The prevention of cutaneous necrosis following extravasation of hypertonic saline and sodium tetradecyl sulfate

Interventions For the Treatment of Lower Limb Telangiectasias and Reticular Veins: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To assess the safety and efficacy of available interventions in the treatment of lower limb reticular veins and telangiectasias.

DATA SOURCES

An electronic search was performed on Scopus, Embase, and Google scholar.

REVIEW METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Following data extraction and processing, a Bayesian network meta-analysis and meta-regression was undertaken. The primary endpoint was telangiectasia and reticular vein clearance.

RESULTS

Nineteen studies, 16 randomised controlled trials and three prospective case series, including 1 356 patients and 2 051 procedures, were finally incorporated. All interventions, apart from 0.5% sodium tetradecyl sulphate (STS) and 0.25% STS displayed statistically significantly superior telangiectasia and reticular vein clearance compared with normal saline (N/S), Meta-regression analysis employing the type of the venule treated (telangiectasia or reticular vein) as a covariable, revealed a positive correlation between Nd:YAG 1064 nm laser and telangiectasia clearance (β = 1.38, 95% CI 0.56 - 2.14). Further exploration unveiled the superiority of Nd:YAG 1064 nm in the treatment of telangiectasias compared with all included interventions except 72% chromated glycerin (CG). STS 0.25% increased the risk of hyperpigmentation compared with all interventions except 0.5% STS, and 1% polidocanol. CG 72% decreased the risk of matting compared with polidocanol foam (risk ratio [RR] 0.14, 95% CI 0.02 - 0.80) and STS (RR 0.31, 95% CI 0.07 - 0.92). Non-statistically significant differences were identified between interventions regarding pain outcomes.

CONCLUSION

This network meta-analysis has demonstrated a proportional relationship between sclerosant potency and side effect occurrence in the treatment of telangiectasias and reticular veins and the superiority of laser therapy compared with injection sclerotherapy in treating telangiectasias. The transition of telangiectasia and reticular vein treatment from highly potent detergent solutions to equally effective but milder sclerosants could potentially reduce undesirable adverse events.

Recommendations for Management of Noncytotoxic Vesicant Extravasations

To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.

Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension

BACKGROUND/OBJECTIVE

Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl.

METHODS

Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access.

RESULTS

Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001).

CONCLUSIONS

Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.

Viability of randomized skin flaps-an experimental study in rats

BACKGROUND

Randomized skin flaps are extensively used in plastic surgery, but the possibility of necrosis has challenged their use. Several studies have been conducted aiming to find ways to reduce the occurrence of necrosis. We evaluated the effects of pentoxifylline (PTX) and hyaluronidase (HLD), each alone or combined, on randomized rat skin flaps.

MATERIALS AND METHODS

Fifty male Wistar rats were divided into five groups of 10 animals each: control I, control II, PTX, HLD, PTX-HLD. Substances were administered from the first to the 14th postoperative day. The necrotic area was measured on the seventh and 14th postoperative day; the animals were killed on the 14th day, when samples were collected for histologic and immunohistochemical examination.

RESULTS

On the seventh day, percentage of the necrotic area was significantly reduced in PTX, HLD, and PTX-HLD animals compared with control groups. On 14th day, percentage of the necrotic area in PTX, HDL, and PTX-HLD groups was also significantly reduced compared with control groups. PTX and PTX-HLD showed a significant reduction in dermis cellularity, V_V of macrophages, and myofibroblasts compared with control groups; PTX showed a significant enhancement of L_V of blood vessels compared with all other groups.

CONCLUSIONS

The use of each substance alone or combined increased flap viability compared with control groups. On the seventh day, PTX exhibited lower viability than HLD, whereas on the 14th day there was no difference between treated groups. PTX alone enhanced the L_V of blood vessels, whereas PTX-HLD did not. However, PTX-HLD was more effective in decreasing the dermis cellularity and macrophage V_V than HLD alone.

Complications in the Cosmetic Dermatology Patient: A Review and Our Experience (Part 1)

BACKGROUND

Over recent decades, the options available to patients for cosmetic rejuvenation have expanded dramatically. The range of options commonly available to patients now includes neuromodulators, fillers, sclerotherapy, chemical peels, liposculpture, lasers, and lights and other energy devices and continues to grow. As with all therapeutic interventions, these cosmetic dermatologic procedures are not without risk. Timely recognition of complications and intervention are paramount for optimal patient outcomes.

OBJECTIVE

Part 1 of this review will focus on the common complications of injectable cosmetic procedures, such as neuromodulators, fillers, and sclerotherapy. The second part will discuss the complications of chemical peels, lasers, light and energy devices, and fat removal procedures.

MATERIALS AND METHODS

A MEDLINE search was performed on cosmetic dermatology complications from 1989 to 2015, and results are summarized. Practical considerations of these complications are also provided.

RESULTS

Reports of complications after neuromodulator, injectable hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, polymethylmethacrylate, sclerotherapy, fat transfer, liposuction, cryolipolysis, chemical peels, lasers, and light sources, such as Q-switched laser, intense pulsed light, nonablative and ablative resurfacing lasers, were found.

CONCLUSION

Review of the literature revealed multiple management options for potential complications of the multitude of cosmetic dermatology procedures now available to patients.

Management of extravasation injuries: a focused evaluation of noncytotoxic medications

Extravasations are common manifestations of iatrogenic injury that occur in patients requiring intravenous delivery of known vesicants. These injuries can contribute substantially to patient morbidity, cost of therapy, and length of stay. Many different mechanisms are behind the tissue damage during extravasation injuries. In general, extravasations consist of four different subtypes of tissue injury: vasoconstriction, osmotic, pH related, and cytotoxic. Recognition of high-risk patients, appropriate cannulation technique, and monitoring of higher risk materials remain the standard of care for the prevention of extravasation injury. Prompt interdisciplinary action is often necessary for the treatment of extravasation injuries. Knowledge of the mechanism of extravasation-induced tissue injury, agents for reversal, and appropriate nonpharmacologic treatment methods is essential. The best therapeutic agent for treatment of vasopressor extravasation is intradermal phentolamine. Topical vasodilators and intradermal terbutaline may provide relief. Intradermal hyaluronidase has been effective for hyperosmotic extravasations, although its use largely depends on the risk of tissue injury and the severity of extravasation. Among the hyperosmotic agents, calcium extravasation is distinctive because it may present as an acute tissue injury or may possess delayed clinical manifestations. Extravasation of acidic or basic materials can produce significant tissue damage. Phenytoin is the prototypical basic drug that causes a clinical manifestation known as purple glove syndrome (PGS). This syndrome is largely managed through preventive and conservative treatment measures. Promethazine is acidic and can cause a devastating extravasation, particularly if administered inadvertently through the arteriolar route. Systemic heparin therapy remains the accepted treatment option for intraarteriolar administration of promethazine. Overall, the evidence for managing extravasations due to noncytotoxic medications is nonexistent or limited to case reports. More research is needed to improve knowledge of patient risk, prompt recognition of the extravasation, and time course for tissue injury, and to develop prevention and treatment strategies for extravasation injuries.

Extravasation injuries in adults

Insertion of an intravascular catheter is one of the most common invasive procedures in hospitals worldwide. These intravascular lines are crucial in resuscitation, allow vital medication to be administered, and can be used to monitor the patients' real-time vital parameters. There is, however, growing recognition of potential risks to life and limb associated with their use. Medical literature is now replete with isolated case reports of complications succinctly described by Garden and Laussen (2004) as "An unending supply of "unusual" complications from central venous catheters." This paper reviews complications of venous and arterial catheters and discusses treatment approaches and methods to prevent complications, based on current evidence and endeavours to provide information and guidance that will enable practitioners to prevent, recognise, and successfully treat extravasation injuries in adults.

Sclerotherapy: it is back and better

With the recent US Food and Drug Administration (FDA) approval of polidocanol in the United States, there has been a resurgence of interest in sclerotherapy. Despite the popularity of laser therapy, sclerotherapy remains the gold standard for treating spider and reticular veins. Although this traditional method of treatment has been around for more than 100 years, better sclerosing agents and newer techniques have made sclerotherapy safer and more efficacious than ever before. This article is a primer for physicians interested in updating their skills in sclerotherapy. It reviews common sclerosants, sclerotherapy techniques, patient evaluation, complications, and recent advancements in sclerotherapy.

Complications of Sclerotherapy

Sclerotherapy is the systematic, targeted elimination of intracutaneous and subcutaneous varicose, reticular, telangiectasias by the injection of a locally irritating chemical substance, called a sclerosant. The endpoint of this process is functionally analogous to surgical removal of a vein. However, regardless of the best of intentions, complications can and will occur with enough sclerotherapy treatments. Complications resulting from sclerotherapy can be divided into the following categories for ease of explanation: (1) frequent but transient, (2) rare but self-limited, and (3) rare but major. This article will focus on select complications in sclerotherapy, review the most common complications observed, and discuss how to minimize these in daily practice.

Sclerotherapy basics

Sclerotherapy involves the injection of a fluid into blood vessels to eradicate them. A thorough understanding of the basics of sclerotherapy are important when beginning sclerotherapy procedures in practice. This article reviews the essential information of sclerosants, treatment of small vessel disease, and patient management.

Sclerotherapy treatment of telangiectasias and varicose veins

Telangiectasias and/or varicose veins are present in about 33% of adult women and 15% of adult men. Although they may be only of cosmetic concern, superficial varices often cause significant symptoms such as pain, aching, heaviness, and pruritus. Venous ulceration is commonly caused solely by superficial venous insufficiency. Superficial thin-walled veins may rupture and hemorrhage. Sclerotherapy is a nonsurgical procedure that can be used to treat both small and large varices of the superficial venous system and perforators. This involves injecting a sclerosant intraluminally to cause fibrosis and eventual obliteration of a vein. The most common sclerosants used in the U.S. include sodium tetradecyl sulfate, polidocanol, 23.4% saline, and a combination of 25% dextrose with 10% saline. Treatment generally proceeds from proximal to distal and largest to smallest vein, based on a reflux map developed from physical examination, Doppler, and duplex ultrasound. Sclerotherapy results can be optimized and the risk of complications minimized by choosing the proper sclerosant, sclerosant concentration, sclerosant volume, and injection sites for the vein(s) being treated. Post-treatment instructions, particularly compression and ambulation, are designed to improve the results and safety of sclerotherapy. Adequate understanding of an appropriate history and physical, ultrasound evaluation, anatomy, pathophysiology, knowledge of sclerosing solutions, patient selection, and post-treatment care, as well as the ability to prevent, recognize, and treat complications are required before embarking on treatment.

Diffusion and short-term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis

BACKGROUND

Botulinum toxin adequately treats hyperkinetic facial lines and hyperhidrosis. Higher doses of botulinum toxin appear to enhance efficacy and longevity possibly through greater evenness of diffusion; however, recurrent treatments with higher doses are expensive.

OBJECTIVE

To admix botulinum toxin with hyaluronidase and to test whether there is maintenance of efficacy, a spread of effect, and possibly a decrease in required dose compared with botulinum toxin.

METHODS

Six patients participated in a double-blinded side-to-side comparison pilot study with photographic analysis for frontalis overactivity and Minor's iodine and gravimetric testing for axillary hyperhidrosis.

RESULTS

Initial efficacy of botulinum with admixed hyaluronic acid appeared maintained with possibly increased diffusion when hyaluronic acid is added. No difference was evident on short-term review of patients treated with 50 U of botulinum in one axilla compared with the contralateral side injected with 25 U with admixed hyaluronidase.

CONCLUSION

There may be a role for hyaluronic acid in aiding diffusion and decreasing the required dose of botulinum toxin in hyperhidrosis axillaris.

Hyaluronidase in the prevention of sclerotherapy-induced extravasation necrosis. A dose-response study

BACKGROUND

A previous study found hyaluronidase to be effective in the prevention of necrosis following intradermal sodium tetradecyl sulfate and 23.4% sodium chloride. There are no published dose-response studies of hyaluronidase used in this manner.

OBJECTIVE

To conduct a dose-response study using hyaluronidase in the prevention of necrosis following intradermal 23.4% sodium chloride.

METHODS

Study I evaluated control vs hyaluronidase groups (150, 300, 450 units; all in volume of 3 mL) in the prevention of necrosis following intradermal 0.25 mL 23.4% sodium chloride. Incidence and size of necrosis were compared between groups. In study II, hyaluronidase was administered in doses ranging from 18.75 to 900 units (all in volume of 3 mL) immediately following the intradermal instillation of 0.25 mL of 23.4% sodium chloride. A control group had no therapy. The incidence of necrosis was compared between groups. A dose-response curve was constructed. Both studies were randomized and blinded and used Sprague-Dawley rats.

RESULTS

A statistically significant protective effect was found in the treated vs the untreated groups in both studies. Maximal protection was achieved by 75 units of hyaluronidase and was not improved upon by higher doses.

CONCLUSION

In the event of extravasation with 23.4% sodium chloride, in the model studied, one can expect maximal protection with a dose of 75 units of hyaluronidase.

Cutaneous necrosis, telangiectatic matting, and hyperpigmentation following sclerotherapy. Etiology, prevention, and treatment

BACKGROUND

Telangiectatic matting and hyperpigmentation are some of the most commonly observed side effects of sclerotherapy. Cutaneous necrosis is relatively rare and often of limited sequelae but most commonly related to extravasation of sclerosant. Physicians treating varicosities and telangiectasia by sclerotherapy must be familiar with causes and means for minimization of all three side effects.

OBJECTIVE

This review article discusses the proposed etiology, risk factors, approach for minimizing, and suggested treatment for the three side effects of cutaneous necrosis, telangiectatic matting, and hyperpigmentation.

RESULTS

Cutaneous necrosis may occur with the injection of any sclerosing agent even under ideal circumstances and does not necessarily represent physician error. When sclerosant extravasation occurs, dilution must occur immediately. Telangiectatic matting is a recognized complication occurring in approximately 15-20% of patients treated by sclerotherapy. Although the exact mechanism of the phenomena remains unknown, reactive inflammatory and/or angiogenic mechanisms are felt to play a role. Patients are advised that telangiectatic matting is usually not permanent and usually resolves spontaneously in 3-12 months. Postsclerosis pigmentation is defined as the appearance of persistent, increased pigmentation running the course of an ectatic blood vessel treated by sclerotherapy. The general incidence of hyperpigmentation ranges from 10 to 30%. Although hyperpigmentation may persist for months, its presence rarely deters patients from continuing treatment. Spontaneous resolution occurs in 70% at 6 months with 99% resolution occurring within 1 year.

CONCLUSIONS

With understanding the etiology, risk factors, and ways to minimize these side effects our goal is to reduce their incidence. Attempting prevention may ultimately be the most effective means of treatment. Dermatol Surg 1995;21:19-29.

LEARNING OBJECTIVES

After studying the following article, participant should be able to: 1. Understand the definition and potential causes of cutaneous necrosis, telangiectatic matting, and hyperpigmentation following sclerotherapy. 2. Advise patients prior to treatment on the common risks involved in sclerotherapy and to advise them on the relative incidence. 3. Understand the concept of minimal sclerosant concentration and how it can help the physician to choose sclerosing solution concentrations to minimize risks.