EDUC 8114 - Natural Latex Allergy Study Guide

Natural Latex Allergy/Sensitivity Definition of Latex Latex is the term used to identify the cytosol portion of the sap of the rubber tree called Hevea brasiliensis, as well as products made from the sap. This term is ...

Natural Latex Allergy/Sensitivity Definition of Latex Latex is the term used to identify the cytosol portion of the sap of the rubber tree called Hevea brasiliensis, as well as products made from the sap. This term is used interchangeably with natural rubber latex (NRL). On March 29, 1991, the FDA issued a medical alert titled “Allergic Reactions To Latex-Containing Medical Devices.” This alert advised health care professionals to identify latex-sensitive patients and to be prepared to treat allergic reactions promptly. This alert came out because of reports of patients having severe allergic reactions to latex-containing devices, resulting in several patient deaths. Theories for Causes of Latex Allergy/Sensitivity Different theories have been put forth in the effort to explain the increase in sensitivity to latex. Reason 1 The hypothesis most often considered is the correlation between implementation of universal (standard) precautions and the increased use of latex gloves by health care workers. This led to increased patient exposure, as well as increased exposure for the health care worker. Reason 2 Another possibility is that, due to the increased need for latex gloves, manufacturing processes changed, leaving more water-soluble latex proteins in the glove product itself. Reason 3 The rise in latex allergy/sensitivity might be related simply to the fact that there is now better recognition of the clinical signs and symptoms by the medical community. Reactions to Latex Exposure to latex gloves and latex containing products can cause three different types of adverse reactions. These reactions have been classified into three distinct diagnostic categories: 1. Irritant Contact Dermatitis 2. Delayed Type IV Hypersensitivity Reaction OR Allergic Contact Dermatitis 3. Immediate Type I Hypersensitivity Reaction OR Latex Allergy 1. Irritant Contact Dermatitis Irritant contact dermatitis is a nonallergic reaction of the skin. Localized inflammation of the skin surface is caused by direct contact with a substance that physically or chemically damages the skin. This skin irritation may be aggravated by glove powder and the chemical agents that are added to the raw latex. Triggering factors Dermatitis on the hands may begin or worsen by:  Frequent hand washing  Poor hand hygiene practices  Frequent wearing of gloves or skin contact with glove powders Symptoms Symptoms of irritant contact dermatitis include:  Red, swollen, dry skin  Thickening and fissuring of the skin  Pruritus (itching)  Burning  Formation of papules These symptoms are usually confined to the area of the body that comes in contact with the irritant. Remember, this is not an allergic reaction. Most glove-related skin reactions are this type. Environmental Conditions Influencing Irritant Contact Dermatitis  The friction of the surgical scrub and/or improper hand drying following the scrub.  Contact with degreasing agents in surgical scrubs, detergents, disinfectants and other cleaning compounds can remove the outer protective layer of the skin and lubricating oils.  Contact with glove powder can damage skin by friction and drying action.  The action of wearing gloves causes sweating that can lead to a macerating effect on the skin. It can aggravate existing hand dermatitis reactions and may cause chemicals in the gloves to be absorbed by the skin.  Wind and cold can also cause existing dermatitis reactions to worsen. 2. Immediate Type I Hypersensitivity Reactions/True Latex Allergy  The third category of skin reactions to latex gloves is immediate type I hypersensitivity reactions or latex allergy. This type of reaction will occur within 5 to 30 minutes of exposure to an antigen or have a delayed onset of 10 to 12 hours.  Type I reactions to latex are usually attributed to extractable, water-soluble proteins that occur naturally in raw latex. This type of allergic reaction is the true latex allergy reaction. Remember, this is a systemic allergic reaction. Symptoms of immediate type I hypersensitivity reactions include  Contact urticaria (hives)  Eczema  Eyelid, facial swelling, orbital edema  Generalized wheal and flare reactions  Burning and itching  Allergic rhinitis  Swelling of the throat, nasal passages, and bronchi  Difficulty breathing, including wheezing  Allergic conjunctivitis  Asthma  Systemic anaphylaxis 3. Delayed Type IV Hypersensitivity Reactions/Allergic Contact Dermatitis  Delayed type IV hypersensitivity reaction or allergic contact dermatitis is a delayed allergic reaction that occurs 24 to 72 hours after a sensitized individual has contact with the allergen.  This reaction is usually a result of the chemical compounds added to the latex before and during the manufacturing process. Factors affecting intensity Allergic contact dermatitis is caused by chemicals added to latex during the manufacturing process. The potential of these compounds to cause sensitizing will depend on three factors:  The potential of the compound to act as an allergen  The concentration of the compound  The ability of the compound to enter the skin; this will depend on the compound and/or the condition of the skin Symptoms  Swelling  Redness (erythema) extending beyond the area of skin contact  Pruritus  Cracking, hardening, or thickening of the skin  Eczema This is a localized reaction caused by chemicals added to the latex in manufacturing the gloves. Although this form of allergic reaction is very irritating, it is not life-threatening. Factors Influencing Reactions to Latex The following factors will affect the severity and type of sensitivity reactions an individual will experience: 1. Individual susceptibility 2. The antigen's portal of entry 3. Type and amount of antigen 4. Duration of exposure Clinical Manifestations The clinical manifestations associated with an immediate allergic response usually occur within 30 minutes from exposure, but onset can be as short as 5 minutes or as late as 10 to 12 hours after exposure. Stage I: The first signs and symptoms the patient will exhibit will be contact urticaria. This presents as swelling and redness at the site of exposure. It also can be accompanied by itching and burning. Stage II: The allergic reactions can spread beyond the area of contact with the latex-containing product, and can be accompanied by the following respiratory symptoms:  Edema and itching around eyes  Acute rhinitis  Nasal itching  Sneezing  Asthma  Shortness of breath  Bronchial obstruction Stage III: If allowed to persist, in some rare cases, the reaction can progress to a sudden drop in blood pressure with increased heart rate that can lead to circulatory collapse and anaphylactic shock. Routes of Exposure 1. Direct external contact  Skin contact is also known as direct external contact. This is the least likely to cause a severe reaction.  Contact can occur from rubber anesthetic face masks, adhesive tape, Band-Aids, blood pressure cuffs and tubing, monitoring probes, and electrodes, as well as from contact with latex gloves. 2. Mucosal contact  Mucosal contact occurs when the person’s mucous membranes come in contact with rubber products, such as rubber oral or nasal airways, dental dams, Foley catheters, condoms, barium enema tips, and rubber masks.  More than 15 deaths have been reported from patients being exposed to latex enema tips. Most reported cases of latex anaphylaxis have occurred from direct contact between gloves and mucous membranes. 3. Airborne contact  The third route of exposure is airborne contact. This occurs primarily when latex proteins bound to glove powder are aerosolized from removing powdered surgical and exam gloves.  Rubber allergens can also be aerosolized in anesthetic gas mixtures. 4. IV exposure  The final route is IV exposure. This can occur when medications are drawn up from a vial containing a rubber stopper. As the needle punctures the rubber stopper, small particles of the rubber can break off in the solution and be injected into the patient. This can be very serious when a patient is being given an IV.  Also, rubber particles can end up in medications just from the liquid coming in contact with the rubber stopper or when the syringe plunger contains latex.  Other sources of IV latex are saline locks and IV tubing injection ports. This type of exposure can be the most severe because the allergen is in direct contact with the cells in the blood responsible for the body's allergic response. The Nursing Process 1. Assessment: Determine if the patient is latex-allergic/sensitive or otherwise. 2. Nursing care planning: The outcome identified for the perioperative period is to provide a safe environment so the patient is free from signs and symptoms of a latex-allergic/sensitive response. 3. Implementation: Communicate latex allergy/sensitivity to all involved in care, eliminate latex products in environment of care, pre- medicate the patient as ordered, be aware of signs/symptoms of latex allergy/sensitivity reaction, and provide supportive treatment. 4. Evaluation: Intraoperatively and immediately postoperatively evaluate the patient for any signs or symptoms of latex allergy or sensitivity. Adjust care plan and implementation strategies as appropriate. Latex-Allergic/Sensitive Patients • The first step in the nursing process is assessing the patients. • It is very important to determine which patients should be treated as latex-allergic/sensitive. A detailed, accurate history is essential for identifying a patient at risk. Many hospitals have a latex allergy-screening tool or questionnaire Who should be treated as latex-allergic/sensitive? Patients who should be treated as latex-allergic/sensitive include anyone who:  Has a history of anaphylaxis to latex.  Has had allergic reactions of a nonsystemic nature to latex.  Has had multiple surgical procedures  Is a child with spinal bifida and genitourinary abnormalities requiring surgical procedures  Who is from a high-risk group. When health care providers or other workers give a history of severe or worsening latex glove-induced eczema, urticaria, or work-related conjunctivitis, rhinitis, asthma, or urticaria, this suggests allergic sensitization. These people are at an increased risk for more severe reactions in the future. Latex Allergy/Sensitivity Testing Skin prick test  The first, the skin prick test (SPT) involves taking a drop of latex extract diluted in saline, placing it on the skin, and gently scratching the skin with a needle. The patient is checked for a response after 10 minutes and compared with a control group.  Advantages of this test include easy availability, low cost, and quick results.  The disadvantage is that it can cause a severe reaction in highly sensitive patients. The Wearer or Use test The wearer or use test requires the patient to wear a finger of a latex glove or a whole glove on one hand and a vinyl glove on the other as a control. The person is then checked for a response in approximately 15 minutes to see if symptoms develop. Patients with a history of anaphylaxis should not be given the use test, as there is a risk it could result in anaphylaxis. The RadioAllergoSorbent Test (RAST) This test is done on a blood sample from the patient. It measures specific IgE antibodies against latex allergens. This test is less sensitive than the SPT, not readily available, and more costly. Documentation Once the patient is identified as having a latex allergy/susceptibility, thorough documentation is essential.  Communicating with everyone involved in the patient’s care is critical. This includes the preop area, the OR, the surgeon, anesthesia care providers, and the PACU.  The outcome identified for the perioperative period is to provide a safe environment so the patient is free from signs and symptoms of a latex-allergic response. General Guidelines for Caring for a Latex-Allergic Patient During the preoperative period in the admission and preop area: Notify the physician of the patient’s allergy. Check to see if the patient is scheduled as the first case of the day. Scheduling the patient as the first case is encouraged but not required.) This is done to reduce airborne contact with latex-bound powder. Admit the patient in a latex-safe area. Have a latex-safe cart available. Place an allergy armband on the patient. (Some facilities use a special color armband for patients to indicate latex allergy. Other facilities note it on the patient’s regular allergy armband.) Flag the patient’s chart with a “Latex Allergy Alert.” Put signs on the door indicating “Latex Precautions” in effect. Start IVs with non-latex supplies (e.g., ports). Do not use a paper bouffant hat because of its elastic band, unless the product is latex-free. Put a paper surgeon’s cap on the patient. Implementation of Nursing Care  Preparing for a latex-allergy patient in the OR can be time-consuming if the facility is not latex-safe. These facilities may schedule these cases as the first case of the day, which help eliminate the effect of aerosolized latex glove powder from an earlier case. Aerosolized latex glove powder may cause a respiratory allergic response.  If it is not possible to schedule the latex-allergy patient as the first case of the day, efforts should be directed toward removing all latex products that may encounter the patient and securing latex free products. Nursing responsibilities on the morning of surgery  Check supply of sterile and nonsterile powder-free, latex-safe gloves.  Check latex-free alternatives for commonly used latex products.  Have Webril available to cover the patient’s arm if the B/P cuff or tourniquet tubing contains latex.  Assess the sterile field/back table with the scrub nurse to ensure a latex-safe set-up.  Have emergency medications available for treatment of anaphylaxis. Nursing responsibilities during the preoperative period  Communicate with the PACU/ICU nurse and all other caregivers (e.g., anesthesia) prior to the patient’s transfer to the OR so a latex-safe environment can be ensured.  Ensure that all products containing latex have been removed from the designated OR. This includes gloves and stock items.  If facility is not latex free, wipe down all surfaces in the designated OR, using powder-free non-latex gloves.  Obtain any latex free alternatives that may be required. Most facilities are latex-safe so a special cart with latex free items is not needed.  Contact the manufacturer if questions arise as to whether a product contains latex. Most manufacturers have an 800 number.  Notify the pharmacy to ensure all medications are prepared from non-latex containers and dispensed in latex-free devices.  Place “Latex Precautions” signs on OR door(s). Limit traffic.  Have emergency medications available for treatment of anaphylaxis. Nursing responsibilities during the intraoperative period  Continue to monitor supplies for latex content prior to adding to sterile field. If latex content of an item is not known, don't use it.  Use only nonlatex tape to secure dressings.  Document latex precautions followed and patient are response.  Observe for signs and symptoms of allergic reactions and document patient’s response. Nursing responsibilities during the postoperative period  Continue with the latex-safe plan of care.  Provide a latex-free resuscitation bag, O2 mask, and supplies.  Ensure that latex-safe supplies are available to follow the patient to all locations within the facility. Allergic Responses - Allergic responses can differ depending on whether the patient is awake or anesthetized. Possible reactions in the awake patient:  Itchy eyes  Generalized pruritus  Urticaria  Shortness of breath  Feeling of faintness  Feeling of impending doom  Agitation  Nausea and vomiting  Abdominal cramping  Diarrhea  Wheezing Possible reactions in the anesthetized patient:  Tachycardia  Hypotension  Wheezing  Bronchospasm  Cardiorespiratory arrest  Flushing  Facial edema  Laryngeal edema  Urticaria Airflow in ORs ORs have positive pressure airflow. What this means is when a door from the OR is opened, air will flow from the OR into the hallway. If powdered latex gloves are used in an OR near the latex-safe room, aerosolized powder-containing latex proteins could be transferred through the air or shed from scrub attire of persons working with or near powdered latex products. Inhaling latex particles from this airborne glove powder could induce an allergic response in sensitive individuals. Preoperative Medications Recommendation According to the American Association of Nurse Anesthetists (AANA) Latex Allergy Protocol (see Bibliography), the following preoperative medications may be used for the patient with a latex allergy:  Methylprednisolone  Diphenhydramine  Ranitidine Latex-allergic patients scheduled for surgery may have an order for premedication before coming to the OR. Although pretreatment has not been proven effective in the prevention of reactions to latex, there is still a theoretic rationale for its use, and it therefore might be considered Latex-free Alternative Products Due to the increased availability of latex free equipment and supplies, the need for a latex-safe cart has decreased significantly. The American Latex Allergy Association has a list of latex-free alternative products. Perioperative staff need to pay particular attention to any equipment or supplies that will be used on a latex sensitive patient and ensure that they are truly latex free. Consult with the manufacturer if you have any question Evaluation, Assessment, and Documentation While caring for a latex allergic/sensitive patient, perioperative nurses must constantly evaluate the care given and assess the patient for any negative changes. This plan of care and any changes must be recorded on the patient's chart or electronic medical record by thorough documentation. This can be done through narrative documentation or by check-off type documentation, as seen on the Latex Allergy Perioperative Checklist Treatment of Allergic Reactions A patient may develop an allergic reaction during any invasive procedure. Actions that should be taken if a reaction occurs are described below. Action by the anesthesia care provider The anesthesia care provider will: 1. Assess and sustain airway, breathing, and circulation 2. Support airway 3. Administer 100% O2 4. Start intravascular volume expansion with Ringer’s lactate or normal saline 5. Administer epinephrine 0.5-1.0 mcg/kg bolus (10 mcg/mL dilution) – may need to repeat dose. Give subcutaneously or by ET tube only if no IV access. Action by the surgical team The surgical team must be prepared to respond with the following actions: 1. Remove all latex products 2. Call for help 3. Start emergency protocol (Check with your facility to see if they have a latex-free code chart.) 4. Stop surgery Secondary Treatment The following secondary treatment is recommended in the “AANA Latex Protocol”:  (0.5 to 1 mEq/kg for persistent hypotension with acidosis diagnosed with Diphenhydramine 0.5 to 1mg/kg (max. dose 50 mg)  Methylprednisolone 1 mg/kg IV  Ranitidine 0.5 to 2 mg/kg IV (max. dose 150 mg)  Epinephrine infusion (2 to 4 mg/min. or more, titrate to effect)  Aminophylline (5 to 6 mg/kg over 20 minutes for persistent bronchospasm)  Sodium bicarbonate laboratory confirmations) Implications for the Health Care Worker  Gloves are the main source of latex exposure for the perioperative staff.  As mentioned before, exposure to latex can be from different routes. The employee can be exposed primarily through direct external contact and the airborne route, but mucosal contact can also occur by touching the nose or mouth after glove removal if proper hand hygiene has not been used.  Remember, exposure to latex gloves by sensitive individuals can cause any of the three different types of adverse reactions previously discussed, that is, irritant contact dermatitis, allergic contact dermatitis, and latex allergy. Preventive Measures to Reduce the Risk of Exposure to Latex:  Use hand creams only when gloves are not worn. Applying hand creams before donning gloves appears to increase the amount of latex proteins on the wearer’s skin. Also, oil-based creams may actually alter the physical characteristics of latex gloves, decreasing their effectiveness as a barrier.  Wash hands immediately after glove removal. This will reduce latex allergens on the skin that may be transferred to mucous membranes by touching the nose, mouth, or eyes. This will also help reduce transfer of latex proteins to other surfaces, such as doorknobs, phones, and patient carts that could be a source of contact for latex-sensitive individuals.  Avoid touching the eyes, nose, or mouth while wearing gloves.  Wear a well fitting mask when in contact with glove powder to prevent airborne contact with latex particles.  Minimize exposure to detergents, cleaners, and other chemicals, which can lead to dry, chapped, or irritated skin.  Use proper hand care to reduce skin breakdown.  Wear powder-free, latex gloves, low in latex proteins, or nonlatex gloves. (Many health care facilities provide powder-free exam gloves or vinyl gloves throughout the facility to reduce the exposure to airborne latex particles.) NIOSH Alert In June 1997, NIOSH (National Institute for Occupational Safety and Health) issued an alert titled “Preventing Allergic Reactions to Natural Rubber Latex in the Workplace.” The alert states that “Latex allergy in the workplace can result in potentially serious health problems for workers”. NIOSH Recommendations for Employers NIOSH makes the following recommendations for employers to help protect workers from latex exposure and allergy in the workplace:  Provide workers with nonlatex gloves to use when there is little potential for contact with infectious materials (e.g., in the food service industry).  Appropriate barrier protection is necessary when handling infectious materials [CDC 1987]. If latex gloves are chosen, provide reduced protein, powder- free gloves to protect workers from infectious materials.  Ensure that workers use good housekeeping practices to remove latex-containing dust from the workplace.  Identify areas contaminated with latex dust for frequent cleaning (upholstery, carpets, ventilation ducts, and plenums).  Make sure that workers change ventilation filters and vacuum bags frequently in latex-contaminated areas.  Provide workers with education programs and training materials about latex allergy.  Periodically screen high-risk workers for latex allergy symptoms. Detecting symptoms early and removing symptomatic workers from latex exposure are essential for preventing long-term health effects.  Evaluate current prevention strategies whenever a worker is diagnosed with latex allergy. At the present time, these recommendations are voluntary. NIOSH Recommendations for Workers The NIOSH alert also makes recommendations for the workers to protect themselves:  Use nonlatex gloves for activities that are not likely to involve contact with infectious materials (e.g., food preparation, routine housekeeping, maintenance).  Appropriate barrier protection is necessary when handling infectious materials [CDC 1987]. If you choose latex gloves, use powder-free gloves with reduced protein content.  Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy (though symptoms may still occur in some workers).  Hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis).  Use appropriate work practices to reduce the chance of reactions to latex.  When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and are compatible with latex gloves.  After removing latex gloves, wash hands with a mild soap and dry thoroughly.  Use good housekeeping practices to remove latex-containing dust from the workplace.  Frequently clean areas contaminated with latex dust (upholstery, carpets, ventilation ducts, and plenums).  Frequently change ventilation filters and vacuum bags used in latex-contaminated areas.  Take advantage of all latex allergy education and training provided by your employer.  Become familiar with procedures for preventing latex allergy.  Learn to recognize the symptoms of latex allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and shock. NIOSH Recommendations for Workers The other NIOSH recommendations for workers are: If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other latex-containing products until you can see a physician experienced in treating latex allergy.  If you have latex allergy, consult your physician regarding the following precautions:  Avoid contact with latex gloves and other latex-containing products.  Avoid areas in which you might inhale the powder from latex gloves worn by other workers.  Tell your employer and your health care providers (e.g., physicians, nurses, dentists) that you have latex allergy.  Wear a medical alert bracelet.  Carefully follow your physician’s instructions for dealing with allergic reactions to latex. Natural Latex Allergy/Sensitivity - Module Summary  Latex is the term used to identify the cytosol portion of the sap of the rubber tree called Hevea brasiliensis, as well as products made from the sap.  The medical alert, titled “Allergic Reactions To Latex-Containing Medical Devices,” advises health care professionals to identify latex sensitive patients and to be prepared to treat allergic reactions promptly.  Several possible causes have been forwarded to explain the increase in latex allergy/sensitivity, including increased implementation of standards, leading to increased use of latex gloves.  The three types of reactions to latex include irritant contact dermatitis, allergic contact dermatitis (delayed type IV hypersensitivity reaction), and finally, the true latex allergy (immediate type I hypersensitivity reaction).  There are four routes of exposure to latex: direct external contact, mucosal contact, airborne contact, and IV exposure.  The nursing process for latex-allergic/sensitive patients consists broadly of four phases: assessment, planning, implementation, and evaluation.  Patients who should be treated as latex-allergic include anyone with a history of anaphylaxis to latex, or who have had allergic reactions of a nonsystemic nature to latex, or who are from a high-risk group.  Latex allergy testing may be carried out through any one of three tests: the skin-prick test, the wearer or use test, or the radioallergosorbent text (RAST).  Once a patient has been diagnosed as latex-allergic/sensitive, precautions are taken to safeguard the patient from latex allergy, including ensuring that all products used on the patient are latex-free.  There are specific nursing responsibilities that should be implemented during the preoperative, intraoperative, and postoperative periods.  General guidelines for caring for a latex-allergic/sensitive patient:  Notify the physician of the patient's allergy.  Check to see if the patient is scheduled as the first case of the day. Scheduling the patient as the first case is encouraged but not required. This is done to reduce airborne contact with latex-bound powder.  Admit the patient in a latex-safe area. Have a latex-safe cart available if appropriate.  Place an allergy armband on the patient.  Post latex allergy warning signs on OR doors.  The anesthesia care provider and the surgical team each have defined responsibilities in the treatment of latex allergy if the patient manifests symptoms.  The health care worker can be exposed to latex allergy through the direct external contact and airborne routes. Exposure of sensitive individuals to latex gloves can cause any of the three different types of adverse reactions.  The NIOSH alert makes recommendations for health care workers as well as for employers to help protect health care workers from latex exposure and allergy in the workplace.