DR MARTYN KING
Dr Martyn King is a GMC-registered doctor and the director of Cosmedic Skin Clinic and the Aesthetic Complications Expert (ACE) Group World. He is a recognised expert in the field of complications and cosmetic medicine, is a national and international accredited trainer and has had several articles published in leading journals. Follow ACE Group World on Instagram: @acegroupworld
Aesthetic practitioners have a professional and moral duty to be not only trained and competent in performing treatments, but also to understand and be able to manage possible risks and complications that may occur during and after the procedure. Practitioners should have the skills and knowledge to risk-assess their practice and take appropriate steps to mitigate risk, considering product and patient characteristics.
One of the key aspects of successfully managing a complication is to be able to identify where it occured and correctly diagnose the problem. Practitioners should seek the help of a more experienced colleague if the diagnosis is in doubt, as providing an incorrect remedial treatment may result in further harm and a worse outcome.
Some complications require immediate attention, either because they are life-threatening, can have catastrophic consequences or because a delay in treatment could result in greater harm to the patient. Managing these emergency events requires competency, a safe environment, familiar and reliable management protocols and access to necessary medicines and devices.
It is recommended that quick-reference guides and treatment algorithms are available within practitioners’ emergency kits, and practitioners should be familiar with them. In order to provide safe treatments and correctly manage adverse events, practitioners must have and be competent to use and administer essential medicines and devices. The management of an aesthetic complication may require intervention from a more specialised practitioner and referral pathways should be in place if this is needed. Except for certain complications, such as anaphylaxis and visual loss, sending a patient to an Accident and Emergency department is often detrimental to their care, as these medical staff often do not have the necessary experience or medication to successfully manage the problem.
Reporting of complications in aesthetic practice is lacking, and it is only by greater reporting that problems associated with products, procedures, training and injectors can be identified and managed appropriately. ACE Group World is a strong advocate for the reporting of complications and provides a function for this on its website, although this is not intended to replace the recommended reporting to the (Medicines and Healthcare products Regulatory Agency) and the manufacturer’s regulatory affairs department.
Although the ACE Group World Emergency Kit covers the most widelyperformed aesthetic treatments, it is not intended to be all-encompassing. The Emergency Kit contains medicines to deal with common aesthetic procedures, however, practitioners should carry out a risk assessment for every procedure they provide and ensure they have the appropriate equipment and/or drugs to manage an adverse reaction. Practitioners conducting surgical procedures are likely to need additional prescription medications and equipment, such as AEDs, oxygen and cardiac monitoring, to manage potential complications.
While it is vital to have an emergency kit available, it is equally important that the practitioner is competent to use it appropriately. As complications in aesthetic practice are rare, regular CPD activities to maintain and demonstrate competency are essential. Basic life support and anaphylaxis training should be undertaken annually to refresh and update knowledge and skills in line with guidelines from professional bodies. In an instance where a patient’s life or sight is threatened, emergency services should be called to attend immediately, and the patient transferred to hospital for further treatment or monitoring. Even if the patient appears to have recovered from an anaphylactic event, the patient must go to hospital for observation.
Quick-reference guides and management algorithms are useful aide memoires when an adverse event occurs, and these should be kept with the emergency kit and at other identified sites where it is easily at hand if a complication arises.
Since the emergency kit contents are likely to be used infrequently, it is important that it is checked regularly, to ensure the medicines and devices are present, have not passed their expiry dates, have not been damaged and are in proper working order. A chart is useful to record these checks and this should be completed at least monthly.
The Resuscitation Council recommends the use of adrenaline ampoules, rather than auto-injectors, for healthcare workers who should have the competency and skills to draw up and administer from ampoules.2 The ampoules offer significant cost benefits to the practitioner, particularly when they will need to be discarded and replaced when they reach their expiry date.
Auto-injectors are designed primarily for lay people to be simple and efficient to use and often have a shorter shelflife of about six months. Branded pens EpiPen and Jext, are preloaded with a 300mcg dose – less than the 500mcg recommended for adults. The needle length of 15/16mm risks subcutaneous rather than intramuscular injection, which may affect efficient absorption.3 The brand Emerade supplies auto-injectors with a choice of doses which includes the adult dose of 500mcg. The injector also has a 23mm needle, increasing the likelihood of an intramuscular injection in most adults.
Doses may need to be repeated at fiveminute intervals until the emergency services arrive. Based on the ten-minute national standard for emergency services to attend the scene of an emergency, a minimum of two doses should be contained within the emergency kit – further doses if ambulance services are likely to take longer than ten minutes to arrive in more rural locations.
According to the latest guidance from the Resuscitation Council, the administration of chlorphenamine and hydrocortisone should be restricted to practitioners who are experienced in their use and not administered first line. 2 It is unlikely that practitioners who are working solely in aesthetic medicine would be considered experienced, and therefore the recommendation would be to call an ambulance and carry out basic life support until help arrives.
ACE Group World no longer recommends the inclusion of 2% glyceryl trinitrate (GTN) paste in the emergency kit for the management of a vascular occlusion. GTN paste induces vasodilatation and can increase blood flow, however it may also allow embolised filler material to diffuse into surrounding vessels, leading to more congestion, and worsening of perfusion.4
Prescription medication that does not need to be administered immediately can be issued via a prescription. ACE Group World provides a list of formulary items that can be referred to for this purpose.
Non-prescribing practitioners must discuss policy with their prescriber and agree a protocol for prescription, supply and administration of emergency prescriptiononly medicines. Prescribers and those who administer are equally accountable to the patient and their professional bodies, and must be aware of relevant legislation.
Adrenaline can be administered without a prescription according to Regulation 238 of the Human Medicine Regulations 2012.5 In an emergency, anybody can inject adrenaline and other drugs listed in Schedule 19 of the Regulations for Saving a Life.
ACE GROUP WORLD EMERGENCY KIT
The following table outlines the medicines and devices the emergency kit should contain. These are contained in the ACE Group World Emergency Kit:
In addition, it is good practice to include in the kit any needles, syringes or diluents needed to administer emergency drugs:
Other essential items include:
• Telephone to call 999 or ACE Group World Emergency Helpline
• Strong paper bag (for re-breathing for visual loss)
• Hot/cold gel packs
Also consider the following desirable items:
• Oxygen with mask and tubing
• Guedel airway/mask
• Pulse oximeter
• Blood pressure machine
FORMULARY FOR THE MANAGEMENT OF COMPLICATIONS
Adrenaline is required in the event of an anaphylactic reaction and should always be available when performing non-surgical aesthetic procedures. Although auto-injection devices are available, healthcare practitioners should stock adrenaline ampoules for drawing up and administering when required.
Adrenaline is an alpha-receptor agonist and reverses peripheral vasodilation and reduces tissue oedema. Its beta-receptor activity dilates the bronchial airways, and it suppresses the release of histamine and leukotrienes. It also acts directly on beta-2 adrenergic receptors on mast cells and inhibits their activation (RCUK,2021).
Hyaluronidase is licensed in the UK for enhancing permeation of subcutaneous or intramuscular injections, local anaesthetics, and subcutaneous infusions and to promote resorption of excess fluids and blood. There is considerable evidence for the off-label use in aesthetic medicine for dealing with vascular compromise (due to inadvertent intravascular injection or external compression), over-correction, asymmetry, lumps and nodules, caused by the injection of hyaluronic acid filler.
Hyaluronidases are enzymes that can depolymerise hyaluronic acid leading to its degradation by hydrolysing the disaccharides at hexosaminidic beta (1-4) linkages.
In the UK, Hyalase (manufactured by Wockhardt UK) is available in a 1500 I.U. powder for solution ampoule.
Aspirin should be immediately available in the instance of a vascular occlusion or visual loss after the injection of soft-tissue filler. The evidence base recommends the immediate use of aspirin and to continue this until the vascular occlusion has resolved. This limits platelet aggregation, clot formation and further vascular compromise. ACE Group World recommends a stat dose of 300mg followed by 75mg a day until the vascular occlusion has resolved and where there are no contra-indications to the use of aspirin, such as aspirin allergy or gastric ulcer.
4. Timolol Eye Drops
If visual loss occurs following the injection of soft-tissue filler, initial treatment involves strategies to reduce intraocular pressure, dislodge the embolus to a more peripheral location and dissolve the hyaluronic embolus. Timolol is a beta-adrenergic antagonist that reduces intraocular pressure by reducing aqueous humor production. Administering Timolol 0.5% (one to two drops in the affected eye) is recommended by ACE Group World to be used immediately in the management of visual loss secondary to cosmetic filler injection.
5. Apraclonidine 1% ophthalmic solution
Apraclonidine 1% ophthalmic solution (brand name Iopidine), is sometimes used for the management of an upper eyelid ptosis following botulinum toxin treatment. Apraclonidine eye drops can be prescribed at a dosage of one to two drops three times a day. It is an alpha-adrenergic receptor agonist and a mydriatic agent which causes contraction of Müller’s muscle, also known as the superior tarsal muscle. This is an adrenergic muscle situated beneath the levator muscle and is an involuntary muscle supplied by sympathetic nerves which may elevate the lid by 1-2 mm.6 There is a risk of causing miosis and closed-angle glaucoma in susceptible individuals and it is essential to check whether a patient wears glasses and to review their ophthalmic medical history. Apraclonidine is generally well tolerated but may cause some sensitivity of the eye with longer term use.
Tetracyclines are antibiotics used for the treatment of both Gram-positive and Gramnegative bacteria and certain other microorganisms. They are bacteriostatic and exert their effects by inhibition of protein synthesis. They also have additional anti-inflammatory and immunomodulatory effects7 and have a high degree of lipid solubility, making them particularly useful in aesthetic medicine. They should not be used in children or during pregnancy and should be used cautiously in hepatic or renal impairment. Tetracyclines can lead to photosensitivity and patients should be advised on UV protection. They are recommended first line by ACE Group World when managing a delayed-onset nodule. Tetracyclines include Doxycycline 100mg OD and Minocycline 100mg OD.
Macrolides are highly potent against certain aerobic and non-aerobic Gram-positive and Gram-negative bacteria. They exert their effect by suppressing protein synthesis in susceptible bacteria. They also have high tissue penetration and localise in adipose tissue. The most common sideeffects include abdominal pain, diarrhoea, nausea and vomiting. There are several contraindications and drug interactions which the prescriber should be familiar with.
Macrolides include Clarithromycin 500mg BD and Azithromycin 500mg TDS.
“Prescribers and those who administer are equally accountable to the patient and their professional bodies, and must be aware of relevant legislation”
Fluoroquinolones are used for skin and soft tissue infections caused by Gram-negative bacteria. They work by inhibition of bacterial enzymes responsible for DNA replication, transcription, repair, and recombination. Due to the risks of adverse events, including tendon rupture, visual disturbance, neurological effects, cardiac disturbances, hepatic monitoring, and aortic rupture, ACE Group World recommend that this class of antibiotics is used third line.
Fluoroquinolones include Ciprofloxacin 500mg BD.
Antihistamines may be used in non-surgical aesthetic practice where patients experience a histamine mediated side-effect which may include itching, swelling or erythema. Antihistamines are antagonists that act on the H1-histamine receptor. They are rapidly well-absorbed, giving a fast onset of action. They are generally well tolerated with few sideeffects. ACE Group World recommends the use of non-sedating antihistamines, such as Loratadine 10mg OD or Cetirizine 10mg OD.
10. Oral corticosteroids
Oral corticosteroids are widely used in medicine for a variety of conditions and may be prescribed in aesthetic medicine to manage angioneurotic oedema. They have anti-inflammatory and immunosuppressive effects on the body. Dosage may vary according to the needs of the patient and abrupt withdrawal should not occur if they have been prescribed for a period longer than three weeks. Side-effects include severe psychiatric reactions, adrenocortical insufficiency, immunosuppression and sleep disturbance. According to ACE Group World guidelines, oral corticosteroids may be used to treat inflammatory reactions following softtissue filler treatments or the management of oedema in certain instances.
Oral corticosteroids include Prednisolone and Dexamethasone.
11. Guanine nucleoside analogues
Guanine nucleoside analogues are antiviral drugs that inhibit viral replication and are converted into their active drug component within an infected cell by the action of viral thymidine kinase. They are prescribed in non-surgical aesthetic medicine for the prevention and treatment of herpetic infections. Most viral replication occurs within the first 24 hours of infection, so prompt treatment at the prodromal stage, prior to lesions erupting, is recommended to limit epithelial damage and possible secondary complications. 8 The most frequent side-effects of guanine nucleoside analogues are headache, abdominal pain, diarrhoea and vomiting. Examples include Aciclovir, Valaciclovir and Famciclovir.
• Ensure that the Aesthetic Complication Expert Group World complications guidelines folder is kept with the Emergency Kit in the case of a complication. This will allow easy reference to treatment algorithms and dosages and reconstitution for the drugs that may be required.
• Display Resuscitation/DRABC laminated posters in all clinical rooms.
• Ensure patients are fully informed of common and serious complications that may occur with a specific treatment and that if a patient has an increased risk, this is highlighted on the consent form that they sign.
• If a patient requires resuscitation or has been treated for an anaphylactic reaction, they should be admitted to hospital via ambulance conveyance as further anaphylaxis may occur.
• In the event of a complication, ensure contemporaneous records and photographs are made. After a complication has occurred, ensure that there is appropriate follow-up until it has fully resolved.
• Complete a significant event form and inform your medical defence insurance company at the earliest convenience.
• For complications caused by a certain medical product, consider whether this needs reporting via the Yellow Card scheme to the MHRA and/or reporting to the manufacturer.
• Seek more expert help from a practitioner experienced in managing complications when needed. For immediate assistance, contact the ACE Group World Emergency Helpline.
• Grab packs should have been prepared by the Laser Protection Advisor in clinics offering laser/IPL treatments which provide details on the laser device, power output and wavelength. These should be sent with the patient in the event of an eye injury.
The ACE Group Emergency Kits will be exclusively available through Cosmedic Pharmacy.
1. English Oxford Living Dictionaries, available at https://en.oxforddictionaries.com/definition/ emergency [Accessed 07/09/2021]
2. Resuscitation Council (UK), 2014-18. FAQs. [Online] Available at: https://www.resus.org. uk/faqs-anaphylaxis-treatment/ [Accessed 07/09/2021]
3. Simons FE, et al, 2001. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunil., 5(108), pp. 871-3
4. Hwang C.J., Morgan, P.V., Pimentel, A., Sayre, J.W., Goldberg, R.A. and Duckwiler, G. (2016) ‘Rethinking the Role of Nitroglycerin Ointment in Ischemic Vascular Filler Complications: An Animal Model With ICG Imaging’, Ophthalmic Plast Reconstr Surg, Mar-Apr;32(2), pp 118-22. doi: 10.1097/IOP.0000000000000446.
5. The Human Medicine Regulation 2012 [Online] Available at : https://www.legislation.gov.uk/ uksi/2012/1916/part/12/chapter/3/crossheading/ exemptions-in-relation-to-specific-kinds-ofproduct/made [Accessed 12/08/2021]
6. Omoigui S, Sunday I. Case report: Treatment of ptosis as a complication of botulinum toxin. Pain medicine 2005;6:2;149-151.
7. Ledon JA, Savas JA, Yang S, Franca K, Camacho I, Nouri K. Inflammatory nodules following soft tissue follow use: A review of causative agents, pathology and treatment options. Am J Clin Dermatol 2013;14(5):401-411
8.National Institute for Clinical Excellence. Clinical Knowledge Summary. Oral Herpes Simplex. Available at https://cks.nice.org.uk/ herpes-simplex-oral#!topicsummary [Accessed 03/05/2021]