1. Gorski, Lisa A. MS, HHCNS-BC, CRNI(R), FAAN

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Standard 64.1: Continuous subcutaneous infusion administration shall be initiated upon the order of a physician or an authorized prescriber in accordance with the state's Nurse Practice Act, rules and regulations promulgated by the state's Board of Nursing, organizational policies and procedures, and practice guidelines.

Figure. Lisa A. Gors... - Click to enlarge in new windowFigure. Lisa A. Gorski

Standard 64.2: The nurse shall assess the patient for appropriateness and duration of the prescribed therapy. Drug dose, volume, concentration, and rate shall be appropriate with regard to the integrity and condition of the patient's subcutaneous tissue.


Standard 64.3: The nurse shall have validation of competency in the care of the patient requiring continuous subcutaneous infusion therapy including, but not limited to, knowledge of anatomy and physiology; care and maintenance practices; potential complications; patient and family education; and documentation.


Standard 64.4: Aseptic technique shall be used and Standard Precautions shall be observed for subcutaneous access. Administration of medications or isotonic fluids subcutaneously is becoming more common in infusion therapy. Because it is considered safe, efficacious, and less costly, subcutaneous infusion is the most frequently selected infusion route used for opioids in hospice organizations.1,2 Subcutaneous immunoglobulin is emerging as an alternative to intravenous (IV) infusions for patients with primary immune deficiencies, allowing patients to manage their own infusions at home.3 There is renewed interest in the subcutaneous infusion of hydration fluids, commonly called hypodermoclysis and first used in the 1940s, for short-term fluid and electrolyte imbalances, particularly for patients in long-term care settings and now beginning to be used in homecare.4 In a recent review of the literature, including 1 systematic literature review, 2 randomized, controlled trials, and 6 cohort studies, the evidence demonstrated that hypodermoclysis was as effective as IV administration in older adult patients with mild to moderate dehydration. Advantages included the same number of or fewer complications, less cost, greater patient comfort, and less nursing time required.5


The subcutaneous tissue lies beneath the dermis and contains blood vessels, nerves, and adipose tissue. When medications or fluids are administered subcutaneously, they enter the bloodstream by a combination of perfusion, diffusion, hydrostatic pressure, and osmotic pressure.4


The Practice Criteria of the Standard state that the selected site for subcutaneous infusion should be located away from bony prominences and the umbilical area. Common sites used include the abdomen, thighs, upper arms, buttocks, and supraclavicular areas.2-4 Devices used include specially designed subcutaneous needles/over-the-needle catheter sets or a 25-to 27-gauge IV catheter inserted into the subcutaneous tissue at an angle of 45[degrees] to 60[degrees]; there are also specially designed sets that allow infusion at 2 sites simultaneously used for fluid administration.2,4 Site rotation should occur every 3 to 5 days and as clinically indicated.6 The maximum infusion rate is not specified by INS and is dependent upon the type of infusate. For example, subcutaneous immunoglobulin infusion rates vary from 10 to 40 mL per hour, whereas subcutaneous opioid infusions are well tolerated at rates of 3 to 5 mL per hour.2,3 Higher rates of hydration fluids are considered safe, for example, 1.5 L/d per injection site (1 mL/min).4


Potential complications of subcutaneous infusions are relatively uncommon. They include inadvertent puncture of a blood vessel, local complications such as warmth or redness at the site, abscess formation at the site, cellulitis, patient complaints of pain or burning at the site, and bruising.2,4 When the subcutaneous access device is placed, the device is aspirated to ascertain the absence of blood prior to use.6 Sites should be rotated sooner if site irritation occurs. Patient education is essential. Patients should be instructed to report any leakage, pain, redness, bruising, burning, or swelling; homecare patients or caregivers should check their site twice a day.2


It is imperative that organizations have policies and procedures in place guiding the use of subcutaneous infusion access devices; specifying indications, appropriate use, and specific access products used; and ensuring competency of nurses managing patients on subcutaneous infusions. Subcutaneous administration offers a cost-effective and safe alternative to the IV route for short-term isotonic fluid administration and selected medications. Infusion nurses should be well educated in use of this alternative route and advocate for its appropriate use.




1. Herndon C. Continuous subcutaneous infusion practices of United States hospices. J Pain Symptom Manage. 2001;22(6):1027-1034. [Context Link]


2. Justad M. Continuous subcutaneous infusion: an efficacious, cost-effective analgesia alternative at the end of life. Home Healthcare Nurse. 2009;27(3):140-147. [Context Link]


3. Kirmse J. The nurse's role in administration of intravenous immunoglobulin therapy. Home Healthcare Nurse. 2009;27(2):104-111. [Context Link]


4. Lybarger EH. Hypodermoclysis in the home and long-term care settings. J Infus Nurs. 2009;32(1):40-44. [Context Link]


5. Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc. 2007;55:2051-2055. [Context Link]


6. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(suppl 1):S1-S92. [Context Link]