About AnsellCares Source To Surgery Source To Surgery Request Form Risk Management Programs Health & Medical Resources Career Opportunities		NEWS & INFORMATION    Source To Surgery - May 1996, Vol. 4 Issue II Care of the Hospitalized Latex-Sensitized Patient Linda L. Gehring, RN, MS, Division of Allergy/lmmunology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Latex is a milky cytosol secreted from the rubber tree Hevea brasiliensis, and used in the manufacture of multiple rubber products. Patients are sensitized to proteins in latex presumably through frequent contact. During the past fifteen years, there has been an increased rate of sensitization. This is manifested as a (Type IV) delayed hypersensitivity or a (Type I) immediate hypersensitivity. A strong correlation has been made between idiopathic anaphylactic reactions and immediate hypersensitivity to natural latex protein. Delayed (Type IV) hypersensitivity (e.g., contact dermatitis) to latex products has been reported since 1935. This is related to chemicals used such as accelerators or antioxidants, in the vulcanization of latex products. In a (Type IV) reaction, the patient is repeatedly exposed to an offending antigen, resulting in contact dermatitis (dry crusty bumps, erythema, pruritus, scaly vesicles, papular lesions at site of contact including the palms). This reaction is not life-threatening and may be treated by altering the individual's exposure to a non-antigenic alternative product. Patients with mild latex glove eczema rarely anaphylaxis. If they have severe or worsening latex glove-induced eczema, urticaria, conjunctivitis, rhinitis, or asthma, their sensitivity may increase and more severe reactions will follow. In contrast, immediate (Type I) hypersensitivity to latex was first reported in 1979. In the immediate reaction, immunoglobulin E (IgE), made in response to environmental protein contact, binds to the surface of a mast cell and reacts with the constituent protein retained in latex. The mast cell releases mediators which cause vasodilation, smooth muscle constriction (bronchospasm), increased vascular permeability, while recruiting inflammatory cells to the site of reaction. The patient may react within minutes to contact with either local or systemic symptoms. Aerosolization of latex protein bound to cornstarch donning powder of latex gloves, may result in respiratory contact symptoms alone. The symptoms of (Type I) latex allergy can include local and/or generalized urticaria, rhinitis, nasal pruritus, conjunctivitis, angioedema, asthma, wheezing, bronchospasm, shock and/or systemic life-threatening anaphylactic reactions. Thus, the care of patients sensitized to latex is important and includes personal changes in latex use at home, work and in the healthcare environment. The primary principle in sensitization is to avoid the offending antigen by limiting environmental contact with products that contain the allergen. All hospitals need to develop guidelines that will minimize the contact with latex allergens for patients with latex sensitization. We have identified 11 basic steps needed when developing Latex Allergy Guidelines (Figure 1). In the hospital environment, communication, documentation and coordination of care is essential for patients with latex allergies. The hospital is a prime place for inadvertent contact with latex allergens. This task frequently is assumed by the patient's nurse. To assist the nurse in caring for patients with a confirmed or suspected diagnosis of latex allergy, eleven recommendations are made (Figure 4). Following these guidelines, while tailoring them to your needs, will result in improved quality of care for the sensitized patient. Complete avoidance of the latex protein is unlikely even in the best situation as adequate substitute materials may not be available. A limited number of latex products seem to be associated with anaphylactic reactions; therefore, it is important to prioritize what can be eliminated. When eliminating items to create a safe environment for your patient, it has been shown that gloves and catheters are the most important. The proteins in gloves vary 10,000-fold between brands. The highest protein level is usually found on the inside surface of the glove. Powdered gloves contain higher levels of protein than powder-free. Studies have shown that reactivity correlated with antigen protein levels, thus the use of low protein powder-free gloves is recommended. As healthcare professionals, we must work with manufacturers to see that, when possible, adequate substitutes of equal quality and prices are available. In-home products need to be properly labeled. Additionally, a list of non-medical products with latex should be developed for use by the public. Samples of product lists and policies and procedures are available through the Allergy Department at the Medical College of Wisconsin, MS 411, P.O. Box 1997, Milwaukee, WI. 53201. FIGURE 1 BASIC STEPS IN THE DEVELOPMENT OF LATEX ALLERGY GUIDELINES Form a multi-disciplinary latex allergy committee which includes medical/surgical anesthesia/allergy staff, nursing, hospital administration, pharmacy, central sterilization processing, central supply, employee health, and quality assessment. These members are needed to coordinate a uniform policy throughout the institution. Develop a uniform policy to handle the latex-sensitive patient. Also, a procedure is needed to care for employees who are at risk for, or develop, a latex sensitivity. Develop a standard patient questionnaire aimed at detecting undiagnosed or confirmed latex allergy (Figure 2). Clarify (in writing from manufacturers or distributors) the latex rubber content of all products used in the hospital. Set up a uniform system to update (every 3-6 months), and disseminate this information on a scheduled basis, (See sample (Figure 3), Letter from Children's Hospital of WI). Develop carts with safe "latex-free" emergency equipment with adequate substitute devices. Ancillary departments that have contact with latex-sensitive patients need to develop guidelines for handling these patients. All departments should develop an educational plan to familiarize the staff regarding latex allergies and precautions. Develop and disseminate educational materials for OR staff and patients. Establish an interdisciplinary quality assessment system to review all suspected reactions to natural rubber latex and monitor the effectiveness. Educate staff on the personal risks of latex allergy. Recommend purchasing low allergen latex gloves to minimize allergen exposure to the healthcare worker and patient. FIGURE 2 QUESTIONS TO ESTABLISH HISTORY OF SUSPECTED OR KNOWN LATEX-SENSITIZED PATIENTS Do you have or think you have an allergy to latex or rubber? If yes, is your current physician aware of this? Do your hands break out when you use rubber gloves? Does your face or tongue swell when you have dental work done? Have you any vaginal or penile discomfort, swelling or itching after the use of a condom? Do you have any swelling or discomfort after a rectal or pelvic exam? Do your allergies or your breathing get worse after you are in a place where latex gloves are worn? Have you ever had an allergic reaction during or after a dental procedure, childbirth or surgery? How many surgeries, including dental, have you had in the past? FIGURE 3 LETTER TO MANUFACTURERS Dear Product Manager: As a result of documented incidents of anaphylactic reactions by patients and staff from exposure to natural rubber latex products, the Administration of (________) has directed Materials Management to determine the natural rubber latex content of all items in the hospital inventory. We currently stock the following product, purchased from your company, as a hospital inventory item. PRODUCT DESCRIPTION: _____________ MFG. PRODUCT NO: _________________ CHW ITEM NUMBER:_________________ Please complete the section below and retum this letter to me at the above address. _____ The above product does not contain any natural rubber latex in its components or ingredients. _____ The above product does contain natural rubber latex in its components and/or ingredients. Please identify the natural rubber latex components and/or specify the latex ingredients. ____________________________________________________________________ ____________________________________________________________________ On behalf of the manufacturer (please fill in):________________________________, the above section is complete and accurate to the best of my knowledge. Name__________ Title__________ Signature__________ Date__________ RETURN COMPLETED LETTER NO LATER THAN ______________. FAILURE TO RESPOND MAY RESULT IN THE INVESTIGATION OF DOCUMENTED NON-LATEX ALTERNATIVES TO YOUR PRODUCT. Sincerely, Materials Management FIGURE 4 RECOMMENDATIONS FOR CARE OF THE LATEX-SENSITIZED PATIENT The patient should wear a medical bracelet alerting personnel to the risk of latex allergy. The medical chart, room, and bed is labeled to avoid latex products being inadvertently brought or stored in the room. Clear notation in the medical record of how a diagnosis or suspected diagnosis was made. Only non-latex exam gloves be used in the room where a latex-sensitive patient is cared for (e.g., on another patient) whether they actually contact the patient or not. Prepackaged kits and trays that contain latex products should not be used. Packages may be closed using a latex glue. Keep this in mind when opening the package. Three-way stopcocks are placed in intravenous lines for the administration of medications. Rubber medication stoppers should not be used. Remove the stopper with a can opener before drawing up the medication. Intravenous tubing without latex injection ports should be used. If this is not possible, tape over the ports and do not use. Patients with suspected latex sensitization are referred to their physician for evaluation. Patients who have developed systemic symptoms or anaphylaxis should carry an injectable epinephrine emergency medication at all times. Patients in a high risk group (e.g., genitourinary tract anomaly) who have not exhibited symptoms of latex allergy should have limited exposure to latex products when possible. Previous Article Source to Surgery Index Table of Contents
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