The dangers of AIDS, hepatitis and sexually transmitted diseases have led to a dramatic increase in the use of latex products -- especially gloves -- in recent years. Unfortunately, there's been a corresponding increase in allergic reactions to latex. Some reactions, such as a rash, are minor. But others are far more serious; some individuals have gone into cardiorespiratory arrest.

This problem affects both patients and healthcare workers, especially in a hospital setting or an ambulatory surgery center (ASC). In fact, the likelihood of an allergic reaction often increases with exposure to latex, putting you and your staff at risk even if no problem has existed previously.

What can you do to protect yourself, your staff and your patients? Instead of waiting for a problem to occur, institute a latex management policy to ensure that you provide a safe environment for latex-sensitive people (both patients and staff members). The policy should create protocols for accomplishing four objectives:

�        determining which patients may be at risk and altering their care accordingly

�        educating your staff

�        minimizing unnecessary latex exposure

�        being ready to treat anyone who has an allergic reaction.

1. Determine who is at risk        

To make sure you've identified all patients who may be at risk (See "Who is At Risk?" right), and to ensure that staff members are able to recognize the nature of the problem if they experience it themselves, your latex management policy should:

�        Create a protocol for screening patients. Upon admission to the ASC, the history or screening questionnaire should establish each patient's latex allergy status. The result should be documented, and a wristband should indicate the patient's status.

�        Assign a specific individual to identify patients with latex sensitivity. (Someone should also be responsible for identifying employees with a potential for latex allergy. Pre-employment questionnaires and interviews with staff members who will be working in a latex environment should address this issue.)

�        Specify persons at the ASC and/or hospital who should be notified when a latex-sensitive patient is scheduled.

�        Establish special surgery-scheduling protocols for latex-sensitive patients (if appropriate).

�        Establish a policy regarding latex-sensitive employees working in the OR.

2. Educate your staff

To avoid problems, education is crucial. Provide your staff with information about latex allergies, including:

�        An explanation of the physiology of the different types of allergic reaction (see "Physiology and Symptoms of Latex Allergy" right)

�        instructions for preventing allergic reactions

�        a list of substitutes for latex products

�        instructions for proper handling of latex products

�        a list of individuals at risk for latex allergies.

An annual presentation for all staff members on patient and employee safety is also important.

3. Minimize unnecessary exposure

The most significant exposure to latex comes from latex gloves. Healthcare providers in the United States often use latex gloves several times a day, adding up to 12 billion units of latex gloves each year.

The quality of latex glove manufacturing may also be playing a role in the growing allergy problem. Manufactures have been forced to greatly increase their production. Some of them may be taking manufacturing shortcuts, which can increase the amount of latex protein in their products.

Chemicals used in the production of latex can also be present if certain steps in the manufacturing process are omitted. These residual chemicals can trigger allergic reactions as well.

To minimize potential trouble:

�        Encourage the use of nonlatex gloves for all activities that aren't likely to involve contact with infectious materials. In the absence of gross contamination, the use of rubber or plastic gloves can reduce latex exposure.

�        Train all staff members who wear latex gloves to use proper technique when putting the gloves on and removing them. Latex proteins adhere to the powder in the gloves; "snapping" the gloves allows latex-containing powder to become airborne where it can be inhaled, increasing the exposure to the latex protein.

Minimizing exposure in the operating room

To prepare your operating area:

�        Establish protocols for maintaining a latex-minimized environment in the ASC. A specific individual should be responsible for making sure supplies are latex-free, including any anesthesia equipment.
Many products used in the typical ASC setting contain latex. (For a partial list, see "Commonly used Surgical Items That May Contain Latex," on page 106.) For this reason, check every item you use for latex content. If the item in question doesn't specifically state that it's latex-free, contact the manufacturer or substitute a similar product that's known to be latex-free. (Some items you may not wish to remove or replace, such as EKG lead wires, can be wrapped or covered.)
Once you've minimized the latex in the OR, your responsible individual should review your product purchase lists periodically to ensure that suppliers haven't made changes in the products they're providing.

�        If you know that a patient is latex-sensitive, have the OR cleaned to remove residual powder from previously used latex gloves. (Also, make sure that the person doing the cleaning doesn't wear latex gloves.)

�        Once the OR is latex-free, post a sign on the door warning people to avoid bringing in latex gloves or other potential contaminants. (Limiting traffic in and out of the OR may also be advisable for the same reason.)

4. Be prepared to respond to a crisis

How you respond to an allergic reaction should depend on the severity of the reaction. Symptoms of Type IV reactions, such as dermatitis, can be treated with topical ointments such as hydrocortisone creams and by avoiding further contact with latex-containing products.

In contrast, a Type I reaction -- with symptoms such as wheezing or cardiorespiratory arrest -- is a life-threatening situation. For details on responding to this level of emergency, see "Treating a Severe Allergic Reaction," below.

To ensure that any allergic reactions are handled properly:

�        Make sure that appropriate emergency drugs and equipment for treating a serious allergic reaction are available.

�        Document any allergic reactions that do occur. A chart review may be warranted to insure that policy guidelines were followed and the appropriate actions were taken.

Why you really need a policy

Some doctors believe that their ASC doesn't need a latex management policy because they can refer patients with a known latex sensitivity to a facility that's specifically geared to caring for these patients. Two major problems weaken this line of reasoning:

�        Patients who aren't known to have a sensitivity to latex may suddenly have an allergic reaction. You need to be prepared to deal with this situation should it arise.

�        Healthcare workers are considered a high-risk group for latex allergies. A latex policy will give your employees valuable information about the risks of latex and allow them to take proactive steps to protect themselves.

I know that everyone reading this article has nothing but the best intentions for both patients and fellow healthcare professionals, especially where safety is concerned. Latex sensitivity is just one more challenge for all of us to meet.

By instituting a latex management policy that screens patients, educates your staff, minimizes exposure and keeps you in readiness should a crisis occur, you'll be able to meet the challenge. And you'll know that you're providing the best care possible -- for your patients and your staff.

Who is At Risk?

Many different groups have been identified as likely candidates for an adverse response to latex:

�        Patients with neural tube defects, such as spina bifida and myelomeningocele. These patients have the highest incidence of latex allergy. Studies have shown that pediatric patients with spina bifida are 500 times more likely to have an anaphylactic reaction to latex under general anesthesia than control groups.

�        Patients with urological disorders. Frequent exposure to the latex in urinary bladder catheters can sensitize them.

�        Persons with a history of rubber sensitivity.

�        Patients who have asthma, hay fever or eczema.

�        Individuals who are allergic to avocados, bananas, pears, chestnuts or peanuts.

�        Healthcare providers, because of their daily exposure to latex-containing products. (Of this group, operating room personnel are at the greatest risk.)

The Hidden Dangers of Latex Physiology and Symptoms of Latex Allergy

Latex allergy reactions are grouped into four classifications (Types I through IV). Type I reactions are the most serious; Type IV are the least serious. Both are described below.

�        Type IV reactions. These are delayed hypersensitivity reactions, mediated by T-cells, limited to the skin surface that comes into contact with the latex product. They're usually caused by the chemicals used during manufacturing. These reactions aren't life-threatening, but people with a history of Type IV reactions are more likely than nonreactive individuals to eventually develop a more serious reaction.
Clinically, Type IV reactions include:

o       A       dermatitis of the hands caused by latex gloves

o       A       oral reactions caused by dental appliances

o       A       penile and vaginal reactions caused by condoms.

�        Type I reactions. These are true allergic reactions, involving the body's immune system. This type of reaction occurs when a foreign protein (antigen) interacts with the body's cells, resulting in the production of IgE antibodies.
The reaction between the antigen and antibody causes mast cells to release histamine, prostaglandin and kinin into the circulatory system. The release of these bodily chemicals creates the symptoms of the allergic reaction, which may include:

o       rhinitis

o       flushing of the skin

o       respiratory wheezing

o       bronchospasm

o       laryngeal edema

o       cardiorespiratory arrest.

Commonly Used Surgical Items that May Contain Latex

The following items are all potential sources of latex that could trigger an allergic reaction:

�        exam gloves     

�        IV solution bags

�        stretcher mattress      

�        drug vial stoppers

�        IV catheters       

�        syringes

�        tape 

�        bulb syringes

�        eye patches       

�        surgical drapes

�        surgical hats      

�        cuffs of surgical gowns

�        instrument pads

�        phaco tubing.

Anesthesia equipment may also contain latex:

�        bp cuff       

�        stethoscope tubing

�        ecg patches       

�        O₂ mask

�        breathing circuit

�        endotracheal tubes    

�        IV set up   

�        SaO₂ and ECG lead wires

�        ventilator bellows       

�        reservoir bag.

Treating a Severe Allergic Reaction

�        Type I allergic reaction to latex, with symptoms such as flushing of the skin, wheezing, laryngeal edema or cardiorespiratory arrest, is a life-threatening situation. You must provide immediate emergency therapy.

�        Notify the surgical team of the emergency.

�        Remove all latex-containing products from the surgical field and the vicinity of the patient.

�        Decide whether to abort the procedure or to continue.

�        Assess the patient's condition and sustain the ABCs of resuscitation (airway, breathing and circulation). Administer 100% oxygen. (Endotracheal intubation may be necessary if there's airway obstruction secondary to laryngeal edema.) If the patient is undergoing a general anesthetic, inhalational agents may need to be discontinued.

�        You may need to treat hypotension, secondary to the vasodilatation seen in an allergic reaction. If necessary, establish an intravenous (I.V.) line to begin intravascular volume expansion with Ringer's lactate or normal saline.

�        Pharmacological treatment should be determined by the clinical course. The primary drug used to resuscitate a patient having an anaphylactic reaction is epinephrine. If an I.V. hasn't been started, epinephrine can be administered subcutaneously or via the endotracheal tube. (Secondary pharmacological treatment may include hydrocortisone, diphenhydramine, epinephrine infusion, aminophylline, and sodium bicarbonate.)

Lynn Dunford, a Certified Registered Nurse Anesthetist (CRNA), works for Garden Anesthesia Services, P.A., and is director of anesthesia at the Fry Eye Surgery Center in Garden City, Kan. He's a member of the American Association of Nurse Anesthetists and the Ophthalmic Anesthesia Society (OAS), where he serves on the scientific advisory board and holds the office of treasurer. You can reach him at (316) 276-6912, or at boomer@odsgc.net.