EMERGENCY DEPARTMENT POLICY & PROCEDURE
To establish guidelines for the safe administration of subcutaneous (SC) fluids (hypodermoclysis),
and the initiation, maintenance, and discontinuation of subcutaneous line placement when
hyaluronidase is given as an adjuvant.
A. Subcutaneous catheters are inserted by a registered nurse or physician knowledgeable in
subcutaneous infusion therapy.
1. Competency is validated by:
a. attending a class or in-service by a healthcare provider who has demonstrated
proficiency and teaching in the skill.
b. demonstrating the appropriate technique on a mannequin/SC pad, or on a
patient with a healthcare provider who has demonstrated proficiency in the skill.
B. A new catheter is used for each SC line attempt.
C. Begin the infusion immediately at a rate as below:
50 mLs/hr x 5 minutes, then 100 mLs/hr x 5 minutes, then at full bolus rate at approximately 15
minutes into the infusion.
D. A programmable infusion pump is required for all infusions.
E. The nurse will assess the infusion site at minimum every 30 minutes initially, and then every 2
hours for the presence of increased redness and swelling that is out of proportion, or increased
tenderness, and documents the assessment. If any signs of sensitivity to the medication are
observed, stop the infusion and notify the physician immediately.
F. All equipment used for subcutaneous infusions must be clearly identified for SC line use.
G. All SC lines are removed prior to discharging a patient home.
H. Hyaluronidase is stored in the refrigerator at all times.
I. Hyaluronidase is not given intravenously.
J. Life Span Considerations
a. To provide patient and family centered care, patients’ caregivers will be offered the
option of staying with the child, or leaving during the SC line placement.
b. If available, child life services should be utilized whether or not patient caregivers
choose to remain with children during SC line placement.
c. Avoid using the abdomen to prevent perforation of the peritoneal lining.
ED Policy Manual
Policy #: _12.0_____
Page 1 of 5
Title: Hyaluronidase Administration and
a. The back may not be the ideal subcutaneous space for the middle adult population,
but the back is the ideal area for the geriatric patient since there is more SC tissue
and for those with dementia, there is less chance of them pulling it out. Allow the
patient the choice of location of subcutaneous infusion if they are able to.
b. All other aspects of this policy the same for the adult/geriatric patient such as using
LMX, size of needle, choosing the site, injection of hyluronidase, securing the site,
and administering ordered infusions.
c. Avoid using the abdomen to prevent perforation of the peritoneal lining.
a. LMX 4%
b. 20, 22 or 24g angiocath h. Gloves
c. 3mL LR/normal saline flush i. Tegaderm
d. 200 units hyaluronidase j. Isotonic crystalloid fluid bolus
e. IV tubing k. Programmable infusion pump
g. Chlorhexidine prep or
povidine iodine for patients
under 2 months of age
A. Explain the procedure to the adult, child, and/or patients’ caregivers, using appropriate
terminology for the patient's developmental level. For pediatric patients, use child life services
as a support adjunct in explaining the procedure.
B. Apply appropriate topical/local anesthetic – 4% LMX Cream or J-tip – in preparation for
C. Assess sites for device placement (not limited to and in no particular order):
1. Anterior and lateral aspects of thighs and hips
2. Upper abdominal wall (to be avoided if possible to prevent perforation of the
3. Subclavicular region (recommended for ambulatory patients because it allows for free
4. Between scapula region (most recommended site)
5. Dorsal aspect of upper arm.
Avoid areas of compromised integrity, such as, but not limited to:
5. Bruise or hematoma
6. Scar tissue
Avoid areas located near:
a. Breast tissue (fluid may drain into axillary lymph nodes)
b. Perineum (fluid may drain into scrotum or labia)
c. Umbilical area
Avoid areas that may be prone to irritation from clothing and body motion. Always be aware of
how the needle placement may affect mobility or comfort.
C. Perform appropriate hand hygiene and use appropriate PPE.
D. Disinfect the site with chlorhexidine or povidine iodine and allow the skin to completely dry.
Do not wipe, rinse, blow, or blot the site dry.
E. Use an angiocath or butterfly needle. Inspect angiocath or butterfly needle for any signs of
damage to needle and/or catheter. Position the needle, directed towards the head, with the
bevel up with a 20-30 degree angle to the skin surface.
F. To insert the SC catheter, lightly lift up and hold a small mound of skin. Make sure that the site
has enough subcutaneous tissue (a fat fold of at least 1 to 2.5cm's, when the thumb and the
forefinger are pinched together). The tip of the catheter should be able to move freely
between the skin and the muscle.
H. Observe for blood return. If blood return is observed, consider keeping the site for intravenous
fluid infusion, but do not use hyaluronidase or remove the device and select a new site.
H. SC lines are stabilized using a method that does not interfere with assessment and monitoring
of the site, or impede vascular circulation or delivery of the prescribed therapy. Apply
Tegaderm loosely over insertion site, to allow tissue room to expand during fluid infusion. Tape
may also be used to stabilize catheter/needle hub.
Photos courtesy of
American Academy of
I. Inject 200 units of Hyaluronidase medication followed by 3mL of a lactated ringers or normal saline flush
through the catheter. The dose is the same for all patients, it is not weight dependent.
J. Infusion rate should be based upon the ability of the fluid to flow without an occlusion alarm.
1. Begin the infusion immediately at a rate as below:
50 mLs/hr x 5 minutes, then 100 mLs/hr x 5 minutes, then at full bolus rate at
approximately 15 minutes into the infusion.
2. If occlusion alarm occurs, the administration rate should be slowed down on the
K. Only solutions containing NS or LR are to be given subcutaneously [i.e., NS, LR, D51/4NS (with or
without KCL), D51/2NS (with or without KCL), D5NS (with or without KCL), D101/4NS (with or
without KCL), D101/2NS (with or without KCL), D10NS (with or without KCL), D5LR (with or without
1. For neonates, ask attending physician for dosage and rate of administration.
2. For infants 2 months or older and children, the rate and volume of administration
should not exceed those employed for IV infusion; however, the volume of fluid infused
should not exceed 1000 mLs in 1 hour.
3. Fluid boluses of 20 mLs/kg over 1 hour are recommended for more rapid fluid
rehydration in infants 2 months of age and older. In some cases, hypodermoclysis may
be administered as a dual site infusion when larger volumes (>1000 mLs) are needed but
does not exceed 3000 mLs/24 hours.
L. Program solution into an infusion pump at the remaining volume that was ordered by the
provider. If any signs of sensitivity to the medication or hypodermoclysis are observed, stop
the infusion and notify the physician immediately.
M. Clearly label the infusion pump, site, and tubing with a “SC” label.
N. If the angiocath or butterfly needle becomes dislodged, a new catheter can be inserted into
the same approximate location as the previous catheter was placed, using the procedure
outlined in this policy. If LMX has been placed longer than one hour, another dose may be
needed for adequate topical anesthetic. (Hyaluronidase will continue to work for 24 hours, so
no additional re-dosing of the medication is necessary.)
O. If a "patient side occluded" alarm sounds, troubleshoot the following:
1. Assess the site for increased redness or swelling that is out of proportion, or
2. Gently flush the angiocath or butterfly needle with 3mL of normal saline.
3. Be sure the angiocath or butterfly needle is not kinked.
4. If the line flushes without increased resistance, resume infusion as ordered. If there
is increased resistance after all troubleshooting measures, stop the infusion and notify
5. If the patient develops any signs of sensitivity such as skin reactions or pain,
discontinue infusion and notify the physician immediately.
P. Documentation of Infusion Therapy:
1. The SC line site, angiocath or butterfly gauge, procedural pain interventions, and
tolerance of the procedure are all documented in the patient’s medical record
Q. Discontinuation of SC line:
1. Remove catheter and place bandage over the site.
2. Assess site after removing catheter.
3. Record reason for discontinuation (sensitivity, physician order, time lapse of 24
hours, etc...), and observations of the site and catheter after removal.
V. UWHC CROSS REFERENCE
A. UWHC Hospital Administrative Policy 13.08, (Hand Hygiene)
A. Allen CH, Etzwiler LS, Miller MK, et al. (2009). Recombinant human
hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics,
B. Brown, M.K., and Worobec, F. (2000). Hypodermoclysis another
way to replace fluids. Nursing, 30(5), 58-9.
C. Kuensting, LL (2011). Subcutaenous infusion of fluid in children. Journal
of Emergency Nursing, 37, 346-349.
D. Spandorfer, P (2011). Subcutaneous rehydration: updating a traditional
technique. Pediatric Emergency Care, 27(3), 230-236.
E. Remington, R. & Hultman, T. (2007). Hypodermoclysis to treat
dehydration: A review of the evidence. Journal of American
Geriatric Society. October.
VII. REVIEWED BY
ED Pediatric Emergency Medicine Committee
ED Clinical Nurse Specialist
ED Clinical Operations Committee
ED Nursing Council
Joshua Ross, MD
Associate Vice Chair
Pediatric Emergency Medicine
Mike Safa, MD
Anne LeGare, RN, MSN, CEN