Emergency kits for managing filler-induced vascular occlusions
Drs Pearce and Subbio recently came together on Instagram to host a free live video discussing how to manage a dermal filler-induced vascular occlusion (VO) which included some great insight from two of the world’s leading aesthetic doctors, later hosted on the Aesthetic Mastery Show.
In this blog, we have condensed down some of their lengthy discussion and Dr Tim Pearce invites Dr Christian Subbio to explain what he keeps in his emergency kit for managing vascular occlusions, and why. As an American physician, some of the components and protocols differ from the UK, but he provides a good understanding of the principles when managing an emergency adverse vascular event.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
What should aesthetic injectors have in their VO emergency kit?
As an aesthetic injector, it is vital that you have an emergency kit just in case you are unfortunate enough to experience a vascular occlusion with a patient; but what should be in the kit?
Dr Subbio explained that he understood things in the United States of America are often different to the rest of Europe and the UK. The first being the type of hyaluronidase available. In the USA, the market leading, and only FDA-approved recombinant human hyaluronidase is Hylenex®, available in a 150 unit/ml vial. In the UK, we commonly use Hyalase®/Hyaluronidase containing 1,500 units/vial.
As you can imagine, this can be a real problem for injectors in the USA, explained Dr Subbio. They will often carry one to three vials in clinic and think they are safe to practice, especially those new to the specialty, but he warned this is not the case should you experience a large vascular event, something he understands is less of a problem for practitioners in the UK, where hyaluronidase is both cheaper and available in larger doses.
He recommends that those practising in the USA, (who may also be reading this blog), should have at least 10 vials of Hylenex in stock, i.e., a minimum of 1,500 units. This may not seem a lot to us in Britain, but remember the cost of hyaluronidase is also at a premium in the USA, therefore the next part of his advice makes a lot of sense.
He advised that you have a network of other aesthetic clinicians and colleagues, as part of a joint preparation plan, whereby you can reach out to each other to pool your stocks of hyaluronidase, should any one healthcare practitioner (HCP) have an emergency. This avoids individual prescribing HCPs wasting large sums of money on emergency medicines which may expire before they are ever needed. This concept of an emergency support network is still very relevant to UK based aesthetic clinicians.
Dr Subbio believes it is also important to have an EpiPen in your emergency kit just in case your patient has an allergic reaction to the hyaluronidase. The protocol recommendation is not to perform allergy testing prior to administering the hyaluronidase, because time is of the essence in an emergency vascular event; the risk of allergy is theoretical and can be managed with an EpiPen if required.
Dr Subbio has nitroglycerin paste in his emergency kit, and has and will continue to use it, he stated, something he recognises is controversial and no longer recommended in Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion from CMAC (the Complications in Medical Aesthetics Collaborative). They state,
“Nitroglycerin paste and hyperbaric oxygen are not evidence-based ancillary therapy for cross-linked hyaluronic acid filler in early management of vascular compromise, but they are still recommended for the treatment of particulate filler vascular compromise, as all measures should be undertaken to reverse compromise.
Clinicians can treat these hyaluronic acid filler complications with topical nitroglycerin paste based on the knowledge that topical nitroglycerin causes vasodilation. In filler-induced tissue ischemia, however, filler product is present within arterioles. Theoretically, applying nitroglycerin paste early might not improve perfusion and could worsen ischemia with dilation of vessels and further propagation of product into the smaller arterioles and capillaries. Given the lack of evidence and risk of venous congestion to the area, CMAC does not recommend nitroglycerin paste.”
Explaining why he uses nitroglycerin paste, Dr Subbio noted that arterial vessels have smooth muscle in them, and this is how you control contraction, or constriction, and dilatation is with smooth muscle. The nitroglycerin or nitric oxide relaxes muscle; therefore, it makes sense to use it and is something used all the time in Dr Subbio’s plastic surgery experience.
Responding to being asked for his opinion on UK practice, Dr Tim explained that he had never had to use nitroglycerin paste but believed that it dilates veins more than arteries and could cause congestion, with some study work demonstrating the use of Viagra® (sildenafil) as a preferred option.
Dr Subbio concluded that there remains a lot of conjecture, and without the science behind it, we simply do not know if nitroglycerin paste is inferior to sildenafil until it is better studied in this population.
Aspirin is commonly prescribed in cases of vascular occlusion to prevent platelet aggregation so should be in your emergency kit.
Prednisone is also no longer recommended, as noted in the CMAC Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion, where it states,
“CMAC would urge clinicians to avoid using steroids routinely unless there is a clinical indication. Wound management and infection prevention is of paramount importance and giving steroids can compromise wound healing or worsen any existing, early infection.”
Dr Subbio explained that he understood that the concern is with infection, but highlighted that if you are talking about infection, then you are already several steps down the line with the emergency and encountering necrosis.
His ideal scenario is to be able to give the patient prednisone early because it will minimise inflammation and swelling, explaining that the more swollen a tissue bed is, the less blood flow there is going to be in that capillary bed.
He concluded that what you want in your emergency kit are all the things that are going to help increase blood flow to the tissues, and he believes that prednisone will decrease inflammation, decrease extravasation of fluid, decrease pressure, and prevent stasis.
When asked for his thoughts, Dr Tim concurred that prednisone should be available within the emergency kit but noted that aesthetic clinicians should extend all their efforts towards not needing it in the first place by diagnosing and treating the vascular occlusion quickly. He has never needed to prescribe prednisone when managing a VO in his clinic or when training others.
Lidocaine is a vasodilator, it will relax the smooth muscle, the same way as sildenafil but via a different pathway. It will decrease the pain for the patient, it will dilate the vessels, therefore, Dr Subbio highly advocates its use.
Dr Tim noted that he felt that lidocaine was helpful to get the patient through the trauma of repeatedly injecting them with hyaluronidase, but he had not thought about using it as a dilator.
Responding, Dr Subbio explained that his thinking stemmed from his micro surgical training. When creating surgical flaps, he would sew micro vessels together and use papaverine and lidocaine to get the vessels to dilate so the connected anastomosis would work. He reiterated that the aim is to increase pressure behind and decrease resistance, all with the goal of increasing blood flow.
Applying heat will encourage vasodilation so have some heating packs in your emergency kit.
Is an emergency kit enough for managing a vascular occlusion?
Concluding, Dr Subbio explained that having an emergency kit is not enough, if you do not have protocols in place for vascular emergencies, or a local support network, alongside access to a referral pathway for hyperbaric oxygen, should it be required, or an ophthalmologist if vision loss occurs.
If you have staff, go through the emergency protocols with them, and even consider a trial run or emergency drill where you pretend a patient has a VO as part of a training exercise.
For more on managing vascular occlusions, read these blogs on how to reduce risk and avoid vascular occlusion with dermal fillers and Dr Tim’s lessons from vascular occlusion cases seen in 2021.
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Aesthetics Mastery Show
Managing Vascular Occlusions: Dr. Subbio’s Success Story in Saving a Patient from Necrosis
In this episode Dr Tim chats to Dr Subbio – a plastic surgeon with many years of experience, about how he saved a patient from a VO emergency. Plus, his tips for safe injecting and what you need in your emergency kit so that you can learn how best to manage and minimise vascular occlusions in your own practice. Watch the full Aesthetics Mastery Show here.
You might also like reading some of the comments from fellow injectors, including:
“As an injector of 25 years, i still appreciate, enjoy and learn from your videos. And this collaboration with Dr. Subbio was extremely useful and informative. I would recommend any new injector (or experienced one…) watch your videos. Thanks for your work in the field. Best.”
Read more and join in the debate on our YouTube channel..
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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