AHS

Subcutaneous Therapy
Clinical Resource

Purpose: To provide clinical support for health care professionals working in the Continuing Care
programs to aid in the insertion of the Saf-T-intima™ and Cleo® devices and management of
subcutaneous therapy including hypodermoclysis.

Table of Contents
Introduction ................................................................................................................................................................2
Guiding Principles .......................................................................................................................................................2
Special Considerations ................................................................................................................................................2
Selecting a Site............................................................................................................................................................3
Procedure – Saf-T-Intima............................................................................................................................................4
Procedure – Cleo 90 ...................................................................................................................................................6
Intermittent Medication Administration....................................................................................................................7
Continuous Infusions ..................................................................................................................................................7
Subcutaneous Catheter Dwell Time ...........................................................................................................................8
Tubing and Solution Change .......................................................................................................................................8
Potential Complications of Subcutaneous Therapy ................................................................................................ 10
Documentation ........................................................................................................................................................ 10
Meditech Documentation ................................................................................................................................... 10
Paris Documentation (Calgary Zone) ................................................................................................................... 11
Client Teaching Tips ................................................................................................................................................. 11
References: .............................................................................................................................................................. 12
Appendix A: Body Areas Appropriate for Subcutaneous Therapy .......................................................................... 13
Appendix B: BD Saf-T-Intima insertion directions ................................................................................................... 14
Appendix C: Smiths Medical Cleo 90 Infusion Set Training Guide .......................................................................... 15
Appendix D: Additional Staff Resources .................................................................................................................. 16

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Subcutaneous Therapy
Clinical Resource

Introduction
Clients who are unable to receive adequate oral hydration or take medications by mouth may require
hydration or medication administration through the subcutaneous route.

Subcutaneous therapy – the establishment of temporary subcutaneous access for intermittent

medication doses and/or an intermittent/continuous infusion of medication.

Hypodermoclysis (HDC) – refers to the intermittent or continuous infusion of fluids into the
subcutaneous space for hydration or for the prevention of dehydration.

Guiding Principles
 A prescriber’s order is required to initiate/maintain subcutaneous therapy.
o For Continuous infusion, the order should contain the type of solution, rate of flow,
medication rate/dosage (as appropriate), route and reason.
o For Intermittent use, the order should contain the medication name, dosage,
frequency, route, and reason. For intermittent hydration, include the type of solution,
rate of flow or infusion duration, route and reason.
 Regulated health care professionals may:
o Initiate and maintain intermittent subcutaneous sites.
o Administer intermittent subcutaneous medication via established access.
o Initiate and maintain continuous subcutaneous infusions (medications/fluids).
 Regulated health care professionals must monitor the client’s response to subcutaneous
therapy and follow up with the prescriber as necessary.

Special Considerations
 Clients with an increased risk of pulmonary congestion or edema, existing fluid overload or
reduced local tissue perfusion may not tolerate continuous subcutaneous infusions.
 Clients with anticoagulation and clotting disorders may not tolerate subcutaneous access due
to bleeding at the injection site.
 Continuous hydration infusions should not exceed 1500mL/24 hours.
o For pediatrics, the volume is based on age and weight and will be ordered by the
prescriber.
 Intermittent subcutaneous medication administration is a maximum of 2mL per site. If the volume
exceeds 2mL, see Intermittent Medication Administration.
 Multiple sites may be required if a client requires hydration and medication via the
subcutaneous route, as it is recommended to have one site dedicated for hydration.

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Selecting a Site
When selecting a site, consider the following:
 Areas with adequate subcutaneous tissue
 Intact skin
 Avoid skin folds or line of clothes (i.e. waistline), scars, open skin, areas near a joint, areas
that appear acutely inflamed, lymphedema, ascites or pitting edema
 Consider the level of cognitive ability
Common areas of the body include (Refer to Appendix A for Subcutaneous Insertion Sites):
1. Upper chest – Recommended in ambulatory clients as it allows for full range of motion. Saf-T-Intima
catheters should point toward the client’s midline.
2. Upper abdomen – Recommended for clients with minimal subcutaneous tissue. Use upper
abdominal site away from the waistline and ensure the site is more than two inches from the
umbilicus. Saf-T-Intima catheters are directed medially to prevent pinching when the person sits
or bends.
3. Upper Arm – Recommended in ambulatory clients as it allows for full range of motion.
4. Scapular Region – Caution with this site as it may cause a pressure injury in clients who are not mobile,
check the site frequently. Saf-T-Intima catheters should point towards the cervical spine.
5. Anterior or Lateral Upper Thigh – Avoid this site if it will impede the client’s mobility. This site is not
recommended if the client has lower leg edema. Saf-T-Intima catheters point towards the head so fluid
does not accumulate in the client’s legs.

Label each site with the date/time the catheter was inserted and the
medication name and concentration.

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Procedure – Saf-T-Intima
1. Review the prescriber’s order and ensure the infusion solution or medication, dose, rate, and
route of administration are appropriate for the client's age, condition, and access device.
2. Perform hand hygiene.
3. Gather supplies:
a. #24 Gauge Saf-T-Intima Cannula
b. Needleless Connector
c. Transparent Dressing (e.g. Tegaderm™)
d. Alcohol/Chlorhexidine wipes
e. Tape
f. Medication/Fluid to be administered with Syringe or Infusion Set
g. Gloves
h. Label for infusion set
4. Obtain informed consent (verbal is appropriate).
5. Depending on the purpose of the site, prepare as noted below:
a. For a single medication dedicated site: prepare medication according to the prescriber
orders. For the initial dose ONLY, prepare additional medication to prime the tubing and the
needleless connector to ensure client receives the full.
Prime Volumes:
i. Saf-T-Intima: 0.2mL
ii. MicroClave Cap: 0.04mL

Saf-T-Intima volume (0.2mL) + Cap volume (0.04mL) = total prime

volume (0.24mL then round up to 0.25mL)

b. For an infusion site: prime the infusion line with the ordered solution.
c. For a multi-use site: ensure a prefilled saline syringe is available to prime the site.
6. Perform hand hygiene and apply clean gloves and any other PPE required as per the Point of
Care Risk Assessment (PCRA).
7. Prepare selected site. Cleanse site with alcohol or chlorhexidine swab. Use friction and cleanse
a 5cm area in a back and forth motion for 15 seconds, flip the swab and repeat in other direction.
Allow to dry.

**wait until dry before proceeding

8. Remove the Saf-T-Intima from the package, by grasping the wings only, to prevent accidental
retraction of the needle. Remove protective cover from Saf-T-Intima needle and inspect the unit.
Do not pull on the white safety barrel.

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*for the next steps – refer to Appendix B for visual reference

9. With the bevel pointing upwards, firmly grasp the pebbled side of the wings.
10. Using the thumb and index finger of your non-dominant hand, pinch the client’s skin around the
injection site creating a roll of 1.25cm to 2.5cm diameter. Insert the needle through the skin at a
30-45 degree angle. If there is minimal subcutaneous tissue, use a lower angle upon insertion.

11. If blood return is noted, remove and discard the Saf-T-Intima. Using a new Saf-T-Intima, start
the procedure again. (Note: research and best practice is unclear concerning the benefits and
possible harm related to aspiration when initiating a subcutaneous site. We recommend
observing for flash back instead of actively aspirating due to the low likelihood of a vessel being
present and the possible tissue damage that could occur).
12. Release the wings and stabilize the catheter against the skin’s surface with non-dominant hand.
With dominant hand, grasp the white shield at the base/pebble end and pull in a straight
continuous motion until the shield pops off exposing the injection cap.
13. Apply a transparent dressing over the insertion site and most of the tubing.
14. Replace the existing cap with a needleless connector. Remove the white clamp. Secure the
tubing to the skin, as appropriate.
15. Cleanse the hub of the needleless connector with alcohol/chlorhexidine wipe (for 15 seconds)
and allow to dry.
16. Depending on the purpose of the site, either:
a. slowly inject the medication (for medication specific site) including the initial prime
volume (see step 5),
b. begin the infusion (if the infusion is supposed to be at a later time, ensure the infusion
works then disconnect the tubing maintaining sterility),
c. for patient controlled analgesia, ensure the site is primed (see step 5), prior to initiating
the infusion (follow your zone processes), or
d. flush the site (see step 5 for prime volume) with saline (for a multiuse site).
17. Label the site with the date/time of insertion (and tubing, if in use, in alignment with the Invasive
Infusion Line and Tubing Verification Policy).
a. For a medication specific site, include the medication name and concentration. For
subsequent doses, maintain the same drug and concentration.

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Procedure – Cleo 90
1. Review the prescriber’s order and ensure the infusion solution or medication, dose, rate, and
route of administration are appropriate for the client's age, condition, and access device.
2. Perform hand hygiene.
3. Gather supplies:
a. 6mm or 9mm Cleo infusion set
b. Alcohol/Chlorhexidine wipes
c. Tape (to secure tubing)
d. Medication/Fluid to be administered and infusion set
e. Gloves
f. Label for infusion set
4. Obtain informed consent (verbal is appropriate).
5. Connect the clave to the infusion line and prime the infusion line with the ordered solution.
6. Perform hand hygiene and apply clean gloves and any other PPE required as per the Point of
Care Risk Assessment (PCRA).
7. Prepare selected site. Cleanse site with alcohol or chlorhexidine swab. Use friction and cleanse
a 5cm area in a back and forth motion for 15 seconds, flip the swab and repeat in other direction.
Allow to dry.

**wait until dry before proceeding

8. Apply a skin barrier wipe.

9. Remove the Cleo infusion set from the package and inspect the device ensuring the needle is
engaged and adhesive is intact. See Appendix C for visual reference or Smiths Medical Cleo
Infusion set video.
10. Press the device firmly on the site for 5-15 seconds. This will activate the needle, insert the
cannula and retract the needle with an audible ‘click’.
11. Tilt the device and gently rotate off the skin. If a corner of the adhesive lifts, press it down firmly
with a finger.
12. Apply a skin barrier wipe.
13. Pinch the connector arms inward and slide the protective end off of the clave. Attach tubing to
the site in the most appropriate position, there should be an audible ‘click’ confirming the tubing
is secure.
14. Initiate the infusion as per orders.
15. Label the site with the date/time of insertion (and tubing, if in use, in alignment with the Invasive
Infusion Line and Tubing Verification Policy).

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Intermittent Medication Administration

When administering multiple medications in a single site:
 Administer the medication dose as per order.
 Flush with normal saline after each medication. The amount of normal saline is according to
the device manufacturer’s guidelines (0.25 mL).
 Refer to the AHS Provincial Parenteral Manual for medication compatibility.

When administering a single medication in a single site (e.g. Haldol):

 Label the site with the medication name and concentration.
 Prime the tubing with the same concentration of medication (see directions in step 5 of the
Procedure).
 Administer the medication dose as per order (not including the tubing volume).
 Do NOT flush the site.

There is no evidence to favour multiple sites versus multi-use sites for medication
administration. Refer to compatibility monographs and remain mindful of the maximum
volume for intermittent subcutaneous medications of 2mL (not including flush volume).

If the volume of medication exceeds 2mL:

 Attempt to obtain a higher concentration of the ordered medication so the volume does not
exceed 2mL. If this is not possible
 Administer 2mL of the ordered medication, wait 15-20 minutes. If the medication has not
absorbed (presence of a palpable bump) determine if a second site is required for future
doses and/or wait an additional 15-20 minutes then administer the remainder of the
medication (no more than 2mL at a time).

Continuous Infusions
 Confirm the expiry date for Pharmacy or Commercially Prepared solutions.
 Solutions mixed by health care professionals should be administered within 1 hour of drawing
up the medication (CARNA Guidelines for Medication and Vaccine Injection Safety), or as per
site direction.
 Fluids may be administered via gravity or infusion pump.
 For continuous medications, an infusion pump must be used.
o For Edmonton zone, refer to the Administering Medication via Ambulatory Infusion
Pump Clinical Resource.
 There is no maximum infusion rate for a hydration infusion (some resources recommend no
more that 75mL/h). The maximum volume is 1500mL over a 24 hour period. Assess the client
for systemic fluid overload, local and/or dependent edema, cellulitis, erythema, pain and
leaking at site. Multiple sites at a reduced flow rate may be required if the fluid is not being
absorbed at a single infusion site.

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Subcutaneous Catheter Dwell Time

Rotate the site if erythema, significant swelling, fluid leakage, bruising, bleeding, burning, abscess, or
pain is identified at the site. Some swelling at the insertion site is expected. Do not massage the site.

For End of Life clients, consider the overall condition and comfort of the client when assessing the need
to rotate the site.

The Saf-T-Intima catheter may stay in place for up to 10 days.

 When administering hydration fluid, it is recommended to use clinical judgement when
determining how often to replace the site. Often, it is every 24-48 hours or after infusing 1.5-2L
of fluid and as clinically indicated.
 When administering medication, rotate the site every 7-10 days and as clinically indicated.

The Cleo 90 infusion set may stay in place for up to 72 hours.

Tubing and Solution Change

Intermittent Use:
 Tubing and solution change
o every 3-4 days
o with site change
o if contaminated or system integrity is compromised
 Label tubing and solution in accordance with the Invasive Infusion Line and Tubing
Verification Policy

Continuous Use:
 Tubing change
o Every 4-7 days
o With site change
o If contaminated or system integrity is compromised
 Solution change
o For commercially prepared solutions – every 96 hours
o For pharmacy prepared solutions – replace as per expiration date specified by
pharmacy
o For nursing prepared solutions – every 24 hours
o Exceptional palliative care situations require discussion with the appropriate manager
and the client and/or agent.
 Use pump or gravity as per the AHS Parenteral Manual
 Label tubing and solution in accordance with the Invasive Infusion Line and Tubing
Verification Policy

To prevent medication waste consider the following:

 Prepare the smallest volume of the appropriate dose and concentration for an infusion.

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 Intermittent medication administration (instead of in an infusion).

 Consider alternate routes of administration.

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Potential Complications of Subcutaneous Therapy

Complication Action
Infection at the insertion site  Immediately discontinue the use of the site and remove the
catheter
 Initiate a new site with new tubing
 Notify the most responsible health practitioner (MRHP)
Fluid Overload (tachycardia,  Slow the infusion rate when signs of edema are present
hypertension, systemic  Stop the infusion rate when cardiac or respiratory symptoms
edema, respiratory are present
congestion, etc.)  Monitor the client closely and notify the MRHP
Pain at the insertion site  Consider
o rotating the site more frequently,
o use gentle heat or cold to soothe the area (consider using
a bean bag),
o decreasing the concentration of the medication,
o using a site with more adipose tissue,
o discuss alternate therapies with the care team

Documentation
The following should be documented on the client’s chart
 Client’s verbal consent.
 Assessment of the site including location and status.
 If a new site is initiated, indicate the type, gauge, and length of device used and dressing
applied.
 For intermittent use: the name and dose or medication administered.
 For continuous use: the type of solution, flow rate, medication (including dose and pump
details).
 Client’s response to treatment.
 Unexpected outcomes of treatment, if any.
 Client/caregiver teaching.

Meditech Documentation
Information related to the appropriate Meditech interventions for documentation of subcutaneous
therapy, please see the following Meditech Documentation Resources available on Insite:

Zone Resource
Edmonton Zone  For intermittent use, use the Medication Administration Community
North Zone intervention
 Infusion: Injections Using Indwelling Subcutaneous Sites Documentation
Resource
 Infusion Using a Pump Documentation Resource
 Infusion Using Gravity Documentation Resource
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Zone Resource
Central Zone  Documentation of Infusion Using a Pump
Direct questions to:
 Central Zone Home Care eDoc Help
<[email protected]>
 Central Zone - LTC eDoc Help
<[email protected]>
South Zone  Direct Questions to eDoc education team

Paris Documentation (Calgary Zone)

Document in the client’s Electronic Health Record (Paris).
 Record interventions and any special instructions on the flowsheet with additional information
captured in Casenotes.
https://insite.albertahealthservices.ca/Main/assets/tms/sh/tms-sh-cal-paris-case-notes-and-icp-
domain-type-resource-health-related-behaviours-functional-performance.pdf
o Use “medication” as a domain name to title the documentation entry.
 Record the treatment in Special Treatments within the Central Index Application
 Document in the client’s Electronic Care Plan (ECP)

Client Teaching Tips

 Inform the client about the risks and benefits of subcutaneous therapy.
 Educate the client and family how to:
o Check the infusion site at least twice daily
o Monitor for pump failure or other complications such as leakage, pain, redness,
tenderness, bruising, swelling at the site, and contact the AHS Case Manager should
complications arise.
o Identify when an infusion site may need to be rotated
o Change and label tubing if appropriate
o Administer fluid and medication via subcutaneous site, as appropriate.
 Provide teaching sheets/client resources as per your zone processes.

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References:
Alberta Health Services, Provincial Parenteral Manual. Retrieved December 12, 2019 from
https://webappsint.albertahealthservices.ca/Pharmacy/pm/pm_preview.asp?id=9712

Alberta Health Services (May 11, 2017). Invasive Infusion Line and Tubing Verification Policy.
Retrieved August 19, 2020 from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-
line-and-tubing-verification-ps-15-policy.pdf#search=line%20verification

Alberta Health Services, Vascular Access Device Infusion Therapy: Adult and Pediatric version
1.0. PVAD Maintenance: Frequency of Maintenance. Retrieved November 12, 2019 from
https://insite.albertahealthservices.ca/main/assets/cgv/tls-cgv-pvad-maintenance-frequency-
of-maintenance.pdf

College and Association of Registered Nurses of Alberta (Dec 2018). CARNA guidelines for
Medication and Vaccine Injection Safety Retrieved July 22, 2020 from
https://nurses.ab.ca/docs/default-source/document-library/guidelines/medication-and-
vaccine-injection-safety-guidelines.pdf?sfvrsn=4e30ebbc_12

Caple, C. (2016). Administration of Medication: Subcutaneous Infusion. Nursing Reference

Centre. Retrieved from https://web.b.ebscohost.com.ah s.idm.oclc.org/nrc/detail?sid=950a
8881-aaf2-4da5-91e7-0388703674ed%40sessionmgr120&vid=5&hid=107&bdata= JnNpd
GU9bnJjLWxpdmU%3d#AN=T703888&db=nrc

Covenant Health (Sept 2017). Hypodermoclysis (HDC) Administration. Retrieved October 2019
from https://extcontent.covenanthealth.ca/Policy/VII-B-315.pdf

Hospital Pharmacists’ Special Interest Group in Palliative Care. (2009). Chapter 7: Innovative
Routes of Therapy. Care Beyond Cure: Management of Pain and Other Symptoms. (4th
Edition). pp. 120-122. Montreal, Quebec.

Infusion Nurses Society. (2016). Infusion nursing standards of practice. Journal of Infusion
Nursing, 39(1), 84-85, 122-123.

Lippincott Procedures, Subcutaneous Infusion, Continuous (hypodermoclysis) November 14,

2019 retrieved from https://procedures-lww-com.ahs.idm.oclc.org/lnp/view.do?pId=4181451

Scales, K. (2011). Use of hypodermoclysis to manage dehydration. Nursing Older People,

23(5),16-22.

Smiths Medical (n.d.), Cleo 90 infusion set training guide. Retrieved July 9, 2020 from
https://www.smiths-medical.com/~/media/M/Smiths-
medical_com/Files/Import%20Files/IN193874EN-012018.pdf

Queensland Health, Management of Subcutaneous Infusions in Palliative Care. Retrieved

October 25, 2019 from https://www.health.qld.gov.au/cpcre/subcutaneous/section3

Winnipeg Regional Health Authority Palliative Care Program (April 2017). Procedure for
Subcutaneous Insertion, Removal, Medication Administration.

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Appendix A: Body Areas Appropriate for Subcutaneous Therapy

Images retrieved October 2019 from:https://www.bd.com/europe/safety/en/pdfs/Saf-T-Intima%20use%20Guide.pdf

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Appendix B: BD Saf-T-Intima insertion directions

Retrieved from https://www.bd.com/en-ca/offerings/capabilities/infusion-therapy/iv-catheters/bd-saf-t-intima-closed-iv-catheter-system

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Appendix C: Smiths Medical Cleo 90 Infusion Set Training Guide

Retrieved from https://www.smiths-medical.com/~/media/M/Smiths-medical_com/Files/Import%20Files/IN193874EN-012018.pdf

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Appendix D: Additional Staff Resources

Insite pages:
 Provincial Infusion Pump Education

 Infusion Pumps for Medications and Parenteral Fluid Administration

 CADD-Solis Infusion Pumps

 Line Labelling & Tracing

Independent Double-Check
 Practice Support Guideline
 Pocket Card

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