Latex allergy: the perspective from the surgical suite

Management of latex hypersensitivity in the perioperative setting

Despite the introduction and use of latex-free gloves, natural rubber latex hypersensitivity is still an issue in hospital medicine both for patients and healthcare professionals. Clear understanding of the groups at risk as well as perioperative assessment and management is key to reducing complications and improving safety. In this literature review, we cover the perioperative management of patients with latex hypersensitivity, as well as the implications for healthcare professionals. We also review the cost analyses of latex hypersensitivity in the healthcare system and the evidence available.

Anaphylactic reactions during cesarean section

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.

Latex allergy in health care workers in Taiwan: prevalence, clinical features

BACKGROUND

Latex allergy is becoming a major health concern among healthcare workers, of whom approximately 2.8 to 18% are reportedly sensitized.

OBJECTIVE

The purpose of this study was to analyze the results of a natural rubber latex (NRL) allergy screening program to identify sensitized hospital employees.

METHODS

Nurses (n = 130) assigned to operating theaters and intensive care units were evaluated using a written questionnaire for symptoms of atopy (asthma, rhinoconjunctivitis, and atopic eczyma), possible reactions to latex gloves, other medical devices and previous surgery. Serological testing for total immunoglobulin E (IgE), latex-specific IgE, and specific-IgE to melon, banana, kiwi, tomato, and chestnut were performed using Pharmacia CAP radioallergosorbent tests. Skin pick test (SPT) for latex allergen was also performed.

RESULTS

Elevated serum total IgE was found in 22(16.9%) of the 130 nurses, 3(16.7%) of whom had increased latex-specific IgE further confirmed by SPT. The overall prevalence of latex allergy was 2.3% (3/130). No cross reactive fruit-allergy was found among the latex-sensitized nurses.

CONCLUSION

This study supports the existence of other forms of atopy are related to an increased risk of latex sensitization. The NRL screening program used in this study is feasible for use in identifying latex-sensitized employees.

The Use of Latex Gloves in the School Setting

In 1987, when the U.S. Centers for Disease Control and Prevention recommended the use of universal precautions in response to the HIV/AIDS epidemic, the demand for medical gloves dramatically increased. Unfortunately, the manufacturing techniques for the most widely-used gloves—natural rubber latex—also changed, in order to expedite production. These changes resulted in an increase in latex allergies, because excessive residual proteins that cause allergies remained on the gloves and became airborne with the gloves’ high level of powder. This allergy concern is especially relevant in the school setting where school nurses are not only concerned about their own well-being, but the well-being of the children in their care. Today, latex gloves are still the most widely used of any medical gloves, but they have much lower levels of protein and are available in low-or no-powder. This article examines whether the current latex gloves indeed reduce the allergenicity of the gloves and how allergy and barrier protection data can assist school nurses in making informed glove choices.

Prevention of latex sensitization in guinea pigs by a bacterial and viral filter used in anaesthesia

BACKGROUND

Preventing anaphylactic reactions as a result of natural rubber latex (NRL) proteins is an important concern in anaesthesia. The clinical relevance of a bacterial/viral filter (Pall BB25) in preventing sensitization to NRL by inhalation was tested in guinea pigs.

METHODS

Guinea pigs (n=8-10 in each group) were exposed to aerosolized NRL-contaminated cornstarch powder or to NRL in saline for 1 h every day for 2 weeks. The experiments were repeated with a Pall BB25 filter placed over the aerosol system. Control groups were exposed to non-contaminated cornstarch or to saline alone. Three weeks after the last exposure, specific bronchial challenge was performed and thromboxane (Tx) B2 levels in bronchoalveolar lavage fluid were measured.

RESULTS

After bronchial challenge, the animals exposed to NRL or NRL-contaminated cornstarch with the BB25 filter in place showed a level of bronchoconstriction (i.e. the variation of pulmonary insufflation pressure) not different from controls. Conversely, those exposed to NRL or NRL-contaminated cornstarch without the filter showed a higher level of bronchoconstriction (respectively, P<0.02 and P<0.001) than control. Elevated TxB2 levels were found in the lungs of the guinea pigs, which inhaled NRL or NRL-contaminated cornstarch in the absence of a filter. Animals treated with the filter showed comparable TxB2 levels with those of control.

CONCLUSION

The Pall BB25 filter efficiently protected the guinea pigs from sensitization to NRL. This filter can be used as a complementary measure for avoidance of NRL contact during surgical procedures particularly if the mechanical ventilator apparatus contain NRL devices.

Le gantage chirurgical en France : une évolution lente mais nécessaire

Since the end of the 19th century, surgeons have used gloves to prevent infectious complications to the patient. The AIDS epidemic of the 1980's sparked the use of universal precautions to protect the surgeon from infection and vice-versa. The interface between surgeon and patient is in effect a two-way street. Surgical techniques must be modified and barrier protection optimized to minimize these risks. A single layer glove is a fragile barrier to blood exposure; unrecognized glove perforations may lead to unrecognized and prolonged exposure. Double gloving, though far from being a widespread practice in France, seems to be the best protection from pathogen exposure. Glove powder and latex allergies have their own inherent risks to both surgeon and patient in the form of latex allergies and adhesive peritonitis. New institutional protocols will be necesssary in order to make powder-free non-latex gloves available to French surgeons.

Latex allergy: diagnosis and management

Latex allergy is an IgE-mediated immediate hypersensitivity response to natural rubber latex (NRL) protein with a variety of clinical signs ranging from contact urticaria, angioedema, asthma, and anaphylaxis. Major allergens include dipped latex products such as gloves and balloons. In highest risk for NRL allergy are patients with spina bifida, but health care workers and others who wear latex gloves are also at risk. NRL allergic patients may also react to fruits/foods, especially banana, kiwi, and avocado. Diagnosis is made by a positive latex RAST and/or skin prick test or challenge test to NRL. Allergen avoidance and substitution and the use of latex-safe devices including synthetic gloves (vinyl, synthetic polyisoprene, neoprene, nitrile, block polymers, or polyurethane) are essential for the affected patient. Accommodation in the workplace may include the use of powder-free, low-allergen NRL gloves or synthetic gloves. These preventive measures have significantly reduced the prevalence of reported reactions to NRL. Hyposensitization is not yet feasible.

Different latex aeroallergen size distributions between powdered surgical and examination gloves: significance for environmental avoidance

BACKGROUND

Proactive medical institutions implement latex allergen avoidance to protect workers and patients with latex allergy and to prevent latex sensitization in these groups by creating latex-safe environments that include replacement of natural rubber latex examination and surgical gloves, especially those that are powdered, with synthetic alternatives. We have hypothesized that an apparent decreasing trend in new latex allergy cases in hospitals using only synthetic examination gloves but the occasional powdered latex surgical glove might result from constitutive differences in allergen content (particle size distribution and quantity) between powdered surgical gloves and examination gloves.

OBJECTIVE

Because aerodynamic particle size determines where inhaled airborne allergen deposits in the airway, the aim of this study was to investigate the differential particle size distribution of latex allergen released from powdered latex examination and surgical gloves.

METHODS

Powdered and nonpowdered latex examination and surgical gloves were processed to create an aerosol in a glove box equipped with air sampling equipment capable of total particle number and mass measurements. Air particulate generated in the glove box was collected on impactors with less than 2.5-microm, 2.5- to 10-microm, and greater than 10-microm particle size limits (4 L/min for 4 hours). All filters were extracted, and latex allergen was quantified by using a latex-CAP inhibition assay with a human IgE anti-latex serum pool.

RESULTS

Latex aeroallergen on powdered sterile surgical gloves resided primarily on particles greater than 10 microm in size (P <.006). In contrast, powdered examination gloves released the highest total latex aeroallergen content, with 68% of the particles sized in the respirable 2.5- to 10-microm range and carrying 56% of the airborne latex allergen.

CONCLUSIONS

Significantly lower quantities and larger sizes of latex allergen-containing particles released from surgical gloves provides one potential explanation as to why an apparent decrease in new cases of latex allergy can occur in hospitals that successfully replace latex examination gloves with synthetic gloves but continue occasional use of powdered surgical gloves.

Latex allergy and otorhinolaryngological surgery

Latex allergy in the otorhinolaryngology patient requires forward planning and coordination of management plans between the surgical, nursing and anaesthetic departments in order to ensure a safe outcome.

A Review of Natural‐Rubber Latex Allergy in Health Care Workers

This brief review of natural-rubber latex (NRL) allergy in health care workers (HCWs) includes the definition of NRL allergy and data on its epidemiology, pathogenesis, diagnostic algorithm, management, long-term outcomes, economic impact, cost-effectiveness of changing facilities to a latex-free environment, and prevention. The data presented suggest that an individual with type I or type IV hypersensitivity to NRL should be able to continue to work in the workplace with careful evaluation and reasonable accommodations. Reducing exposure to latex is a safe and more economical alternative to complete removal of the individual from the place of employment. The use of low-allergen, nonpowdered NRL gloves substantially reduces airborne exposure to latex in most health care settings.

Accommodating Latex Allergy Concerns in Surgical Settings

CONCERN ABOUT ALLERGIC REACTIONS to natural rubber latex gloves has increased during the past 15 years. These reactions have been attributed mainly to an influx of high-powder, high-protein gloves in response to increasing concerns about AIDS transmission beginning in the late 1980s. THIS ARTICLE REPORTS ON AVAILABLE RESEARCH that details the types and prevalence of potential allergic reactions, supports the use of natural rubber latex gloves in the OR, and recommends strategies to enable health care who are not latex sensitive to continue wearing natural rubber latex gloves in the OR.

The appropriate use of gloves to reduce allergies and infection

Twenty years ago, the wearing of gloves for non-sterile procedures was viewed as insulting to the patient as it made him/her feel 'unclean'. Today, gloves are worn for all procedures and are often wastefully used. There must be a fine balance between inappropriate and appropriate use of gloves and between the use of latex gloves for comfort and fine movements vs the potential for latex allergies. This article will review the use of synthetic and latex gloves and examine some of the related issues.