Replacing fluids during resuscitation whilst working in a remote clinic can be challenging. The best option, of course, is whole blood followed by various intravenous solutions. Few remote locations have whole blood outside of the walking blood bank option which is still a hot top in the industry and unfortunately, not widely accepted. Once you have depleted your intravenous supplies there still is oral rehydration as a resuscitation option. The body can absorb up to 250ml of fluid every 15 minutes. Anything more than that leaves through the kidneys and is not used efficiently by the body. Other options are dermoclysis and proctoclysis.
Dermoclysis is the infusion of sterile saline fluids into the adipose tissue of the casualty. This is injected using a 25 gauge butterfly needle. It is limited to 1ml per minute per infusion site. The chief advantages of dermoclysis over intravenous infusion is that it is easy to source and can be administered by non-medical personnel with minimal supervision. It is therefore particularly suitable for home care of the diarrhoeal patient and has saved countless lives in Africa and Asia.
This technique was first documented for cholera patients in the 19th century. It was employed by Cantani, at Naples, during the epidemic in 1865, and was again used with great success in 1885. He used a small aspirating needle and attached it to the rubber tube of an ordinary fountain syringe. Currently, there is plenty of research stating that dermoclysis is a viable source for rehydrating the geriatric casualty.
A PubMed search of the last 30 years was initiated to recover all available literature. Dermoclysis rehydration was found to be a safe and effective method to provide fluids and narcotic analgesic therapy in elderly patients that are mild and moderate dehydrated and in patients. It seems to also be a good option to provide antibiotics, but there is a need for more studies to evaluate this indication.
Proctoclysis, also known as the Murphy Drip, has been used for successful hydration in difficult conditions. Lyn Robertson, a trained nurse, kept her family alive for 38 days in a life raft after their 43-foot sailboat sank. The best solution for rectal rehydration is 0.9% normal saline. This can be safely created using sea salt (3.5% saline) with drinking water (0% saline) by combining 3 parts drinking water to 1 part sea water. A best case scenario would have the capacity to boil and cool the solution before administering rectally. There must be salt in the solution in order for the body to successfully absorb the water in the large intestines.
The bottom line is this: We practice medicine in remote, austere and wilderness conditions. We don’t always have access to enough medical kit or sterilization options. We need to have a skill set that can address rehydration issues whilst still providing scientifically based medical treatment.
In remote areas, hydrating the trauma casualty can be challenging at best. The Remote Medic should be comfortable with an enhanced skill set to provide multiple options for rehydrating their casualty.
- Remington, R. and Hultman, T. (2007), Hypodermoclysis to Treat Dehydration: A Review of the Evidence. Journal of the American Geriatrics Society, 55: 2051–2055. doi: 10.1111/j.1532-5415.2007.01437.x
- Subcutaneous Hydration By Hypodermoclysis: A Practical and Low-Cost Treatment for Elderly Patients Authors: Frisoli A.J.1; de Paula A.P.2; Feldman D.2; Nasri F.1
- Drugs & Aging, Volume 16, Number 4, 1 April 2000, pp. 313-319(7)
- Reid A. Midwifery: The Role of Proctoclysis (Rectal Fluid Infusion). Midwifery Today Int Midwife. 2016 Summer;(118):50-1.
- The Telegraph (UK): Shipwrecked for 38 days: the real life family Robertson
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