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Latex Allergy: Diagnosis, Prevention, and Management

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Presentation on theme: "Latex Allergy: Diagnosis, Prevention, and Management"— 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
60% H2O, 35% rubber, 5% protein Rubber molecule: cis-1,4-polyisoprene 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 7 sensitizing proteins identified to date

4 Manufacture of Latex Gloves
Protein content can vary 1000-fold among lots May vary 3000-fold among manufacturers 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

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

6 Hypersensitivity Classification
Type I Immediate Type II Cytotoxic Type III Immune complex Type IV Delayed type

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

8 Irritant Contact Dermatitis
Most frequent reaction to latex products Sxs/signs: scaling, drying, cracking of skin Results from direct action of latex and chemicals 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

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

10 Type I -- Immediate Hypersensitivity
Synonyms: IgE mediated anaphylactic reaction 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 Varied response: local hives to anaphylactic shock Rx: Antihistamines, steroids, anaphylaxis protocol Prevention: avoid latex and areas where powdered gloves used

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

12 Cardiovascular Histamine Receptors
Heart H1 coronary vasoconstriction H2 coronary vasodilation, tachycardia, inotropy Arteries H1 vasoconstriction H1,H2 vasodilation, hypotension Veins H1 increased permeability, edema H1, H2 vasodilation, pooling

13 Pulmonary Histamine Receptors
Bronchioles H1 Bronchoconstriction H2 Mucous secretion Vasculature H1 Increased permeability

14 Gastrointestinal Histamine Receptors
Smooth muscle H2 Constriction, cramping Mucosa H2 Acid secretion

15 Cutaneous Histamine Receptors
H1, H2 Vasodilation, increased permeability Pruritis, urticaria, angioedema

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

17 Myelodysplastic Patients
Prevalence of latex allergy is 18-64% Type I reactions more common Predisposing factors multiple surgeries daily catheterizations / stoma care presence of atopy is synergistic factor 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
Can include conjunctivitis, rhinitis, dermatitis 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

19 Diagnosis of Latex Allergy
*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 Skin testing In vitro testing

20 Diagnosis by Skin Testing
Diagnose Type IV delayed hypersensitivity Positive patch test Reaction appears anytime from 8 hours to 5 days later 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 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) Does not utilize radioactivity Sensitivity & specificity of 80-85%

22 Prevention of Reactions in OR
Identify latex sensitive patients Medic-alert bracelet Signs on hospital bed, room, and OR Schedule as 1st start in OR 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 FDA mandated labeling started February 1998 Pretreat pts with positive hx

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

24 Potential Latex-Derived Products
Gloves Tape, dressings Catheters, drains Tourniquets, elastic bandages IV ports, central lines Medication vials Syringes Nasal airways, masks, straps Breathing bag, bellows BP cuff tubing Stethoscope tubing Oximeter probe *Check labels!

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

26 Pretreatment 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 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 Urticaria Flushing Diaphoresis Perioral / periorbital edema Conjunctival hyperemia Lacrimation Rhinitis

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

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

30 Again…... Identify those pts at high risk
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 Be prepared to treat anaphylaxis

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

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