quality of life (HRQoL) and the prognosis of patients with advanced cancer. This study aimed to assess the clinical benefits of parenteral nutrition (PN) over oral feeding (OF) for patients with advanced cancer cachexia and without intestinal impairment.
MATERIAL AND METHODS: In this prospective multicentric randomized controlled study, patients with advanced cancer and malnutrition were randomly assigned to optimized nutritional care with or without supplemental PN. Zelen's method was used for randomization to facilitate inclusions. Nutritional and performance status and HRQoL using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL questionnaire were evaluated at baseline and monthly until death. Primary endpoint was HRQoL deterioration-free survival (DFS) defined as a definitive deterioration of ≥10 points compared with baseline, or death.
RESULTS: Among the 148 randomized patients, 48 patients were in the experimental arm with PN, 63 patients were in the control arm with OF only, and 37 patients were not included because of early withdrawal or refused consent. In an intent to treat analysis, there was no difference in HRQoL DFS between the PN arm or OF arm for the three targeted dimensions: global health (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.88-1.94; p = .18), physical functioning (HR, 1.58; 95% CI, 1.06-2.35; p = .024), and fatigue (HR, 1.19; 95% CI, 0.80-1.77; p = .40); there was a negative trend for overall survival among patients in the PN arm. In as treated analysis, serious adverse events (mainly infectious) were more frequent in the PN arm than in the OF arm (p = .01).
CONCLUSION: PN improved neither HRQoL nor survival and induced more serious adverse events than OF among patients with advanced cancer and malnutrition. Clinical trial identification number. NCT02151214 IMPLICATIONS FOR PRACTICE: This clinical trial showed that parenteral nutrition improved neither quality of life nor survival and generated more serious adverse events than oral feeding only among patients with advanced cancer cachexia and no intestinal impairment. Parenteral nutrition should not be prescribed for patients with advanced cancer, cachexia, and no intestinal failure when life expectancy is shorter than 3 months. Further studies are needed to assess the useful period with a potential benefit of artificial nutrition for patients with advanced cancer.

© 2020 The Authors. The Oncologist published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.
PMID 32212354
Kenneth Fearon, Florian Strasser, Stefan D Anker, Ingvar Bosaeus, Eduardo Bruera, Robin L Fainsinger, Aminah Jatoi, Charles Loprinzi, Neil MacDonald, Giovanni Mantovani, Mellar Davis, Maurizio Muscaritoli, Faith Ottery, Lukas Radbruch, Paula Ravasco, Declan Walsh, Andrew Wilcock, Stein Kaasa, Vickie E Baracos
Definition and classification of cancer cachexia: an international consensus.
Lancet Oncol. 2011 May;12(5):489-95. doi: 10.1016/S1470-2045(10)70218-7. Epub 2011 Feb 4.
Abstract/Text To develop a framework for the definition and classification of cancer cachexia a panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. Cancer cachexia was defined as a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. The agreed diagnostic criterion for cachexia was weight loss greater than 5%, or weight loss greater than 2% in individuals already showing depletion according to current bodyweight and height (body-mass index [BMI] <20 kg/m(2)) or skeletal muscle mass (sarcopenia). An agreement was made that the cachexia syndrome can develop progressively through various stages--precachexia to cachexia to refractory cachexia. Severity can be classified according to degree of depletion of energy stores and body protein (BMI) in combination with degree of ongoing weight loss. Assessment for classification and clinical management should include the following domains: anorexia or reduced food intake, catabolic drive, muscle mass and strength, functional and psychosocial impairment. Consensus exists on a framework for the definition and classification of cancer cachexia. After validation, this should aid clinical trial design, development of practice guidelines, and, eventually, routine clinical management.

Copyright © 2011 Elsevier Ltd. All rights reserved.
PMID 21296615
Shalini Dalal, Eduardo Bruera
Dehydration in cancer patients: to treat or not to treat.
J Support Oncol. 2004 Nov-Dec;2(6):467-79, 483.
Abstract/Text Many patients in the terminal phase of their illness experience reduced oral intake before death, due to causes related to their cancer or its treatment. When oral intake is not adequate, dehydration and malnutrition are the obvious results. But these terminally ill patients present a challenge to healthcare providers: to rehydrate these patients or not and, if so, how? Adequate hydration levels are much lower in terminal patients with cancer than in normal adults. Healthcare professionals should assess the patient's hydration needs through personal history, physical examination, and laboratory evaluation before considering the advantages and disadvantages of rehydration, as well as the wishes of the patient and his or her family. In doubtful cases, a short trial of hydration may be appropriate. If hydration is considered, there are a number of methods to consider based on the needs of the patient, including intravenous administration, hypodermoclysis, and proctoclysis. The subcutaneous route is an excellent alternative due to its simplicity, low cost, and feasibility in the home setting.

PMID 15605914
M Sasson, P Shvartzman
Hypodermoclysis: an alternative infusion technique.
Am Fam Physician. 2001 Nov 1;64(9):1575-8.
Abstract/Text Hypodermoclysis, the subcutaneous infusion of fluids, is a useful and easy hydration technique suitable for mildly to moderately dehydrated adult patients, especially the elderly. The method is considered safe and does not pose any serious complications. The most frequent adverse effect is mild subcutaneous edema that can be treated by local massage or systemic diuretics. Approximately 3 L can be given in a 24-hour period at two separate sites. Common infusion sites are the chest, abdomen, thighs and upper arms. The preferred solution is normal saline, but other solutions, such as half-normal saline, glucose with saline or 5 percent glucose, can also be used. Potassium chloride can be added to the solution bag if needed. Hyaluronidase can also be added to enhance fluid absorption. Hypodermoclysis can be administered at home by family members or a nurse; the technique should be familiar to every family physician.

PMID 11730312
P A Rochon, S S Gill, J Litner, M Fischbach, A J Goodison, M Gordon
A systematic review of the evidence for hypodermoclysis to treat dehydration in older people.
J Gerontol A Biol Sci Med Sci. 1997 May;52(3):M169-76.
Abstract/Text BACKGROUND: The purpose of the study was to evaluate the evidence supporting the use of hypodermoclysis (i.e., subcutaneous infusion of fluids) to treat dehydrated elderly patients, and to discuss clinical applications of this mode of therapy in the long-term care setting.
METHOD: Articles reporting the use of hypodermoclysis were identified using a systematic MEDLINE search between January 1966 and May 1996. Articles were included in our sample if they contained original patient data that evaluated either the efficacy or adverse effects associated with the use of subcutaneous infusions to treat dehydration in adults, whether hyaluronidase was required to facilitate the absorption of subcutaneous fluid, or if potassium could be added to the solution.
RESULTS: Eighteen articles met the inclusion criteria. Since we hypothesized that adverse effects associated with hypodermoclysis may have been related largely to the use of nonelectrolyte or hypertonic solutions, the studies were evaluated according to the type of fluid administered. Six hundred and eighty-five patients were described in 13 studies evaluating the efficacy and toxicity of subcutaneously administered fluid. Four studies evaluated hypodermoclysis using electrolyte-containing solutions in 25 patients. Two of these were randomized control trials (RCT) that compared hypodermoclysis to intravenous therapy. Both reported similar absorption of fluids. In the single RCT that evaluated adverse effects, 4 of 17 patients receiving hypodermoclysis reported minor side effects similar to those reported with intravenous therapy. Adverse effects were more severe when electrolyte-free or hypertonic solutions were evaluated. Of the 639 patients who may have received electrolyte-free solutions, 16 patients (2.5%) reported adverse effects, 8 of which were severe. Both patients reported to have received hypertonic solutions noted adverse effects, one of which was severe. The use of hyaluronidase to facilitate absorption was evaluated in 74 patients. These studies suggest that hyaluronidase improves the speed of fluid absorption but may not change the patient's comfort level. A single case report of 350 subcutaneous infusions in 67 patients investigated the administration of up to 34 mmol/L of potassium chloride (KCl) by hypodermoclysis. The only adverse reaction observed was discomfort at the infusion site.
CONCLUSIONS: Hypodermoclysis can be used to most safely provide fluids when electrolyte-containing fluids are administered. Hypodermoclysis may have fallen into disuse because of reports of severe adverse reactions related to infusions of electrolyte-free or hypertonic solutions that would likely be considered inappropriate today. Whether or not hyaluronidase is required to promote subcutaneous fluid absorption remains unresolved. Limited evidence suggests that potassium chloride may, with caution, be safely added to subcutaneous infusions. The majority of the available studies evaluating hypodermoclysis are of poor quality. Because of the tremendous potential benefits of administering fluid subcutaneously, there is a need for good quality studies to evaluate the efficacy of hypodermoclysis.

PMID 9158559
Riccardo Caccialanza, Thierry Constans, Paolo Cotogni, Gary P Zaloga, Alessandro Pontes-Arruda
Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review.
JPEN J Parenter Enteral Nutr. 2018 Feb;42(2):296-307. doi: 10.1177/0148607116676593. Epub 2017 Dec 20.
Abstract/Text Subcutaneous infusion, or hypodermoclysis, is a technique whereby fluids are infused into the subcutaneous space via small-gauge needles that are typically inserted into the thighs, abdomen, back, or arms. In this review, we provide an overview of the technique, summarize findings from studies that have examined the use of subcutaneous infusion of fluids for hydration or nutrition, and describe the indications, advantages, and disadvantages of subcutaneous infusion. Taken together, the available evidence suggests that, when indicated, subcutaneous infusion can be effective for administering fluids for hydration or nutrition, with minimal complications, and has similar effectiveness and safety to the intravenous route. Of note, subcutaneous infusion offers several advantages over intravenous infusion, including ease of application, low cost, and the lack of potential serious complications, particularly infections. Subcutaneous infusion may be particularly suited for patients with mild to moderate dehydration or malnutrition when oral/enteral intake is insufficient; when placement of an intravenous catheter is not possible, tolerated, or desirable; at risk of dehydration when oral intake is not tolerated; as a bridging technique in case of difficult intravenous access or catheter-related bloodstream infection while infection control treatment is being attempted; and in multiple settings (eg, emergency department, hospital, outpatient clinic, nursing home, long-term care, hospice, and home).

© 2016 American Society for Parenteral and Enteral Nutrition.
PMID 29443395
Daphne Broadhurst, Marie Cooke, Deepa Sriram, Brenda Gray
Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews.
PLoS One. 2020;15(8):e0237572. doi: 10.1371/journal.pone.0237572. Epub 2020 Aug 24.
Abstract/Text OBJECTIVE: To synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality.
INTRODUCTION: Peripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route.
METHODS: Systematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation.
RESULTS: The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery.
CONCLUSION: Subcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.

PMID 32833979
M R Crain, M G Horton, M W Mewissen
Fibrin sheaths complicating central venous catheters.
AJR Am J Roentgenol. 1998 Aug;171(2):341-6. doi: 10.2214/ajr.171.2.9694448.
Abstract/Text
PMID 9694448
Lyn Howard, Christopher Ashley
Management of complications in patients receiving home parenteral nutrition.
Gastroenterology. 2003 May;124(6):1651-61.
Abstract/Text Patients receiving long-term home parenteral nutrition tend to fall under the care of adult and pediatric gastroenterologists. This article reviews the management of potential infectious, mechanical and metabolic complications and describes common psychosocial issues related to the therapy. The point at which to refer the patient to an intestinal failure program offering autologous bowel reconstruction and small bowel transplantation is discussed.

PMID 12761723
Shawn J Rangel, Casey M Calkins, Robert A Cowles, Douglas C Barnhart, Eunice Y Huang, Fizan Abdullah, Marjorie J Arca, Daniel H Teitelbaum, 2011 American Pediatric Surgical Association Outcomes and Clinical Trials Committee
Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review.
J Pediatr Surg. 2012 Jan;47(1):225-40. doi: 10.1016/j.jpedsurg.2011.10.007.
Abstract/Text OBJECTIVE: The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children.
DATA SOURCE: Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews.
STUDY SELECTION: The review of PNAC/PNALD has been divided into 4 areas to simplify one's understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC.
RESULTS: The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized.
CONCLUSIONS: Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22244423

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