Lois Schick MN, MBA, RN, CPAN, CAPA Latex Allergy Lois Schick MN, MBA, RN, CPAN, CAPA

Latex Sensitivity Review the development diagnosis and current treatment of latex allergies Describe each of the 3 types of human reactions to natural rubber/latex containing products Identify currently available diagnostic tests and medical treatment options

NIOSH National Institute for Occupational Safety and Health Established under the 1970 Occupational Safety and Health Act A division of the Centers fro Disease Control and Prevention (CDC) Not OSHA In Ireland and Great Britain it is the NHS

NIOSH Recommendations June 1997 released-prevention oriented Use the appropriate glove for the task at hand Summarizes employer and worker info Targeted towards hospitals, day care facilities, food service industry, environmental services

June 1997 was too late for nurse Cheryl Maree Mohrbacker Cheryl was a 41 year old RN in Oregon Worked 3-11 Shift Cheri never came home from work one night Her Story: Visiting father in hospital and she develops a severe allergic reaction which required 3 days on a ventilator Carpets were being cleaned at hospital and her reaction was attributed to a reaction to the cleaning chemicals Had a second bout again when carpets were being cleaned at a hospital where she was employed

Cheri’s story Cheri realized she was only having reactions when wearing Latex gloves In 1994, Cheri was tested for and diagnosed with a latex allergy. She switched to hypoallergenic gloves which are meant for those who suffer from dermatitis. Some hypoallergenic gloves have been found to have 3000 times the latex protein as regular latex gloves making them more dangerous to latex sensitive nurses Eventually she got latex-free gloves.

Cheri’s story June 10, 1996 Cheri had a severe attack while at work. She was rushed to the ED and told the staff there that she was latex sensitive. At one point Cheri grabbed one nurse by the arm so hard that she left bruises and her last words to this nurse were: “You’re just going to let me die. I’m not going to make it this time.” Cheri was right – she did die in the ED that night.

Natural Rubber Latex (NRL) Milky fluid derived from the rubber tree (Hevea Brasiliensis) Two methods of treatment prior to use Coagulate to solidify Dry natural rubber i.e. tires, shoe soles Ammonionate to prevent coagulation Gloves, condoms Proteins can cause range of allergic reactions

Latex Allergy 18-73% sensitization rate in children with Spina Bifida Latex allergy affects 18 million Americans Increasing rates of sensitization 18-73% sensitization rate in children with Spina Bifida 33% sensitization rate in those having 3 or more surgeries 15% sensitization rate in RN’s

Latex Allergy 17% sensitization rate in ALL health care workers (2% have occupational asthma) Increased sensitivity in operating room personnel from 2.95% to 15% in less than 10 years Increased rates in dental personnel from 13.7% to 38% in 4 years

Suspected populations at risk Congenital neural tube disorders Urologic disorders requiring catheterizations 3 or more surgeries History of systemic reactions to balloons, latex gloves, condoms, cosmetics, rocket handlers, Poinsettas

Suspected populations at risk History of allergy to fruits with cross reactive proteins Hay fever, asthma, contact dermatitis Food allergies to: bananas, avocados, passion fruit, kiwis, chestnuts, tomato, Celery, melon,

Manifestations of Latex Allergy Delayed hypersensitivity Contact pruritus, erythema, uriticaria, eczema Immediate hypersensitivity Rhinorrhea, conjuctival pruritis & edema, wheezing, bronchospasm, angina, tachycardia & progressively severe hypotension

Onset & Symptoms Type I: Immediate Hypersensitivity Progresses in 15-20 minutes Resolves spontaneously over 1-2 hours Immediate, local and generalized uriticaria, feeling faint, feeling of impending doom, angioedema, nausea, vomiting, abdominal cramps, bronchospasm, anaphylaxis

Onset & Symptoms Type I: Immediate Hypersensitivity Anaphylaxis: Typically within 30 minutes after exposure Cutaneous, GI, CV, Respiratory Laryngeal edema and CV collapse most common cause of death Immunoglobulin & mediated systemic reaction to the latex proteins that if untreated lead to fatality

Onset & Symptoms Type IV: Delayed Hypersensitivity Contact Dermatitis Appears in 18-24 hours Resolves in 72-96 hours Redness & inflammation over exposed sites Blister formation Allergic Dermatitis T-cell mediated delayed localized reaction to chemicals used in manufacture of gloves

More prolonged the latent period between antigen exposure and the onset of symptoms, the more benign the reaction

Equipment Issues act as a vector for patient sensitization GLOVES act as a vector for patient sensitization Workers are at risk as a population from multiple exposures 5-6 million workers wear gloves regularly 117 million pairs of latex gloves were supplied to NHS in 1992 NHS – National Health Services

Equipment Issues itching, hives, vesicles, erythema, and eczema Latex gloves can cause contact allergic reactions itching, hives, vesicles, erythema, and eczema Usually a delayed hypersensitivity reaction Workers may have concurrent chemical sensitivities to additives in latex

Equipment Issues 40,000 consumer products that contain latex in their composition. Makes it difficult to completely delete latex

Environmental Issues Latex particles are suspended in indoor air in health care settings Powder in gloves is the vehicle for latex particle aerosolization Aeroallergens are higher in areas where workers frequently apply and discard gloves When latex particles are inhaled, workers become sensitized

Sources of Latex - Hospital Gloves - sterile and exam Catheters IV injection ports Medication vials with needle access Ventilator, anesthesia, and respiratory therapy equipment Latex tipped enemas, endoscopy parts Mattresses on stretchers Stethoscopes & blood pressure cuff tubing

Source of Latex - Home Environment Household gloves Diapers, bottle nipples, pacifiers Household insulation material, carpet backing Newsprint, coupons, and magazines dusted with latex coating Feminine sanitary pads, adult diapers, condoms, diaphragms Clothing including elastic on underwear

Methods of Exposure Cutaneous & Mucosa Inhalants IV & Parenteral Gloves, dental equipment, surgical procedures, food prepared by people wearing latex gloves, toys, clothing, sports equip. Inhalants Anesthesia machines, powder from latex gloves, balloons, car tires IV & Parenteral IV ports, tubing, burettes, bottles and syringes

Clinical Management of systemic reactions Antihistamines - oral, IM, IV Chlorphenamine Diphenhydramine Steroids - inhaled, oral, IV Bronchodilators - inhaled, oral, IV Epinephrine - SQ & IV

Clinical Management Latex-safe preoperative and patient rooms Latex-safe OR, PACU and anesthesia equipment Latex-safe neonatal resuscitation equipment Drugs must not be administered through latex ports, nor dwell in syringes with latex plungers

Clinical Management Operating Room Schedule latex - safe cases first of the day to allow settling of latex dust overnight Latex-safe anesthesia equipment Latex-safe respiratory equipment Latex-safe IV delivery systems Recognition of inadvertent latex exposure

Clinical Management Emergency Department Latex-safe intubation & ventilation equipment Latex-safe IV equipment Latex-safe gloves and monitoring equipment Laminar air flow available for the “exquisitely” sensitized

Latex Allergy Identification Screening criteria and diagnosis of latex allergy Methods of allergy testing RAST – RIA (invitro test IgE) with variable sensitivity AlaSTAT – ELISA testing ( IgE testing) Skin Prick - Most sensitive but carries risk of anaphylaxis

Management of the Latex sensitive individual Non latex gloves for the employee Non latex for co-workers (Preferred) or powder free Medications ( epi-pen, antihistamines, inhalers, steroids) Education of co-workers Complete removal of latex sources from work place

Environmental Preparation Remove latex sources from room Dust and vacuum with HEPA filters Mop all surfaces Label room with a “Latex Allergy”Sign Obtain non-latex medical equipment (Cart) Reverse laminar air flow room if possible

Equipment Concerns Non-latex exam and sterile gloves. NO Exceptions ! neolon, nitrile, & butadene-styrene Latex-Free respiratory support equipment Non-latex ambu bag, ETT, cannulas, & masks readily available Non latex anesthesia machine components (Ohmeda, North American Draeger & Anesthesia Associates retrofits

Latex-Free IV Equipment Clave ( ICU Medical), Interlink ( Baxter), IVAC & Braun needleless IV tubings Protective Plus (Johnson & Johnson) Insyte (Critikon), Abbocath, Clear-cath Central lines-check with Arrow & Bard Heparin Locks - B. Braun and Abbot

Medications & Specialty Procedures Use needleless systems with latex free syringes or prefills Abboject for most emergency drugs Approved Wyeth-Ayerst blunt tip or tubex drugs only Latex-free syringes - Terumo, Norm-ject ( Air-tite) & Becton Dickinson DeRoyal Procedure Packs

Personnel Specifics Nursing, Laboratory, Pharmacy, Housekeeping & Food Service staff don fresh gowns when entering a latex-allergic person’s room to prevent latex glove residue on clothing from being introduced. All personnel wear non-latex gloves Food prep done with non-latex gloves

Items that have caused Anaphylaxis and Fatalities Latex gloves Meds injected through latex topped vials into latex IV ports Latex tipped enema catheters, urinary catheters Respiratory and resuscitation equipment

Nursing Research Sample of 79 Type I allergic response to latex 49% RNs Qualitative - Fears, Lifestyle changes, Job and family impact Findings in a nutshell Almost all respondents fear needing EMS and Medical care Denial of symptoms often results in worsening

10 Latex Precaution Interventions 1. Identify those at risk as well as those who have had reactions. 2. Communicate information about the patient to all departments who have contact with the patient. Latex Precaution checklist 3. Admit patient to environment that reduces exposure to latex

10 Latex Precaution Interventions 4. Call for Latex Precautions cart. 5. Use Latex-free gloves for any patient contact. Sterile & nonsterile. 6. Schedule surgeries/procedures as first case of the day. 7. Protect patient from direct contact. 8. Follow physicians orders for pre and/or post anaphylaxis medications. BE Prepared!

10 Latex Precaution Interventions 9. If appropriate, maintain a unit specific Latex Free “Tool Box”. 10. Educate the patient and the family-Refer cases to appropriate medical care, contact latex information networks. LISTEN TO THE PATIENT!!!

Summary Obtain latex free equipment before it is needed Suspect every patient and any employee with symptoms Resources: Elastic - www.latexallergyhelp.com Latex Cart Products List - Journal of Emergency Nursing 1998; 24L58-61

Foot to the Pedal

Resources: Elastic - www.latexallergyhelp.com Latex Cart Products List - Journal of Emergency Nursing 1998; 24:58-61 http://www.cdc.gov/niosh/latexalt.html AANA: http://www.aana.com http://www.immune.com/allergy American college of Allergy Asthma immunology: http:// www.acaai.org

See YOU in Seattle, WA. USA April 3-7, 2011

Thank YOU Lois Schick MN, MBA, RN, CPAN, CAPA 12823 W. 3rd Place Lakewood, CO USA 80228 E- Mail: Schickles@aol.com Home:303-989-2281 Cell: 303-475-9854