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Am Fam Physician. 2002;66(1):28-30

to the editor: I was glad to read Hypodermoclysis: An Alternative Infusion Technique.”1 In palliative care settings, often rehydration is not necessary for comfort and may worsen the situation with unwanted pulmonary edema, skin edema, or ascites. In addition to fluids, the physician can also provide the patient with parenteral medications during hypodermoclysis. At the Rainey Hospice House, this technique has helped us to medicate patients who cannot swallow or whose vomiting precludes using their gastrointestinal tract, without resorting to intravenous or central lines. We find hypodermoclysis especially useful for three classes of patients.

First, we use hypodermoclysis to give parenteral opioids when patients in pain cannot get adequate relief by oral or transdermal medicines. We find that hydromorphone works best for this indication because its potency requires a very small amount of infusate to deliver high doses of analgesic. Morphine can also be administered this way, using a patient-controlled pump.

Second, in patients with severe nausea syndromes, hypodermoclysis can be used to deliver medicines such as metoclopramide (Reglan), lorazepam (Ativan), diphenhydramine (Benadryl), dexamethasone (Decadron), or promethazine (Phenergan). Some of these medicines can be combined to hit multiple brain and gut receptors that mediate nausea syndromes, but physicians must be careful of parenteral drug incompatibilities. Although little data are available on this topic, we often use a combination drip of dexamethasone, lorazepam and diphenhydramine with good nausea control in these patients. Many of these patients additionally require metoclopramide, which must be administered in a separate drip or transdermally because of incompatibility issues.

Finally, hypodermoclysis can be used for patients who require palliative sedation for uncontrolled delirium near the end of life. One can use a pump to control a drip of lorazepam, midazolam, or others to achieve the proper level of sedation to control the patient's symptoms. In severely agitated patients, one can put the infusion in the skin between the shoulder blades so that the patient cannot pull it out during their confusion.

in reply: We would like to thank Dr. Woodall for his comments. We agree that there is controversy regarding hydration in the palliative care setting. In most cases, the worst case scenario is that it does not help. In our experience, some families find it too hard to deal with the patient not eating and drinking, and hydration through hypodermoclysis symbolically seems to answer this cultural need. Hypodermoclysis can be used in the palliative setting as well as in the geriatric population, and other adult populations in home care or in nursing settings of home care.

We also administer drugs via hypodermoclysis without the use of a pump, and our clinical impression is that it works. A literature search that we conducted found no documentation of this method; we are currently examining this issue. There is wide literature on administering drugs in a subcutaneous infusion by a pump. The following medications are included in this category: atropine (Urised), dexamethasone (Decadron), haloperidol (Haldol), hydromorphone (Dilaudid-Hp), hydroxyzine (Atarax), methadone, methotrimeprazine (Levoprome), metoclopramide (Reglan), midazolam (Versed), morphine (Duramorph), octreotide (Sandostatin), phenobarbital, promethazine (Phenergan), scopolamine (Transderm Scop).

The following medications are incompatible: ranitidine and haloperidol, midazolam and dexamethasone, haloperidol and dexamethasone, ranitidine and metoclopramide, and ranitidine and midazolam. Check with your hospital pharmacist before combining any medicines administered via infusion.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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