Avoiding Disasters With Injectables: Tips From Charlene Lam at the Summer AAD

Preventing complications from fillers and managing sharps injury are important areas for dermatologists who practice cosmetic procedures. Charlene C. Lam, MD, MPH, Penn State Hershey Dermatology, Pennsylvania, provided tips in the presentation, “Preventing Disasters in Your Practice,” at the Summer Meeting of the American Academy of Dermatology.

There are a number of potential complications of fillers, and one of the most serious is blindness. Dr. Lam reported that autologous fat is most often associated with blindness; however, hyaluronic acid, collagen, poly-L-lactic acid, and calcium hydroxylapatite also have been associated. An understanding of facial anatomy is important. (Dr. Julie Woodward reviews the anatomy surrounding the eyes in a November 2016 Cutis article.) If your patient is experiencing vision changes, call ophthalmology immediately. “There is a 90-minute window to start treatment,” said Dr. Lam. “No treatment has been found consistently successful. Theoretically, the use of a retrobulbar injection of 300 to 600 U of hyaluronidase could potentially save the patient’s vision in the setting of hyaluronic acid filler use, though this strategy has not been attempted.

To prevent necrosis, Dr. Lam recommended obtaining a patient history of cosmetic procedures and prior surgical procedures that may alter underlying anatomy, using reversible fillers such as those formulated with hyaluronic acid, using cannulas and smaller-gauge needles, injecting small amounts under low pressure slowly, and keep moving so that you are not depositing a large amount of filler in one area. If you see blanching, Dr. Lam advised to stop; apply warm compresses for 10 minutes every 1 to 2 hours; use vigorous massage; and consider hyaluronidase and nitroglycerin paste 2%, aspirin, and/or prednisone.

In all instances, Dr. Lam recommends having a safety kit that is easily accessible with printed directions of how to handle complications. “I like to have all contact numbers of specialists available, hyaluronidase, aspirin, and nitroglycerin paste 2%,” said Dr. Lam. “These complications occur so rarely that when they do occur, you want to be prepared.”

Dr. Lam polled those in attendance at the session and learned that 91% had a sharps (ie, needlestick) injury. The Centers for Disease Control and Prevention estimates approximately 385,000 sharps injuries annually among hospital-based health care personnel. This number actually may be an underestimate, as many instances go unreported. Nearly half of the injuries associated with hollow-bore needles is related to disposal. “Injuries could be prevented with a safe way to protect the needle after its use,” Dr. Lam said. The Centers for Disease Control and Prevention recommends using devices with safety features engineered to prevent sharps injuries.

However, if a health care provider gets stuck, first wash the area with soap and water, and then have a plan in place for medical care. He/she and the patient should be tested for hepatitis B and C viruses as well as human immunodeficiency virus (HIV). The risk for hepatitis B infection is greatest (6%–30%); the risk for hepatitis C virus is approximately 2% and the risk for HIV is 0.3%. “It is so important to create a positive culture of reporting that makes it acceptable for all members of the team to report a sharps injury,” said Dr. Lam. “Postexposure prophylaxis is available for HIV and it is critical to start as soon as possible.”

Preventing complications from fillers and managing sharps injury are important areas for dermatologists who practice cosmetic procedures. Charlene C. Lam, MD, MPH, Penn State Hershey Dermatology, Pennsylvania, provided tips in the presentation, “Preventing Disasters in Your Practice,” at the Summer Meeting of the American Academy of Dermatology.

There are a number of potential complications of fillers, and one of the most serious is blindness. Dr. Lam reported that autologous fat is most often associated with blindness; however, hyaluronic acid, collagen, poly-L-lactic acid, and calcium hydroxylapatite also have been associated. An understanding of facial anatomy is important. (Dr. Julie Woodward reviews the anatomy surrounding the eyes in a November 2016 Cutis article.) If your patient is experiencing vision changes, call ophthalmology immediately. “There is a 90-minute window to start treatment,” said Dr. Lam. “No treatment has been found consistently successful. Theoretically, the use of a retrobulbar injection of 300 to 600 U of hyaluronidase could potentially save the patient’s vision in the setting of hyaluronic acid filler use, though this strategy has not been attempted.

To prevent necrosis, Dr. Lam recommended obtaining a patient history of cosmetic procedures and prior surgical procedures that may alter underlying anatomy, using reversible fillers such as those formulated with hyaluronic acid, using cannulas and smaller-gauge needles, injecting small amounts under low pressure slowly, and keep moving so that you are not depositing a large amount of filler in one area. If you see blanching, Dr. Lam advised to stop; apply warm compresses for 10 minutes every 1 to 2 hours; use vigorous massage; and consider hyaluronidase and nitroglycerin paste 2%, aspirin, and/or prednisone.

In all instances, Dr. Lam recommends having a safety kit that is easily accessible with printed directions of how to handle complications. “I like to have all contact numbers of specialists available, hyaluronidase, aspirin, and nitroglycerin paste 2%,” said Dr. Lam. “These complications occur so rarely that when they do occur, you want to be prepared.”

Dr. Lam polled those in attendance at the session and learned that 91% had a sharps (ie, needlestick) injury. The Centers for Disease Control and Prevention estimates approximately 385,000 sharps injuries annually among hospital-based health care personnel. This number actually may be an underestimate, as many instances go unreported. Nearly half of the injuries associated with hollow-bore needles is related to disposal. “Injuries could be prevented with a safe way to protect the needle after its use,” Dr. Lam said. The Centers for Disease Control and Prevention recommends using devices with safety features engineered to prevent sharps injuries.

However, if a health care provider gets stuck, first wash the area with soap and water, and then have a plan in place for medical care. He/she and the patient should be tested for hepatitis B and C viruses as well as human immunodeficiency virus (HIV). The risk for hepatitis B infection is greatest (6%–30%); the risk for hepatitis C virus is approximately 2% and the risk for HIV is 0.3%. “It is so important to create a positive culture of reporting that makes it acceptable for all members of the team to report a sharps injury,” said Dr. Lam. “Postexposure prophylaxis is available for HIV and it is critical to start as soon as possible.”

Preventing complications from fillers and managing sharps injury are important areas for dermatologists who practice cosmetic procedures. Charlene C. Lam, MD, MPH, Penn State Hershey Dermatology, Pennsylvania, provided tips in the presentation, “Preventing Disasters in Your Practice,” at the Summer Meeting of the American Academy of Dermatology.

There are a number of potential complications of fillers, and one of the most serious is blindness. Dr. Lam reported that autologous fat is most often associated with blindness; however, hyaluronic acid, collagen, poly-L-lactic acid, and calcium hydroxylapatite also have been associated. An understanding of facial anatomy is important. (Dr. Julie Woodward reviews the anatomy surrounding the eyes in a November 2016 Cutis article.) If your patient is experiencing vision changes, call ophthalmology immediately. “There is a 90-minute window to start treatment,” said Dr. Lam. “No treatment has been found consistently successful. Theoretically, the use of a retrobulbar injection of 300 to 600 U of hyaluronidase could potentially save the patient’s vision in the setting of hyaluronic acid filler use, though this strategy has not been attempted.

To prevent necrosis, Dr. Lam recommended obtaining a patient history of cosmetic procedures and prior surgical procedures that may alter underlying anatomy, using reversible fillers such as those formulated with hyaluronic acid, using cannulas and smaller-gauge needles, injecting small amounts under low pressure slowly, and keep moving so that you are not depositing a large amount of filler in one area. If you see blanching, Dr. Lam advised to stop; apply warm compresses for 10 minutes every 1 to 2 hours; use vigorous massage; and consider hyaluronidase and nitroglycerin paste 2%, aspirin, and/or prednisone.

In all instances, Dr. Lam recommends having a safety kit that is easily accessible with printed directions of how to handle complications. “I like to have all contact numbers of specialists available, hyaluronidase, aspirin, and nitroglycerin paste 2%,” said Dr. Lam. “These complications occur so rarely that when they do occur, you want to be prepared.”

Dr. Lam polled those in attendance at the session and learned that 91% had a sharps (ie, needlestick) injury. The Centers for Disease Control and Prevention estimates approximately 385,000 sharps injuries annually among hospital-based health care personnel. This number actually may be an underestimate, as many instances go unreported. Nearly half of the injuries associated with hollow-bore needles is related to disposal. “Injuries could be prevented with a safe way to protect the needle after its use,” Dr. Lam said. The Centers for Disease Control and Prevention recommends using devices with safety features engineered to prevent sharps injuries.

However, if a health care provider gets stuck, first wash the area with soap and water, and then have a plan in place for medical care. He/she and the patient should be tested for hepatitis B and C viruses as well as human immunodeficiency virus (HIV). The risk for hepatitis B infection is greatest (6%–30%); the risk for hepatitis C virus is approximately 2% and the risk for HIV is 0.3%. “It is so important to create a positive culture of reporting that makes it acceptable for all members of the team to report a sharps injury,” said Dr. Lam. “Postexposure prophylaxis is available for HIV and it is critical to start as soon as possible.”