AANA Latex Protocol

Introduction
In recent years, latex allergy has been recognized as a significant problem for both specific patient and provider populations. The incidence of latex allergy throughout the general population has been estimated between 1% and 6% while certain pediatric populations may experience an incidence as high as 73% (spina bifida and related pathologies). Healthcare workers who are regularly exposed to latex-containing devices and products maintain an incidence of allergic response that ranges from 8% to 17%.

Latex allergy is an immunologic reaction to natural rubber latex, processed from the Hevea Brasiliensis tree indigenous to Central and South America. Newer rubber medical supplies, particularly very soft "dipped" products, contain the greatest proportion of low molecular weight soluble proteins thought to be responsible for the allergic response.

The more recent appearance and recognition of latex allergy as a serious medical concern has resulted from the incorporation of increased barrier precautions in preventing the transmission of infectious bloodborne pathogens. The increase in the number of medical gloves imported to the United States increased awareness among providers. Improved methods in diagnosing latex allergy also accounts for the recent rise in the number of reported cases.

Immediate hypersensitivity reactions to latex vary from contact urticaria to systemic anaphylaxis and laryngeal edema that require lifesaving intervention. Allergic contact dermatitis can also occur and is a delayed hypersensitivity which mimics a poison ivy-type skin reaction. No immunotherapy or desensitization currently exists for latex allergy. Each systemic reaction occurs with less provocation and presentation of a greater magnitude.

Anaphylactic reactions have complicated a variety of common medical procedures including surgery (particularly of the genitourinary tract) and anesthesia, barium enemas, as well as oral, vaginal, and rectal examinations utilizing latex gloves. In most cases, there has been contact between latex products and mucous membranes. However, in some exquisitely sensitive individuals, exposure through inhalation of aerosolized latex or through intravenous administration has led to severe reactions. This type of reaction is similar to immediate drug reactions or stinging insect venom and may be associated with rapidly progressive anaphylaxis and death.

Populations at Risk for Developing Latex AllergyA complete and thorough medical history remains as the most reliable screening test to predict the likelihood of an anaphylactic reaction.

Individuals (particularly in the pediatric population) who are most likely to exhibit a sensitivity to latex that may result in varying degrees of reactivity include:

• Those who possess a known or suspected allergy to latex by having exhibited an allergic or anaphylactic reaction, positive skin testing, or positive IgE antibodies against latex.
  
  
• Those with documented history of intraoperative anaphylaxis of unknown etiology.
  
  
• Those with neural tube defects including: Spina bifidaMyelomeningocele/meningoceleLipomyelomeningocele
  
  
• Those who have experienced some interaction between their central nervous and immune systems.
  
  
• Those who have had multiple operations, particularly as a neonate.
  
  
• Those who require chronic bladder catheterizations as a result of:
  • Spinal cord trauma
  • Exstrophy of the bladder
  • Neurogenic bladder
• Those who possess some history of atopy and multiple allergies including food products. Particular allergies to fruits and vegetables including bananas, avocado, celery, fig, chestnut, papaya and passion fruit are most significant.
• Children with a strong or confirmed allergy to bananas should be considered to be allergic to latex.

Individuals who have experienced a significant degree or repeated exposure to latex products are more likely to develop a latex allergy. These situations may include treatment that involves:

• Occupational exposure to latex (i.e. latex industry, healthcare workers).
  
  
• Repeat surgical procedures
  
  
• Surgical procedures involving mucosal membranes
  
  
• Repeated placement of ventriculo-peritoneal shunts (i.e. cerebral palsy)
  
  
• Repeated or chronic intravenous and urinary catheterizations
  
  
• A history of allergic reaction after touching balloons, rubber gloves or powder from rubber gloves, dental dams, latex consumer products, and medical devices; especially atopic patients.
  
  
• Healthcare providers or other workers who give a history of mild latex glove eczema rarely have anaphylactic events. However, a history of severe or worsening latex glove induced eczema, urticaria, or work-related conjunctivitis, rhinitis, asthma, or urticaria may indicate allergic sensitization and increase the risk for more severe reactions in the future.
  
  

Latex Avoidance PrecautionsBy touching any latex object, the healthcare worker can transmit the allergen by hand to the patient. Caution should be taken to keep the powder from the gloves away from the patient, as the powder will act as a carrier for the latex protein. Therefore, in order to reduce the possibility of the latex protein becoming airborne, care must be taken not to snap gloves on and off.

Patients should be identified as being latex sensitive. The room should be labeled latex free to avoid personnel from bringing rubber products (wrist bands, chart labels, bed, room signs, etc.) into the room. A master list of latex free devices and products is readily available from several internet Web sites including:

Kendall's Healthcare Products
Search their Latex-Free Database
http://www.kendallhq.com/

Hudson RCI
Latex-free respiratory care and anesthesia products
http://www.teleflex.com/usa/product-areas/respiratory/?language_id=1

Establish a latex consultant in your institution; an allergist is recommended. Develop programs to educate healthcare workers in the care of latex-sensitive patients. Develop educational programs for patients and their families in the care and precautions that should be taken to prevent latex exposure. This should encompass a first aid protocol in the event a severe reaction should arise. Encourage latex-sensitive patients to obtain and carry with them, at all times, some type of identification such as a medical alert bracelet and to have an epinephrine auto-injection kit if warranted.

* Resource articles on latex allergy and a sample letter to manufacturers requesting latex information and resource articles are available in a Latex Packet from the Practice Department, American Association of Nurse Anesthetists, 222 South Prospect Avenue, Park Ridge, IL 60068-4001. Phone: (847) 692-7050, ext. 3016.

Recommendations for Patient Care
Patients with Latex Allergy or Latex Risk
Schedule latex-allergy and/or latex-risk patients as the first case(s) in the morning. This will allow later dust (from the previous day) to be removed overnight.

The Operating Room

• Remove all latex products from the operating room.
  
  
• Bring a latex-free cart (if available) into the room.
  
  
• Use a latex-free reservoir bag, airways and endoctracheal tubes and laryngeal mask airways.
  
  
• Use a non-latex breathing circuit with plastic mask and bag.
  
  
• Ventilator must have a non-latex bellows.
  
  
• Place all monitoring devices, cords/tubes (oximeter, blood pressure, electrocardiograph wires) in stockinet and secure with tape to prevent direct skin contact. Items sterilized in ethylene oxide must be rinsed before use. Residual ethylene oxide reacts and can cause an allergic response in a latex-allergic patient.

Intravenous Line Preparation

• Use intravenous (IV) tubing without latex ports; utilize stopcocks if available.
  
  
• If unable to obtain IV tubing without latex ports, cover latex ports with tape.
  
  
• Cover all rubber injection ports on IV bags with tape and label in the following way: Do not inject or withdraw fluid through the latex port. Note: Pulmonary artery catheters (especially the balloon), central venous catheters, and arterial lines may all contain latex components!

Operating Room Patient Care

• Use non-latex gloves. (Use caution when selecting non-latex gloves. Not all substitutes are equally impermeable to bloodborne pathogens; care and investigation should be taken in the selection of substitute gloves.)
  
  
• Use non-latex tourniquets or use non-latex examination gloves or polyvinyl chloride tubing.
  
  
• Draw medication directly from opened multidose vials (remove stoppers) if medications are not available in ampoules.
  
  
• Draw up medications immediately prior to the beginning of the case or their administration. The rubber allergen could leach out of the plunger of the syringe causing a reaction. The intensity of this reaction appears to increase over time.
  
  
• Utilize latex-free or glass syringes.
  
  
• Use stopcocks to inject drugs rather than latex ports.
  
  
• Minimize mixing/agitating lyophilized drugs in multidose vials with rubber stoppers.
  
  
• Notify Pharmacy and Central Supply that the patient you are caring for is latex sensitive so that these departments can use appropriate procedure when preparing preparations and instruments for the patient. Also notify radiology, respiratory therapy, housekeeping, food service and post operative care units so the appropriate precautions can be made to protect the patient.
  
  
• Place clear and readily visible signs on the doors of the operating room to inform all who enter that the patient has a latex allergy.

Signs and Symptoms of Allergic Reactions to LatexSymptoms usually occur within 30 minutes following anesthesia induction; however, the actual onset can range from 10-290 minutes.

Awake Patient	Anesthetized Patient
Itchy eyes Generalized pruritus Shortness of breath Feeling of faintness Feeling of impending doom Unexplained restlessness and crying Agitation Nausea Vomiting Abdominal cramping Diarrhea Wheezing	Tachycardia Hypotension Wheezing Brochospasm Cardiorespiratory arrest Flushing Facial edema Laryngeal edema Urticaria

Emergency Response and Management

• Removal of all latex containing products and agents, if possible. Do not delay immediate emergency therapy.
  
  
• Inform the surgical team to stop treatment/abort procedure.
  
  
• Assess and sustain ABCs of resuscitation.
  
  
• Maintain the airway and administer 100% oxygen.
  
  
• Discontinue inhalational halogenated agents (they are cardiovascular depressants which sensitize the myocardium to catecholamines which may be required for therapy.)
  
  
• Start intravascular volume expansion with Ringer's lactate or normal saline, (10 to 50 mL/kg if hypotension is present and the patient has no history of congestive heart failure or any volume related contraindication.)
  
  
• Treat pharmacologically as indicated by presentation and clinical course. Administer epinephrine; start with a 0.5 to 1 µg/kg bolus (10 µg/mL dilution). Escalate to higher doses depending upon the patient's response. If an IV has not been established, epinephrine can be given subcutaneously in doses larger than would be administered intravenously (10 µg/kg dose). Endotracheal dosage may be necessary if IV access has not been established.

Secondary Pharmacological Treatment may include the following:

• Hydrocortisone 0.25 to 1 g or methylprednisolone 1 mg/kg IV.
  
  
• Diphenhydramine 0.5 to 1 mg/kg (maximum dose 50 mg).
  
  
• Epinephrine infusion (2 to 4 µg/min. or more, titrate to effect).
  
  
• Aminophylline (5 to 6 mg/kg over 20 minutes for persistent bronchospasm).
  
  
• Ranitidine 0.5 to 2 mg/kg IV (maximum dose 150 mg).
  
  
• Sodium Bicarbonate (0.5 to 1 mEq/kg for persistent hypotension with acidosis diagnosed with laboratory confirmation).

Non-Pharmacological Considerations Should Include:

• Obtain allergy, pulmonary, pediatric consults as indicated.
  
  
• Draw and send a blood sample for IgE RAST testing and tryptase level (one-hour postreaction).
  
  
• Report incident to appropriate institutional entities (i.e., pharmacy, therapeutics, UR, QOC, etc.)
  
  
• Document events thoroughly and succinctly to examine at morbidity and mortality review at a later date.

Postreaction stabilization should include appropriate monitoring by dedicated providers well-versed in managing post anaphylaxis patients. The pediatric, intensive or special care area should be used when appropriate.

Pretreatment
Debate regarding the efficacy of premedication agents to treat patients with confirmed latex allergy remains somewhat controversial. Individual consideration for each patient undergoing elective operation or diagnostic and therapeutic procedures who has a known latex allergy should be initiated with the involvement of their primary care or allergy specialist provider. Premedication with steroids, antihistamines, and H2 blockers prior to general anesthesia or deep sedation may be preferred for children with a known and documented latex allergy. While these agents will not prevent an allergic reaction they may attenuate such a response by lessening the severity of a reaction. The patient's regular provider or specialist managing their allergy should consult to recommend appropriate pretreatment when warranted.

Latex Avoidance and Alternative Management Options
Common Latex Medical Devices Used in Perioperative Areas Include:

• Mattresses on stretchers
• Rubber gloves
• Adhesive tape (porous)
• Urinary catheters and drainage systems
• Electrode pads
• Wound drains
• Eyeshields
• Stomach and intestinal tubes
• Chest tubes and drainage systems
• Condom urinary collection devices
• Protective sheets
• Enema tubing kits
• Instrument pads
• IV solutions and tubing systems
• Fluid-circulating thermal blankets
• Hemodialysis equipment
• Ambu (bag-valve) masks
• Medication syringes
• Bulb syringes
• Elastic bandages, wraps
• Medication vial stoppers (multi-dose)
• Stethoscope tubing
• Band-Aidsô and other similar bandage products
• Gloves -- examination and sterile
• Dental dams
• Surgical drapes
• Patient controlled analgesia syringes
• Tourniquets

Anesthesia Equipment and Products Containing Latex Include:

• Stethoscope tubing
• Rubber masks
• Electrode pads, e.g., electrocardiogram, peripheral nerve stimulator, contact pads
• Head straps
• Rubber tourniquets, esmarch bandages
• Rubber, oral, nasal; pharyngeal airways
• Teeth guards, eyeshields, bite blocks
• Blood pressure cuffs (inner bladder, and tubing)
• Breathing circuits containing rubber
• Reservoir breathing bags, disposable oxygen masks, nasal cannulae
• Rubber ventilator hoses and bellows
• Rubber endotracheal tubes
• Latex cuffs on plastic endotracheal tubes
• Latex injection ports on intravenous tubing, stopcocks
• Certain epidural catheter injection adapters
• Multidose vial stoppers
• Patient controlled analgesia syringes
• Rubber suction catheters, specimen traps
• IV solutions and tubing systems (injections ports)

Suggested Reading

(1) Dormans JP, Templeton JJ, Edmonds C, et al. Intraoperative anaphylaxis due to exposure to latex (natural rubber) in children. J Bone Joint Surg [Am]. 1994;76:1688-1691.

(2) Freeman GL, Co-occurrence of latex and fruit allergies. Allergy and Asthma Proceedings. March - April.1997:Vol.18, II.

(3) Holzman R. Latex-Free Environment Precautions for Patients with a Latex Allergy/Patients at High Risk for Latex Allergy. Boston: Boston Children’s Hospital (Departmental Policy). 1992.

(4) Kelly KJ, Kurup VP, Reijula KE, Fink, JN. The diagnosis of natural rubber latex allergy. J Allergy Clin Immunol. May 1994;93(5):813-816.

(5) Latex Allergies: Anesthesia Concerns. AANA NewsBulletin/Anesthesia Quality Plus. 1992; 46(9)(suppl):3.

(6) Pasquariello CA, Lowe DA, Schwartz RE. Intraoperative anaphylaxis to latex. Pediatrics. 1993; 91:983-986.

(7) Porri F, Pradal M, Lemiere C, et al. Association between latex sensitization and repeated latex exposure in children. Anesthesiology. 1997;86(3):599-602.

(8) Theissen U, Theissen JL, Mertes N, Brehler R. IgE-mediated hypersensitivity to latex in childhood. Allergy. 1997;52:655-669.

(9) Turjanmaa K, Alenius H, Makinen-Kiljunen S, Reunala T, Palosuo T. Natural rubber latex allergy. Allergy. 1996;51:593-602.(10) Vessey JA, McVay CJ, Holland CV, et al. Latex allergy: A threat to you and your patients? Pediatric Nursing. 1993;19:517-520.

Developed in 1993 by the Infection and Environmental Control Task Force. Revised by the Occupational Safety and Hazard Committee and approved by the AANA Board of Directors on July 31, 1998.

© 1998-2001 by the American Association of Nurse Anesthetists. All rights reserved. Printed in the United States of America.

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