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Latex Allergy: Diagnosis, Prevention, and Management

Latex Allergy: Diagnosis, Prevention, and Management. Tara Hata, MD Assistant Professor Dept of Anesthesia, UIHC March 27, 2001. History of Latex Allergy. 1933 Contact dermatitis to gloves 1979 Contact urticaria 1982 Identified IgE antibodies to latex proteins

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Latex Allergy: Diagnosis, Prevention, and Management

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  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: 0.1-5 ug/kg IV • Cardiac arrest: peds: 10 ug/kg, adults: 0.5-2 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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