NURSING PATIENT CARE POLICY & PROCEDURE
December 26, 2016
Nursing Manual (Red)
Policy #: 1.52P
Title: Hyaluronidase Administration and
Subcutaneous Hydration for Pediatric Patients
To establish guidelines for the safe administration of subcutaneous fluids
(hypodermoclysis) for the treatment of mild to moderate dehydration, when
hyaluronidase is given as an adjuvant.
A. A provider order is needed for this procedure.
B. Subcutaneous catheters are inserted by a registered nurse or provider
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
c. Demonstrating technique on a patient in the presence of a
healthcare provider who has demonstrated competency.
C. Subcutaneous infusion sites are for the administration of fluids only. No
medications should be administered into this site..
D. A new catheter will be used for each insertion attempt.
E. A programmable infusion pump is required for all infusions.
F. The infusion site will be assessed by a nurse at a minimum of every 30 minutes
during titration, then every two (2) hours. Assessment will include presence of
increased redness and swelling that is out of proportion to the infusion, or
increased tenderness. Assessments will be documented.
G. If any signs of sensitivity to hyaluronidase are observed, the infusion will be
stopped and provider notified.
H. All equipment for subcutaneous infusions must be clearly identified as such.
I. All subcutaneous lines are removed prior to the patient’s discharge.
J. Hyaluronidase is stored in the pharmacy refrigerator at all times.
K. Hyaluronidase is not given intravenously.
L. Avoid using the abdomen to prevent perforation of the peritoneal lining and
A. 4% LMX
B. Chlorhexidine prep (Povidine iodine for patients under 2 months of age)
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C. 20, 22 or 24 g Angiocath
E. 3-5 mL Normal Saline flush
F. 150 units hyaluronidase
G. IV Infusion set
H. Isotonic crystalloid fluid solution (Normal Saline or Lactated Ringer’s)
I. Tape for IV securement
J. Programmable infusion pump
K. Alkare Skin Prep
L. Transparent adhesive dressing (large size) (CS # 1204026)
M. Red subcutaneous line identification stickers
A. Caregivers are offered the option of staying with the patient or leaving during line
B. If available, Child Life services should be utilized whether or not caregivers
choose to remain with the patient during line placement.
C. Explain the procedure to the patient and/or caregivers. Health Facts for You
(HFFY) 7455, What is Hyaluronidase and Subcutaneous Hydration, may be used.
D. Assess appropriate site for infusion. Appropriate sites may include:
1. Anterior and lateral aspects of thighs and hips
2. Subclavicular region (recommended in ambulatory patients)
3. Between scapula (most recommended site)
4. Dorsal aspect of upper arm
E. Areas of compromised integrity which should be avoided may include, but are
not limited to:
5. Bruise or hematoma
6. Scar tissue
7. Breast tissue (fluid may drain into axillary lymph nodes)
8. Perineum (fluid may drain into labia or scrotum)
9. Periumbilical area
10. Areas prone to irritation from clothing or body motion
F. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
G. Apply local anesthetic to selected site.
H. Don appropriate personal protective equipment..
I. Disinfect insertion site with chlorhexidine or Povidine iodine for 30 seconds.
Allow skin to dry completely. Do not wipe, rinse, blow on or blot the site dry.
J. Inspect chosen angiocath for any signs of damage to the needle or catheter.
K. Position the needle directed towards the patient’s head, with bevel up. Insertion
will be at a 20-30 degree angle to the skin surface.
L. To insert the catheter into the subcutaneous space, lightly lift up and hold a small
mound of skin. Ensure that the site has sufficient subcutaneous tissue (at least 1-2
cms when the thumb and forefinger are pinched together). The tip of the catheter
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should be able to move freely between the skin and muscle.
M. Once the needle is inserted, observe for a blood return. Do not administer
hyaluronidase in this site is a blood return is observed.
N. Subcutaneous lines are stabilized using a method that does not interfere with the
assessment and monitoring of the site, impede vascular circulation or delivery of
the prescribed therapy.
1. Apply Alkare skin prep to skin.
2. Attach a large transparent adhesive dressing loosely over the insertion
site, allowing room for the skin to expand during fluid administration.
3. Tape may also be used to stabilize the catheter hub.
O. Inject 150 units hyaluronidase followed by 3-5 mL of Normal Saline through the
catheter. The dose is the same for all patients, it is not weight dependent.
P. Fluid and Infusion Rate:
1. Isotonic solutions of Normal Saline or Lactated Ringers (preferred)
should be used for subcutaneous administration. The volume infused
should not exceed 1,000 mL in one hour.
a. For premature infants, and during the neonatal period, the daily
fluid dosage should not exceed 25 mL/kg of body weight. The
administration rate should not be greater than two (2) mL/minute.
b. For infants two (2) months of age or older, the rate and volume of
fluid administration should not exceed that employed for parenteral
2. The fluid infusion rate should be based upon the fluid’s ability to flow
without a pump occlusion alarm.
3. Begin the infusion at 50 mLs/hr x 5 minutes, then increase to 100
mLs/hr x 5 minutes, then increase rate to intended rate by approximately
15 minutes into the infusion.
4. If any signs of sensitivity to hyaluronidase or hypodermoclysis are
observed, stop the infusion and notify the provider immediately.
5. If an occlusion alarm occurs, the administration rate should be slowed.
6. D5 0.45% NaCl may be administered as a maintenance fluid.
Q. Boluses: Fluid boluses of 20 mL/kg over one (1) hour are recommended for more
rapid fluid rehydration in infants two (2) months of age or older.
Hypodermoclysis may be administered as a dual site infusion when larger
volumes (greater than 1,000 mLs) are needed, but not to exceed 3,000 mLs/24
R. Clearly label the infusion pump, site and tubing as a subcutaneous infusion using
the red subcutaneous label.
S. If the catheter becomes dislodged, a new catheter can be inserted into the same
approximate location as the previous catheter was placed, using the above
procedure. If it has been longer than an hour since LMX was placed, another dose
may be needed for adequate topical anesthesia. Hyaluronidase does not need to be
redosed if it is still within 24 hours of the initial dose as the medication is still
T. If there is a patient side occlusion alarm:
1. Assess the infusion site for increased redness or swelling that is
disproportionate for the amount of fluid infused, or increased tenderness.
2. Gently flush the catheter with 3-5 mL of normal saline.
3. Ensure the catheter is not kinked.
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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 the provider.
5. If the patient develops any signs of sensitivity such as skin reactions or
pain, discontinue the infusion and notify the provider immediately.
U. Documentation of Infusion Therapy:
1. The subcutaneous line site, catheter used, procedural pain interventions,
and procedure tolerance are all documented in the patient’s clinical
2. Education will be provided to the patient, parent(s), guardians, and/or
family members related to the expected erythema and edema that will
V. Discontinuation of subcutaneous site:
1. Catheters must be removed before the patient’s discharge.
2. A bandage is placed over the site after the catheter is removed.
3. Assess site every shift after catheter removal.
4. Record reason for catheter discontinuation, and observations of the site
and catheter upon catheter removal in the patient’s clinical record.
V. UWHC CROSS REFERENCES
A. Health Facts For You 7455, What Is Hyaluronidase and Subcutaneous Hydration?
B. Hospital Administrative Policy 13.08, Hand Hygiene
C. Emergency Department Policy 12.0 Hyaluronidase Administration and
D. Emergency Department Guideline, Pediatric Mild to Moderate Dehydration.
A. Allen, C. H., Etzwiler, L. S., Miller, M. K., & et al. (2009). Recombinant human
hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics, 124(5),
B. Hylenex® recombinant (human hyaluronidase) package insert. Deerfield, IL:
Baxter Healthcare Corporation. 2008.
C. Kuenstring, L. L. (2011). Subcutaneous 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. Kuenstrig, L. L. (2013). Comparing subcutaneous fluid infusion with intravenous
fluid infusion in children. Journal of Emergency Nursing, 39(1), 86-91.
F. Bruno, VG. Hypodermoclysis: a literature review to assist in clinical practice.
Einstein (Sao Paulo). 2015 Jan-Mar; 13(1): 122-8.
G. Constans, T., Cotogni, P., Zalogo, g.P., Pontes-Arruda, A. (2016). Subcutaneous
infusion of fluids for hydration or nutrition; A review. Journal of Parenteral and
H. Gorski L, Hadaway L, Hagle M, et.al. (2016). Subcutaneous access device:
placement and infusion administration. (5th ed) Policies and Procedures for
Infusion Therapy (202-5). Infusion Nurses Society.
I. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. (2016).
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InfusionTherapy Standards of Practice. Journal of Infusion Nursing, 39(1S),
VII. REVIEWED BY
Clinical Nurse Specialist, Universal Care Unit
Pediatric Emergency Care Coordinator
Nursing Patient Care Policy and Procedure Committee, December 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer