TABLE 3. Recommendations for Best Practice in Subcutaneous Infusions Management.

Recommendation
21. Initiate and regulate the flow rate of the infusion at prescribed rate. Use the infusion control device appropriate for the type of therapy. (The following devices have been reported for use with: (i) hydration- electronic infusion device and gravity infusion31,37,45–47 and (ii) medications- mechanical infusion device [eg, syringe driver, elastomeric], electronic infusion device).1,8,30,34,37,46,48 (III)
22. Change administration sets used for continuous infusions at least every 7 days, every 24 hours for intermittent infusions, and immediately if system integrity is compromised or as per organizational policy.23,32,34 (V)
23. Prime all air out of administration set prior to initiation of therapy. Label administration sets with date initiated and initials. Place label identifying subcutaneous access device near device connection on administration set.32,40 (V)
24. Monitor patient, assessing site and infusion, regularly after starting infusion, as per organizational policies (eg, 30- 60 minutes after starting infusion and every shift/visit). In the outpatient or home care setting, teach patient/caregiver to assess site and infusion, reporting any concerns immediately.32,34 (V)
25. Assess patient's tolerance and response to treatment. For subcutaneous hydration, initially include at least daily reassessments of response to therapy, clinical fluid status, laboratory values (urea, creatinine, and electrolytes), fluid balance charts, vital signs, and weight measurement twice weekly and adjust care plan accordingly. Patients on longer-term subcutaneous hydration whose condition is stable may be monitored less frequently, although decisions to reduce monitoring frequency should be detailed in their care plan.35 (V)
26. Employ strategies to prevent, identify, and manage infusion complications, which depend mainly on the infusate and infusion rate.1,8 (III)
27. For initiation and maintenance of subcutaneous hydration and some medications, consider the use of hyaluronidase for continuous subcutaneous infusions to facilitate the dispersion and absorption of the infusate, particularly if the infusion is not well tolerated due to swelling or pain or is running slowly.1,8,34,49–53 Consider hyaluronidase with the administration of the following medications that have been shown to enhance absorption of medications (eg, ceftriaxone, hydromorphone, immunoglobulin, midazolam, morphine, ondansetron, potassium, and trastuzumab).8,28,54 (III)
28. Hyaluronidase dosage and protocols vary. Consider injecting hyaluronidase prior to infusion (eg, 150-300 units) or, if compatible, to the hydration fluid. Patients taking salicylates (eg, aspirin), steroids, or antihistamines may require a larger dose of hyaluronidase for equivalent dispersing effect.1,8,34,50–53,55 (III)
29. Consult drug information references to determine stability/compatibility of hyaluronidase with infusates.23 (V)
30. Assess for adverse reactions to hyaluronidase (eg, mild local access site, allergic, or anaphylactic-like reactions).23 (V)
31. Prior to accessing a needle-free connector on end of access device, perform active disinfection with a vigorous mechanical scrub using an antiseptic wipe, or use a disinfectant cap, and allow solution to dry.35 (V)
32. For administration of multiple solution/medications, consider using a separate subcutaneous access device for each medication. If using one device, and solutions/medications are compatible, do not flush between medications; if not compatible, flush device with sterile preservative-free 0.9% sodium chloride (volume of device and any add-on devices). The use of multiple sites versus multiuse sites for medication administration is an unresolved issue due to lack of evidence.32,33,39 (V)
33. Replace access device, using new subcutaneous access device and site as clinically indicated based on patient comfort and access site assessment findings (eg, erythema, swelling, leaking, local bleeding, bruising, burning, abscess, or pain). Consider reported duration of therapy for frequency of site rotation (eg, reports of 24-48 hours or after 1.5-2.0 L of hydration solution; every 2-7 days for continuous medication infusions or with each intermittent infusion such as immunoglobulin G).1,8,32,34,56 (V)
34. Change the dressing with each subcutaneous site rotation and immediately if the integrity of the dressing is compromised.32,34 (V)
35. Teach patient and/or caregiver to monitor the site, response to therapy, infusion device, and post-removal care. If self-administration is being performed, validate learning of patient and/or caregiver in subcutaneous infusion management.31 (III)
36. Discontinue infusion therapy when indicated: stop the infusion, remove the dressing and subcutaneous set, and apply dry dressing over site. [C]
37. Document fluid/medication, volume, rate and time administered, care provided, assessments, complications, response to treatment, and other related interventions or communications. [C]

Abbreviations: (I), level I evidence: systematic review of randomized controlled trials; (II), level II evidence: randomized trial or observational study with dramatic effect; (III), level III evidence: non-randomized controlled cohort/follow-up (post marketing surveillance) study; (IV), level IV evidence: case series, case-control studies or historically controlled trials; (V), level V evidence: single descriptive and qualitative studies, mechanism-based reasoning (pathophysiologic rationale), expert opinion from clinicians or authorities; (C), level [C] evidence: consensus by research committee.