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Hyaluronidase Availability in Californian Emergency Rooms
Daniel P Zaki MS1, Idean Roohani BS2, Joseph M Firriolo MD3, Sydney J Sawyer BS3, Tiffany R Wong BA3, Corey M Bascone MD3, Jesus A Garcia MD PhD4, PhD. Lee LQ Pu MD PhD FACS3 1University of Arizona College of Medicine, Tucson, AZ 2Keck School of Medicine at USC, Los Angeles, CA 3Division of Plastic and Reconstructive Surgery, University of California Davis, Sacramento, CA 4Department of Plastic Surgery, Kaiser Permanente, Sacramento, CA

Background: Hyaluronic acid filler injection is generally regarded as a safe procedure. However major complications do exist, notably blindness and skin ischemia/necrosis. Hyaluronidase is an enzymatic reversal agent for immediate ischemic complications of hyaluronic acid fillers. Unfortunately, many injector sites are not equipped with hyaluronidase due to the expensive price, short shelf-life, and rare incidence of ischemic complications. As a result, emergency rooms (ERs) are expected to operate as a safety net when injector sites encounter an ischemic complication. Currently, little is known on the availability of hyaluronidase in ERs. The authors sought to: 1) determine the immediate availability of hyaluronidase in ERs across the state of California; 2) determine the institutional and geographical predictors of hyaluronidase availability; and 3) provide injectors with recommendations to obtain hyaluronidase when on-site supplies are inadequate.

Methods: Authors conducted a scripted telephone survey of all Californian ERs, inquiring about hyaluronidase availability. Proportions of hyaluronidase availability were compared among different geographical regions, various trauma center level designations, and children's hospital status, using χ2 tests. A Mann-Whitney U test was used to compare median bed counts between hospitals that had hyaluronidase available and those that did not.

Results: The present study included 330 Californian ERs and achieved an 89.7% response rate (n=296). Overall, 45.6% of ERs were found to not have hyaluronidase in their pharmacy inventory (Figure 1). Hyaluronidase availability was positively associated with level I-III adult trauma center status, pediatric trauma center status, children's hospital status, hospitals with higher median bed counts, and regional geography (p<0.05, all). Of note, while dermal fillers are not used in children, hyaluronidase is frequently on formulary in hospitals with pediatric services for treatment of extravasation injury. As such, hyaluronidase may be sourced from these centers in emergencies as required.

Conclusion: Hyaluronidase availability in ERs is unreliable across the state of California, posing a risk to patient safety as ERs are often expected to function as a safety net for hyaluronic acid filler ischemic complications. In emergent situations for which injectors have inadequate supplies of hyaluronidase, the authors recommend calling hospitals in advance to verify hyaluronidase availability. Injectors should be methodical about their calls, and prioritize according to not only proximity, but also by hospital size, trauma center designation, and availability of pediatric services.

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