Catholic Medical Quarterly Volume 67(4) November 2017
Maintaining Fluid at the End of Life
Dr Bruno Bubna-Kasteliz
I think the article by Dr. Laura Bemand-Qureshi in CMQ (Feb 2017)  was a very timely reminder of the importance of treating thirst and dehydration in all patients, especially not forgetting those patients at the end of life, when those signs and symptoms may be missed or ignored. The reply by Adrian Treloar to Father Hugh MacKenzie's query (CMQ Aug 2017)  is both sensible and balanced but none of the correspondents mentioned using subcutaneous fluids where only hydration is needed (hypodermoclysis). It is interesting that, for some reason, s/c is not used more frequently these days. As a geriatrician for 30 years, I frequently applied it (Ref.1). The subcutaneous (s/c) route has distinct advantages over the intravenous (i/v) route in the elderly confused and at the end of life. This route is easier to apply when the patient is dehydrated with collapsed or thrombosed veins, or if i/v needles keep being pulled out. For instance, a s/c needle can be out of a patient's sight and access by being placed into the skin behind the shoulder. There is no risk from inadvertent air bubbles or delay in replacing empty bottles - useful when rehydrating a patient at home or in a nursing home.
The infusion rate of 0.9% Sodium Chloride solution or 5% dextrose solution should not exceed 15 ml/kg B/W / 4 hrs (Ref.2), otherwise absorption is impeded (i.e. a reasonable rate would for instance be 500 mls over 8 hours in a 40 Kg patient). Potassium may be added to a maximum of 34 mmols per litre (i.e. equals 15 mls of Strong 15%/L KCl injection - so half that amount for 500 mls infusion). There are no other alternative safe solutions for s/c infusion. Swelling around the s/c infusion site usually demonstrates either too rapid infusion or that the patient's kidneys are shutting down, in the process of dying.
- Dr Lucy Bemand-Qureshi (2017) Maintaining fluid intake at the end
Catholic Medical Quarterly Volume 67(1) February 2017. http://www.cmq.org.uk/CMQ/2017/Feb/maintaining_fluid_intake_end_life.html
- Fr Hugh Mackenzie and Dr Adrian Treloar Maintaining fluids in the dying. Catholic Medical Quarterly Volume 67(3) August 2017. http://www.cmq.org.uk/CMQ/2017/Aug/maintaining_fluids_in_the_dying.html
- Ibrahim I , Bubna-Kasteliz B. Subcuaneous route for fluid replacement. Care of the Elderly Journal (October 1993).
- Berger EY. Nutrition by hypodermoclysis. J. Am Geriat. Soc (1984)