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Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Assistant Professor Dept of Anesthesia, UIHC March 27, 2001.

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Presentation on theme: "Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Assistant Professor Dept of Anesthesia, UIHC March 27, 2001."— Presentation transcript:

1 Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Assistant Professor Dept of Anesthesia, UIHC March 27, 2001

2 History of Latex Allergy 1933 Contact dermatitis to gloves 1979 Contact urticaria 1982 Identified IgE antibodies to latex proteins 1989 Anaphylaxis and death from latex exposure Association with spina bifida or severe GU anomalies 1997 Reports to FDA total 2300 allergic reactions (225 anaphylaxis, 53 cardiac arrests, 17 deaths) 1998 FDA mandates labeling of medical products

3 Origin of Latex Latex is sap from rubber tree, Hevea brasiliensis Latex is sap from rubber tree, Hevea brasiliensis 60% H 2 O, 35% rubber, 5% protein 60% H 2 O, 35% rubber, 5% protein Rubber molecule: cis-1,4-polyisoprene Rubber molecule: cis-1,4-polyisoprene Chemicals added during production Chemicals added during production  Preservatives (ie: ammonia), accelerators (ie: thiurams), antioxidants (phenylenediamine), vulcanizing compounds (ie: sulfur)  May elicit delayed hypersensitivity Proteins responsible for most generalized allergies Proteins responsible for most generalized allergies  7 sensitizing proteins identified to date

4 Manufacture of Latex Gloves Protein content can vary 1000-fold among lots Protein content can vary 1000-fold among lots May vary 3000-fold among manufacturers May vary 3000-fold among manufacturers Powdered examination gloves have highest protein content and allergen levels Powdered examination gloves have highest protein content and allergen levels  Cornstarch particles adsorb latex allergens  Particles aerosolized: assoc with respiratory symptoms  Particles also contaminate clothing Lowest levels in powderless gloves that undergo additional washing and chlorination Lowest levels in powderless gloves that undergo additional washing and chlorination

5 Mechanisms of Exposure Cutaneous absorption, ie: from gloves Cutaneous absorption, ie: from gloves Inhalation via aerosolized proteins on powder Inhalation via aerosolized proteins on powder Mucosal Mucosal  Vaginal/rectal exams, dental procedures, surgery Parenteral Parenteral  IVs, surgical wounds, severe dermatitis

6 Hypersensitivity Classification Type IImmediate Type IImmediate Type IICytotoxic Type IICytotoxic Type IIIImmune complex Type IIIImmune complex Type IVDelayed type Type IVDelayed type

7 Types of Latex Sensitivity Irritant contact dermatitis Irritant contact dermatitis Type IV -- Delayed Hypersensitivity Type IV -- Delayed Hypersensitivity Type I --Immediate Hypersensitivity Type I --Immediate Hypersensitivity

8 Irritant Contact Dermatitis Most frequent reaction to latex products Most frequent reaction to latex products Sxs/signs: scaling, drying, cracking of skin Sxs/signs: scaling, drying, cracking of skin Results from direct action of latex and chemicals Results from direct action of latex and chemicals Not a true allergy - no immunologic mechanism Not a true allergy - no immunologic mechanism  However breakdown in skin integrity enhances absorption of latex proteins  Accelerates onset of sensitivity/allergy Rx: identify reaction, use alternative product Rx: identify reaction, use alternative product

9 Type IV -- Delayed Hypersensitivity Synonyms: T-cell mediated contact dermatitis, allergic contact dermatitis Synonyms: T-cell mediated contact dermatitis, allergic contact dermatitis Most common immune response to gloves Most common immune response to gloves Sxs/signs: mild to severe dermatitis (itching, blistering, crusting); appears 6-72 hrs after contact Sxs/signs: mild to severe dermatitis (itching, blistering, crusting); appears 6-72 hrs after contact Cause: processing chemicals in gloves; Cause: processing chemicals in gloves; mediated by T lymphocytes (not antibodies) Rx: Identify chemical and use alternative product Rx: Identify chemical and use alternative product Patients may progress to Type I allergy Patients may progress to Type I allergy

10 Type I -- Immediate Hypersensitivity Synonyms: IgE mediated anaphylactic reaction Synonyms: IgE mediated anaphylactic reaction Cause: proteins in latex Cause: proteins in latex  Antigen induces production of IgE; re-exposure to antigen triggers cascade: release of histamine, arachidonic acid, leukotrienes, prostaglandins Onset within minutes Onset within minutes Varied response: local hives to anaphylactic shock Varied response: local hives to anaphylactic shock Rx: Antihistamines, steroids, anaphylaxis protocol Rx: Antihistamines, steroids, anaphylaxis protocol Prevention: avoid latex and areas where powdered gloves used Prevention: avoid latex and areas where powdered gloves used

11 Type I Mediators Histamine and tryptase release common to type I and IV Histamine and tryptase release common to type I and IV Prostaglandins, leukotrienes, eosinophilic chemotactic factor, platelet activating factor Prostaglandins, leukotrienes, eosinophilic chemotactic factor, platelet activating factor  potent bronchoconstrictors, vasodilators Cytokines released minutes later also cause inflammatory effects Cytokines released minutes later also cause inflammatory effects

12 Cardiovascular Histamine Receptors HeartH1coronary vasoconstriction H2coronary vasodilation, tachycardia, inotropy ArteriesH1vasoconstriction H1,H2vasodilation, hypotension VeinsH1increased permeability, edema H1, H2vasodilation, pooling

13 Pulmonary Histamine Receptors BronchiolesH1Bronchoconstriction H2Mucous secretion VasculatureH1Increased permeability

14 Gastrointestinal Histamine Receptors Smooth muscleH2Constriction, cramping MucosaH2Acid secretion

15 Cutaneous Histamine Receptors H1, H2Vasodilation, increased permeability Pruritis, urticaria, angioedema

16 Risk Groups for Latex Allergy Patients with history of multiple surgeries Patients with history of multiple surgeries  Meningomyelocele or severe urologic anomalies Health care workers Health care workers Other occupational exposure Other occupational exposure  Rubber product workers, hair dressers, house cleaners Individuals with atopy Individuals with atopy  Hay fever, rhinitis, asthma, or eczema Patients with specific food allergies Patients with specific food allergies  Banana, kiwi, avocado, chestnut, etc.  Similar proteins

17 Myelodysplastic Patients Prevalence of latex allergy is 18-64% Prevalence of latex allergy is 18-64% Type I reactions more common Type I reactions more common Predisposing factors Predisposing factors  multiple surgeries  daily catheterizations / stoma care  presence of atopy is synergistic factor Other children at high risk Other children at high risk  multiple surgeries starting in neonatal period  those with spinal cord injuries

18 Health Care Workers Typically display a type IV reaction Typically display a type IV reaction  Can include conjunctivitis, rhinitis, dermatitis 1998 study: prevalence of immediate sensitivity in anesthesiologists & CRNAs 12-16% 1998 study: prevalence of immediate sensitivity in anesthesiologists & CRNAs 12-16%  Over 80% of those sensitized had no sxs yet  Risk factors: hx atopy, skin sxs with latex gloves, tropical fruit allergies Progression from type IV to type I unpredictable Progression from type IV to type I unpredictable

19 Diagnosis of Latex Allergy *Clinical history (ask the right questions) *Clinical history (ask the right questions)  Myelodysplasia / urologic anomalies  Multiple surgeries  Chronic occupational exposure  Previous reactions to latex products (type I)  Certain food allergies  Atopy Refer to allergist Refer to allergist  Skin testing  In vitro testing

20 Diagnosis by Skin Testing Diagnose Type IV delayed hypersensitivity Diagnose Type IV delayed hypersensitivity  Positive patch test  Reaction appears anytime from 8 hours to 5 days later Diagnose Type I allergy Diagnose Type I allergy  Skin prick test using antigens from glove products  Gold standard  Positive test: wheal and flare (c/t + and - controls)  Sensitivity and specificity around 98%  May result in severe reaction

21 Diagnosis by In Vitro Testing No risk to patient No risk to patient RAST (radioallergosorbent test) RAST (radioallergosorbent test)  Measures amount of IgE Ab to latex in serum  Most labs must send out  Takes 5-10 days  Sensitivity 80-90%  Specificity 60-90% EAST (Enzymeallergosorbent Test) EAST (Enzymeallergosorbent Test)  Does not utilize radioactivity  Sensitivity & specificity of 80-85%

22 Prevention of Reactions in OR Identify latex sensitive patients Identify latex sensitive patients  Medic-alert bracelet  Signs on hospital bed, room, and OR Schedule as 1st start in OR Schedule as 1st start in OR Use latex free environment Use latex free environment  For pts with hx of type I or type IV reactions  Meningomyelocele or urologic anomalies Post list of latex-containing devices & alternatives Post list of latex-containing devices & alternatives  FDA mandated labeling started February 1998 Pretreat pts with positive hx Pretreat pts with positive hx

23 Non-latex Equipment Disposable endotracheal tubes Disposable endotracheal tubes Esophageal stethoscopes Esophageal stethoscopes Oral airways Oral airways Suction catheters, Nasogastric tubes Suction catheters, Nasogastric tubes ECG pads ECG pads Temp probes Temp probes LMAs LMAs

24 Potential Latex-Derived Products GlovesTape, dressings Catheters, drainsTourniquets, elastic bandages IV ports, central linesMedication vials SyringesNasal airways, masks, straps Breathing bag, bellowsBP cuff tubing Stethoscope tubingOximeter probe *Check labels!

25 Avoidance of Latex includes: Avoiding skin contact: BP/stethoscope tubing, IV tourniquets Avoiding skin contact: BP/stethoscope tubing, IV tourniquets Remove stoppers from multi-dose med vials Remove stoppers from multi-dose med vials Tape latex injection ports on IV tubing, central lines, IV fluid bags Tape latex injection ports on IV tubing, central lines, IV fluid bags Use latex free syringes (remember the epidural & spinal trays) Use latex free syringes (remember the epidural & spinal trays)

26 Pretreatment Prophylaxis of anaphylaxis is controversial Prophylaxis of anaphylaxis is controversial  Efficacy unknown  Anaphylaxis has occurred in pretreated pts  May mask early signs Pretreat pts with hx of Type I sxs Pretreat pts with hx of Type I sxs Start prophylaxis preop and continue x 24 hr Start prophylaxis preop and continue x 24 hr  Diphenhydramine 1 mg/kg q 6 hr IV or PO  Methylprednisolone 1 mg/kg q 6 hr IV or PO  Cimetidine 5 mg/kg q 6 hr IV or PO (up to 300 mg)

27 Recognition of Anaphylaxis Cutaneous Cutaneous  Urticaria  Flushing  Diaphoresis  Perioral / periorbital edema  Conjunctival hyperemia  Lacrimation  Rhinitis

28 Recognition of Anaphylaxis Respiratory Respiratory  Laryngeal edema  Bronchospasm  Pulmonary edema Cardiovascular Cardiovascular  Tachycardia, dysrhythmias  Hypotension  CV collapse

29 Management of Anaphylaxis Remove antigen Remove antigen 100% oxygen 100% oxygen IV volume expansion (up to 50 ml/kg) IV volume expansion (up to 50 ml/kg) D/C or adjust anesthesia D/C or adjust anesthesia Epinephrine Epinephrine  Bronchospasm or hypotension: ug/kg IV  Cardiac arrest: peds: 10 ug/kg, adults: mg IV Antihistamine: diphenhydramine 1 mg/kg H2 blocker optional Antihistamine: diphenhydramine 1 mg/kg H2 blocker optional Steroids: hydrocortisone 1-4 mg/kg Steroids: hydrocortisone 1-4 mg/kg

30 Again…... Identify those pts at high risk Identify those pts at high risk For myelodysplastic & GU anomaly pts, as well as those with hx of type I sxs: For myelodysplastic & GU anomaly pts, as well as those with hx of type I sxs:  Label pt, chart, pt room, OR as latex free  Use latex precautions Prophylax pts with hx of type I reaction Prophylax pts with hx of type I reaction Be prepared to treat anaphylaxis Be prepared to treat anaphylaxis

31 Conclusion Most important step is avoidance of exposure in susceptible patients Most important step is avoidance of exposure in susceptible patients With universal precautions, the problem will likely worsen With universal precautions, the problem will likely worsen Hospitals should strive for low allergen environments Hospitals should strive for low allergen environments  Powderless gloves with low extractable protein content Protect yourself Protect yourself  Treat dermatitis  Cover hand wounds with tegaderm


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