PATHO CORNER

The Patient With Latex Allergy

Kim A. Noble, MSN, RN, CPAN

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LATEX SENSITIVITY is a silent threat that hasgrown in importance throughout the past twodecades. It affects individuals throughout thegeneral population regardless of race and eth-nicity, sex, or geographic location.1 In additionto the risks of personal exposure and illness,healthcare workers must also manage the ef-fects of latex allergy for the patients under ourcare. The following case study details a fictitiouspatient with a latex sensitivity and her periop-erative experience.

DZ is a 33-year-old patient who presents toa small community hospital for an electivediagnostic laparoscopy. Her past medical his-tory includes 4 prior unremarkable surgerieswith general anesthesia; tonsillectomy andadenoidectomy at the age of 6, appendec-tomy at the age of 11, odontectomy at the ageof 21, and a prior laparoscopy for treatmentof infertility. Her only reported allergies arefood- and environmentally-related. Her cur-rent daily medications are sertraline for de-pression and clomiphene for infertility. DZreported prolonged nausea and vomiting afterher last surgery.

On the day of her laparoscopy, DZ was admit-ted and taken to the operating room withoutincident. She was induced with oxygen, mida-zolam, fentanyl, ondansetron, nitrous oxide,propofol, and succinylcholine, and thensevoflurane, rocuronium, and incrementaldoses of fentanyl for anesthetic maintenance.Twenty-four minutes into the case she wasnoted to have facial redness and swelling, adecrease in pulmonary compliance, and a de-cline in blood pressure with tachycardia. Intra-

venous (IV) fluids were increased without im-

Journal of PeriAnesthesia Nursing, Vol 20, No 4 (August), 2005: pp 285-288

rovement and wheezing was audible withhest auscultation. A second IV was initiatedith rapid infusion of fluids, as her blood pres-

ure continued to decline. Epinephrine, hydro-ortisone, and diphenhydramine were givennd surgery suspended until the cause of herotential anaphylaxis was identified.2

he first investigation of latex sensitivity ap-eared in the literature in 1979,3 and althoughhe initial reported estimation of latex sensitiv-ty in healthcare workers was 2.4% in the980s,4 it has climbed to affect approximately% to 12% of healthcare workers in a 1997tudy.3 In the general population, 0.8% to 6.5%f persons are reported to be latex sensitive,1

ith increases seen in persons having multipleurgical or urinary procedures; for example, asany as 73% of children with spina bifida are

stimated to be latex sensitive.4

he increase in the number of individuals re-orting sensitivities to latex products is attrib-ted to the ten-fold increase in the occupationalse of latex gloves following the introduction ofniversal Precautions in 1987.5 Natural rubber

atex consists of a protein-based structure tohich individuals may become sensitized, withowdered gloves being the most common itemontributing to the development of sensitivities.he powder in the glove, consisting primarily of

Kim A. Noble, MSN, RN, CPAN, is an assistant professor atemple University, Philadelphia, PA.Address correspondences to Kim A. Noble, MSN, RN, CPAN,

emple University, CHP Jones Hall #415, 3307 N Broad St,hiladelphia, PA 19140; e-mail: kim.noble@temple.edu.© 2005 by American Society of PeriAnesthesia Nurses.1089-9472/05/2004-0009$30.00/0

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cornstarch, is particularly problematic becausethe latex allergen leaches out of the glove andinto the powder, and the dry powder carriesthe latex into the environment, contaminatingsurfaces, scrubs and surgical wounds, drapes,instruments, and equipment. Powder that isaerosolized can remain airborne for 5 to 12hours.6 People with a history of environmentalallergies (ie, rhinitis, asthma, or seasonal aller-gies) or severe allergies to certain foods (ie,bananas, avocado, chestnut, kiwi) are at higherrisk1 for the development of latex allergy. Thebest method of treating a latex sensitivity isprevention, both from initial and subsequentexposures.

Pathophysiology of Latex Sensitivity

I. Type IV Hypersensitivity: Allergic ContactDermatitis

There are 2 types of reactions associated withlatex exposure. Cutaneous exposure to latexmay lead to the development of a type IV hy-persensitivity reaction, or an allergic contactdermatitis. Not considered to be a true allergicreaction, contact dermatitis is the result of skindamage from the chemical irritation of multiplehandwashing, poor hand-drying, or mechanicalirritation such as would be seen with rubbingfrom powders inside a glove. This leads to thedevelopment of reddened, irritated, and/or blis-tered skin, with the potential for the develop-ment of hardened, thick, dry skin with cracks orfissures. This reaction is mediated by the T-lymphocytes, leading to the release of irritatingchemical mediators and the activation of addi-tional lymphocytes. The reaction is usuallyslow, with an onset of 18 to 24 hours and a peakwithin 48 hours after the exposure. Symptomstypically resolve in 3 to 4 days. There is a dangerof this type of exposure leading to systemicsensitization and with repeat exposures, thedevelopment of the second type of latex reac-tion.1

II. Type I Hypersensitivity: Anaphylaxis

The second type of latex reaction is the severe

form of a type I hypersensitivity reaction, which b

eads to the immediate development of anaphy-axis. This reaction is mediated by immunoglob-lin E, a form of antibody secreted by plasmaells sensitized by a prior exposure to the latexrotein antigen. Repeated exposures to the la-ex protein cause a large-scale response by theast cells, a mediator of the immune and in-

ammatory reactions found in connective tis-ue. Degranulation, or rupture of the mastells, leads to the release of large quantitiesf histamine, causing severe capillary per-eability and fluid losses from the vascular

pace into the surrounding tissues, resultingn the development of edema and tissuewelling.7 This large-scale loss of intravas-ular fluid leads to a rapid decline in bloodressure and, subsequently, tachycardia,hich is refractory to fluid administration.ecause there is a dense concentration ofast cells in the large airways, the develop-ent of edematous airways leads to an in-

reased resistance to airflow, a decrease inulmonary compliance, and wheezing. The

atex protein may be received directly intohe airways through inhalation of particu-ate laden with the latex protein or throughhe contamination of the surgical incision,rapes, instruments, or patient equipment.

he administration of epinephrine is highly ef-ective in anaphylaxis because it binds withoth �- and �-adrenergic receptors, leading toasoconstriction, increased blood pressure andeart rate, and direct bronchodilation. The ad-inistration of diphenhydramine leads to an

ffective blockage of the histamine-1 receptornd a decrease in the histamine-related effectseen in anaphylaxis. Hydrocortisone is used toecrease the inflammatory response because of

ts ability to stabilize the mast cell membrane,eading to a decrease in rate of degranulationnd mediator release. Hydrocortisone has thedded mineralocorticoid effect, which results inhe reabsorption of Na� and water and expan-ion of the blood volume, further increasing

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Implications for the PACU Patient

Now, how can all of the preceding informationbe applied to your care of DZ in the Phase IPACU? There are several direct implications forpatient care.

Alteration in the Immune Response:Anaphylaxis

The best method of treatment for latex sensitiv-ity is to prevent initial exposure. Once a reac-tion has been triggered, however, additionallatex exposure must be prevented. The provi-sion of a latex-free environment is virtually im-possible and very expensive: latex is found inmany items, including the wheels of gurneysand rolling stools. More appropriate is the pro-vision of a latex-safe environment where reason-able measures have been taken to ensure thereis limited or no direct or airborne contact withlatex-containing items. Latex is found in theequipment used daily in the care of patients inthe PACU, and the use of a latex-free cart withprestocked latex-free equipment and supplieshas been established in many areas throughouthospitals. Recommended supplies for this cartare listed in Table 1.

Powder-free, vinyl, or latex-free gloves shouldbe used when caring for DZ, as well as latex-freeIV tubing and syringes. Because latex is a com-

Table 1. Recommended Supplies for a Latex-free Cart1

Safety needles of varying sizes IV and blood tubingSyringes and 3-way stopcocks Feeding tubes, pump

bags, and tubingTourniquets and tape of

varying sizesBulb syringes

Underpads and small chux Stethoscope, bloodpressure cuffs, andconnecting tubing

Urinary catheters anddrainage systems

Sterile andexamination gloves

Oxygen delivery (ie, cannula,mask) and anesthesiabreathing bags

External catheters

ponent of the stoppers of multidose vials, drugs a

ay become contaminated by the needle mov-ng through the stopper. Medications in theseials should be avoided whenever possible.ype I hypersensitivity reactions have also beeneported following contact with gloves, con-oms, tourniquets, anesthesia masks, rubberhoes, and clothing containing elastic, adhesiveape, electrocardiogram electrodes, elastic ban-ages, condom catheters, balloons, and racquetandles.1

lteration in Gas Exchange

Z will probably arrive in the Phase I PACUith an endotracheal tube in place to secure an

dequate airway, and she may also require me-hanical ventilation. With regard to her physicaltatus and the length of surgery and progressefore the discontinuation of her surgical pro-edure, she may still have the action of thearalytic drug(s) affecting the passage of nerve

mpulses through her neuromuscular junction.irway patency should be assessed upon admis-ion and then at intervals throughout the periodf intubation and the initiation of physicianrders coupled with nursing assessment mea-ures used to monitor the continued need ofirway intubation. Ongoing monitoring of satu-ation, auscultation of breath sounds, and incre-ental blood gas analysis with appropriate in-

erventions will be required. Bronchodilation,ccomplished by the administration of eitherebulized, topical, or IV medications, may beeeded to control bronchospasm.

lteration in Cardiovascular Functioning andluid Balance

Z is in need of frequent monitoring of her vitaligns because hypotension is commonly seen innaphylaxis. Treatment may include the admin-stration of rapid IV fluids and incrementaloses of epinephrine or the use of a continuousrip. Vasopressors may also be used to improvelood pressure, and frequent communicationith the attending anesthesiologist is also nec-

ssary.

ependent on the degree and duration of the

naphylactic response, DZ may require the in-

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sertion of invasive monitoring equipment suchas a pulmonary artery catheter or arterial line,for continuous fluid status monitoring. If notalready in place, a urinary catheter will alsoneed to be inserted; caution must be used,however, because latex is found in many in-dwelling catheter trays. A 100% silicone or poly-vinyl chloride catheter should be used. Urinaryoutput is a good measure of fluid status; thus adecline in the volume of urinary output mayindicate a decline in renal perfusion.

Alteration in Stress Response

Although DZ planned to have a “simple” elec-tive outpatient procedure, the development ofanaphylaxis may cause emotional trauma forDZ, as well as her support system of family andfriends. Information about her current statusand condition should be communicated to DZand her next of kin in a timely fashion; the fearof the unknown can be eliminated or reducedby the considerate provision of support andinformation. The presence and level of painmust be monitored through whatever meanspossible based on DZ’s ability to communicate.Appropriate pain interventions should be madeas DZ’s condition allows. If DZ’s condition sta-

bilizes and visitors are allowed in the PACU, it a

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ay be helpful to have short family visits. If DZeeds to remain mechanically ventilated, seda-ion will be required. Information should beade available to DZ before discharge abouter latex allergy, and she should be encouragedo obtain and wear a medic-alert bracelet listinger anaphylactic reaction to latex.

lteration in Gastrointestinal Functioning

he progress of DZ’s surgery should be ob-ained through the report received from thenesthesia staff upon admission to the PACU.rders are received from the surgeon and mayeed to be instituted in the PACU. With thenset of anaphylaxis in the OR, the surgery wasost likely discontinued and DZ’s abdomenas closed without further intervention. Aus-

ultation of bowel sounds, presence of postop-rative nausea or vomiting, and the condition ofer dressing and/or drainage tubes is part of thedmission and discharge assessment.

he immediate care of DZ would be a challengeor any PACU nurse, but an understanding ofhe underlying pathophysiological processeseading to her critical illness can help the PACUurse anticipate emergent needs and develop

n appropriate plan of care.

Refe1. Association of PeriOperative Registered Nurses: AORN

Latex Guidelines. AORN J 79:653-672, 20042. Drain CB: PeriAnesthesia Nursing: A Critical Care Ap-

proach, ed 4, St Louis, MO, Saunders, 20033. Chummun NH: Latex glove disorders: A management

strategy for reducing skin sensitivity. J Nurs Manag 10:161-166,2002

4. Miller KK: Research based prevention strategies: Manage-ment of latex allergy in the workplace. Am Assoc Occup Health

ces5. Haynes LC: Nursing students’ risk for latex allergy:

mplications for nurse educators. J Nurs Educat 41:471-475,0026. Wai DM: A guide to caring for your latex allergic patient.

astroenterol Nurs 22:262-265, 19997. McCance KL, Huether SE: Pathophysiology: The Biologic

asis for Disease in Adults & Children, ed 4, St Louis, MO,osby, 20028. Karch AM: Focus on Nursing Pharmacology, ed 2, Phila-

elphia, PA, Lippincott Williams & Wilkins, 2003