Urology Nurses Online: ARTICLES

INTRODUCTION

Latex allergy can cause symptoms ranging from allergic rhinitis, urticaria and wheezing, to anaphylactic shock. Certain groups are particularly prone to latex allergy, including patients with spina bifida or spinal cord lesions, and those with complex urological or anorectal malformations. It is important that the urologic nurse, physician or technician identify patients at risk during urological procedures or urologic surgeries, and take steps to avoid an allergic reaction which could lead to brain damage or death from anaphylaxis.

HISTORY OF LATEX ALLERGY

In the mid-1980's, universal precautions were mandated by the Occupational Safety and Health Administration (OSHA) in the United States. Since then, reports of anaphylaxis due to latex allergy have escalated. In fact, such reports have been steadily rising throughout the world (Barton, 1993). In 1991, a Food and Drug Administration (FDA) medical alert warned health-care professionals "to identify their latex-sensitive patients and be prepared to treat allergic reactions promptly" (FDA, 1991). In 1992, the FDA presented reports of more than 850 allergic and anaphylactic incidents. Most of them related to latex covered barium enema catheters which were associated with 15 deaths. Latex examination gloves, and surgeon's gloves were also found to cause problems. (Barton, 1993).

WHAT IS LATEX?

Latex comes from the sap of the rubber tree, Hevea Brasiliensis. To make it pliable the latex is vulcanized, a process in which preservatives, accelerators, and antioxidants are added (Barton, 1993). Latex is present in sterile and non-sterile gloves, catheters, anesthesia tubing and bags, endotracheal tubes, IV ports and tubing, tourniquets, surgical drains etc. Condoms and diaphragms are commonly made of latex, although non-latex alternatives are now available. Latex gloves are worn to prevent filtration of blood-borne pathogens. This effect, however, can be compromised within one minute if exposed to products containing mineral oil or petroleum (Barton, 1993).

LATEX AS AN ALLERGEN

There are two types of allergic response to latex. Type IV is the more common and less serious. It generally causes a delayed, localized dermatitis, although it can spread beyond the area of contact. It is thought to be related to the chemical additives used in the processing (Seymour, 1995). Type IV allergic response to latex may be the precursor to Type I response (Young & Meyers, 1997). The less common and more serious Type I allergy is thought to be an allergy to the latex proteins (Seymour, 1995). Type I reaction is a systemic, IgE mediated reaction that occurs immediately as a response to contact with the latex antigen. Histamine is released in sensitized persons, and can cause symptoms such as urticaria, allergic rhinitis, itchy eyes, facial, periorbital or laryngeal edema, wheezing and anaphylaxis. The individual continues to react on each subsequent exposure. Avoidance of contact with latex products will prevent recurrence of such symptoms (Barton, 1993).

ROUTES OF EXPOSURE

A patient can be exposed to latex in a number of ways. Contact with latex can lead to immediate symptoms in a sensitized patient, or can cause an exposure which may lead to sensitization in the future.

• MUCOUS MEMBRANES:
  • During surgery, the exposed organs and tissues come in contact with latex in surgical gloves, drains, and other medical devices and equipment.
  • Allergic responses during dental procedures, which are often attributed to injectable local anesthetic agents, may in fact be caused by rubber dams and other latex-containing dental equipment (Bubak et al, 1992).
  • A patient who requires clean intermittent catheterization is at risk of latex allergy if latex catheters are used.
  • It has been suggested that food preparation in hospitals should be carried out by dietary personnel wearing non-latex gloves, to prevent the risk of reaction in sensitized patients. Latex glove powder may be rubbed off onto food or utensils (Young & Meyers, 1997).

• SKIN:
  • Contact with the skin can cause urticaria and erythema. Contact dermatitis from the use of latex gloves is a common Type IV allergic reaction to latex.
  • Questioning of the family of a child who is at risk for latex allergy (see below) may elicit a history of swollen lips when blowing up balloons.
  • Latex glove powder which carries particles of latex can stick to surface areas such as equipment, bed sheets etc., and may cause an allergic reaction (Young & Meyers, 1997).

• RESPIRATORY TRACT:
  • Latex carried in respiratory equipment such as endotracheal tubes, ventilation bags and tubing can enter the body through the respiratory tract.
  • Airborne latex particles, carried by the powder from latex gloves, can enter the body by inhalation. Such aeroallergens may remain in the air for some time after a procedure.

• INJECTION:
  • Latex can enter the bloodstream when a medication is given by injecting it through the rubber port on an IV line, and there are reports of such reactions in the literature. It is possible that latex from the rubber stopper of a syringe can leach into a solution after it has been drawn up (Young & Meyers, 1997).
  • A recent study reports latex allergy in a diabetic patient following sub-cutaneous injections of insulin (Towse et al, 1995).

WHO IS AT RISK?

The reason latex allergy occurs is unknown, however it is believed that changes in the manufacturing and vulcanization of latex may have occurred due to the increased demand for latex gloves. Another theory is that sensitivity occurs with exposure over time. The nurse should consider the possibility of latex allergy when caring for individuals who fall into any of the categories below.

1. PATIENTS WITH SPINA BIFIDA, SPINAL CORD INJURY OR COMPLEX UROLOGICAL PROBLEMS.

   Children with spina bifida are those most likely to be allergic to latex (Shaer & Meeropol, 1993). The incidence is currently estimated to be 8%-68% in this population (Young & Meyers, 1997). The incidence of latex allergy in children and adolescents with spinal cord injury was found to be 18% in one study (Vogel et al, 1995). Patients with complex urological or anorectal problems, for example those with cloacal malformation, or imperforate anus are also likely to be affected by latex allergy.

   The high incidence of latex allergy in these patients is thought to be due to early and frequent latex exposure. Such patients are likely to undergo multiple neurological, urological and orthopedic surgeries, as well as diagnostic procedures such as urodynamic and radiologic studies, which require catheterization. They may require digital evacuation of the bowel, or clean intermittent catheterization to manage the bladder.

2. HEALTH CARE WORKERS

   In the United States it is estimated that health care workers are affected by latex allergy at a rate of 2.6%-16.9%. Reports in the literature document symptoms such as contact dermatitis, rhinitis, wheezing and asthma among health care workers. Severe anaphylactic reactions have occurred in both the work environment, and while undergoing surgical procedures (Young & Meyers, 1997). A study in France among nurses showed a sensitization rate of 10.7%. (Seymour, 1995).

   Standards in place to regulate the quality of surgeons' gloves in the United Kingdom may have also had a protective effect on non-sterile gloves. There is, however, anecdotal evidence of an increase in latex allergy, and the Medical Devices Agency (MDA) recently distributed a device bulletin "Latex sensitisation in the health care setting: Use of latex gloves" (O'Gilvie, 1996).

3. INDIVIDUALS WITH CROSS REACTIVITY

   Cinquetti et al (1995), present a case in which a 3-year-old boy, with a hypersensitivity to latex following several surgeries for an imperforate anus, developed an anaphylactic reaction following banana ingestion. The literature also describes latex allergy in patients who have adverse reactions to avocado and kiwi (Knudsen & Menne, 1995). Passion fruit, guava and water chestnuts have also been implicated (Young & Meyers, 1997). There may be cross reactions to other fruits or plants.

4. ATOPIC INDIVIDUALS

   Sorva et al, (1995), in Finland, tested 11 atopic children without a history of latex allergy and found latex specific IgE in all. A latex glove challenge was positive in 9. They suggest that latex allergy should be considered in children with severe atopic excema, urticaria, or anaphylaxis of unknown cause. Multiple allergies or atopy (rhinitis, asthma, food allergies) are present in approximately 54%-57% of those with latex allergy (Young & Meyers, 1997).

5. DIABETICS

   A recent article described a diabetic patient with a history of both local sensitivity at insulin injection sites, and systemic latex allergy manifested as anaphylaxis (Towse et al, 1995). Of note, the patient was a laboratory technician who had prior occupational exposure to latex.

TESTING FOR LATEX ALLERGY

It is difficult to diagnose latex allergy using laboratory testing as "No single diagnostic technique has been shown to be of sufficient predictive value in large scale studies" (Slater et al, 1990, p. 413). Skin testing for latex allergy is generally confined to research studies under controlled conditions. "Unpublished reports have described severe systemic reactions in latex-sensitized persons undergoing skin testing with latex extracts" (Bubak et al, 1992).

The commercial RAST blood tests were shown to be only 53% accurate. A positive test means that latex specific IgE is circulating in the blood stream, but does not predict whether an allergic reaction will occur, or how severe it might be. Tests may show false negatives in patients that have a strong history of latex allergy. Even if a test is truly negative, it is only true at the time of testing (Shapiro, 1992). The FDA recently approved a blood test which is approximately 85% accurate. It is not yet available for general use (FDA, 1995).

MANAGEMENT OF PATIENTS AT RISK FOR LATEX ALLERGY

1. IDENTIFICATION

   An allergy history should be obtained routinely from all patients on admission to the hospital, and before any procedure, examination or investigation. Special attention should be paid to the "at risk" groups. Close questioning may reveal a history such as swelling or urticaria when visiting the dentist, or on blowing up balloons. The patient may not realize the significance of such symptoms. The allergy status may change between one visit or admission and the next, so this information needs to be checked on each visit.

   When latex allergy is identified it should be documented in the medical record. Some institutions have initiated a special latex allergy identification bracelet which is worn by patients with a known history of latex allergy, as well as those who fall into the "at-risk" category. This bracelet is distinct from the bracelet used to identify medication allergies, and is checked before any patient contact is initiated (Young, et al, 1992).

   Communication between nurses about latex allergy status is essential to ensure that guidelines specific to the care of these patients can be followed (Young, et al, 1992). This includes verbal communication between nurses prior to transfer of the patient between departments. Latex allergy signs should be placed at the patient's bedside, and on the door of the operating room during surgery.

2. EDUCATION

   Education of the patient and family is a vitally important part of the nurse's role. The amount of information and the implications of latex allergy may, initially, be overwhelming for the family. Education should begin as soon as possible, and should be documented in the medical record. Information should be concrete and consistent. Families may require repeated latex allergy teaching, but the patient and family will eventually become their own best advocates in the avoidance of latex in the home and hospital environment. Education includes:

   1. What latex is, and where it is found, in the home and hospital.
   2. The signs and symptoms of latex allergy.
   3. The need for a latex allergic person to avoid contact with latex
   4. The need for an "at-risk" individual to avoid latex in order to prevent sensitization.
   5. The need for the family to teach other caregivers of children about latex allergy, for instance teachers and baby-sitters.
   6. The need to inform medical caregivers, e.g. dentists, anesthetists, operating room staff, gynecologists, and emergency room staff, so that a potentially fatal allergic incident can be avoided.
   7. A medical-alert bracelet should be worn, and Auto-injectable Epinephrine should be available for emergency use (Barton, 1993). An allergy consult is recommended.
   8. It is recommended that the patient carry a box of non-latex gloves with them, for example in the car, for situations where gloves might be needed (Young, et al, 1992)

3. AVOIDANCE OF LATEX

   The cornerstone to the management of latex allergy is avoidance of exposure to latex. The patient with a known of latex allergy may develop symptoms. The "at-risk" patient may become latex allergic at any exposure. Avoidance of latex in these patients may prevent the future onset of latex allergy.

   Symptoms can occur immediately on contact with even one latex-containing item. The overwhelming exposure that can occur in an operating room setting, for example, can quickly lead to problems. One case study in the literature describes a child with spina bifida who demonstrated generalized urticaria, facial and periorbital edema, hypotension, wheezing and decreased ventilatory compliance as a result of latex exposure during surgery. Fortunately, these symptoms responded to the administration of several doses of Epinephrine (Sethna et al, 1992).

   A master list of latex-containing items and non-latex alternatives is available from the Spina Bifida Association of America, and is regularly updated. Some centers have developed their own list (Young, et al (1992). These lists are referred to in caring for a patient at risk for latex allergy, to ensure that non-latex alternatives are substituted.

4. OPERATING ROOM POLICIES & PROCEDURES

   Young, et al (1992) describe specific measures taken in the Operating Room at Children's Hospital in Boston to implement the policy regarding patients with latex allergy. These include:

   1. Documenting the latex allergy on the surgical schedule, and placing a sign on the operating room door.
   2. No latex gloves worn by anyone in the room, as the aeroallergens could elicit an allergic response.
   3. Non-latex alternatives are substituted for all items, including anesthetic equipment, blood pressure cuffs, catheters etc.
   4. Rubber stoppers are removed, and medications are drawn up directly from the vials.
   5. Stopcocks are used for medication administration. Rubber injection ports are covered with tape to avoid using them.
   6. Solutions are drawn up in a syringe for no more than six hours, as there is a risk of leaching of latex from the rubber plunger.

CONCLUSION

The incidence of latex allergy is rising. Some urologic patients are particularly at-risk. An allergic reaction to latex during a procedure or surgery can lead to cerebral damage or even death as a result of the circulatory shock of anaphylaxis. When an individual becomes sensitized to latex it may limit their activities on a daily basis. Life may be significantly altered by the need to avoid contact with latex products. Healthcare workers must be aware of the risk of latex allergy not only in their patients, but also in themselves and their co-workers.

Recognizing the risk of morbidity and mortality of both patients and staff, some institutions are moving, wherever possible, to reduce or eliminate latex in medical devices, equipment and gloves. Some manufacturers are aware of the problems posed by latex allergy, and are using methods such as leaching and chlorination to reduce the latex protein levels in their products. This may reduce the incidence of sensitivity and allergic reactions. A dramatic increase in the availability of synthetic, non-latex gloves and other medical products has occurred in recent years (Young & Meyers, 1997).

Urologic patients with spina bifida, spinal cord injury, and complex ano-rectal and urogenital malformations are particularly at risk for latex sensitization and allergic responses. Nurses have a critical role to play in educating patients, families, and other health-care workers, and in developing policies and procedures for prevention and response.

The following Internet sites can provide further information on latex allergy:

• Delaware Valley Latex Allergy Support group at www.latex.org
• The Spina Bifida Association of America at www.infohiway.com/spinabifida

References

1. Barton, E. C. (1993). Latex allergy: Recognition and management of a modern problem. Nurse Practitioner. 18 (11), p. 54-58.
2. Bubak, M. E., Reed, C. E., Fransway, A. F., Yunginger, J. W., Jones, R. T., Carlson, C. A., Hunt, L. W. (1992). Allergic reactions to latex among health-care workers. Mayo Clinical Proceedings. 67, p. 1075-1079.
3. Cinquetti, M., Peroni, D., Vinco, A., Zooppi, G. (1995), Latex allergy in a child with banana anaphylaxis. Acta Paediatrica. 84 (6), p. 709-10.
4. Food and Drug Administration (1991). FDA Medical Alert: Allergic reactions to latex-containing medical devices. Mar, p. 1-2. U.S. Department of Health and Human Services, Rockville, MD.
5. Food and Drug Administration (1995). FDA Medical Bulletin. Aug., p. 1. U.S. Department of Health and Human Services, Rockville, MD.
6. Knudsen, B. B., Menne, T. (1995). Allergy to natural rubber: A current problem. Ugeskrift for Laeger. 157 (34), p. 4682-3.
7. O'Gilvie, W. (1996). Guidance on latex sensitization for the health service. Nursing Times. 92 (15), p. 36.
8. Sethna, N. F., Sockin, S. M., Holzman, R. S., Slater, J. E. (1992). Latex anaphylaxis in a child with a history of multiple anesthetic drug allergies. Anesthesiology. 77, p. 372-375.
9. Seymour, J. (1995). Gloves: Alternatives to latex. Nursing Times. 91 (32), pp. 46, 48.
10. Shaer, C., Meeropol, E. (1993). Latex (natural rubber) allergy in spina bifida patients. Spina Bifida Spotlight.
11. Shapiro, E. (1992). Complications of latex allergy. Dialogues in Pediatric Urology. 15 (3), p. 1-3.
12. Slater, J., Mostello, L.A., Shaer, C. (1991). Rubber-Specific IgE in children with Spina Bifida. Journal of Urology. 146, p. 578-579.
13. Sorva, R., Makinen-Kiljunen, S., Suvilehto, K., Juntunen-Backman, K., Haahtela, T. (1995). Latex allergy in children with no known risk factor for latex sensitization. Pediatric Allergy & Immunology. 6 (1), p. 36-8.
14. Towse, A., O'Brien, M., Twarog, F. G., Braimon, J., Moses, A. C. (1995). Local reaction secondary to insulin injection: A potential role for latex antigens in insulin vials and syringes. Diabetes Care. 18 (8), p. 1195-7.
15. Vogel, L. C., Schrader, T., Lubicky, J.P. (1995). Latex allergy in children and adolescents with spinal cord injuries. Journal of Pediatric Orthopedics. 15 (4), p. 517-20.
16. Young, M.A., Meyers, M., Desotell McCulloch, L., Brown, L.J. (1992). Latex Allergy: A guideline for perioperative nurses. AORN Journal. 56 (3), p. 488-502
17. Young, M.A., Meyers, M. (1997). Latex Allergy: Considerations for the care of pediatric patients and employee safety. Nursing Clinics of North America. 32 (1), p. 169-182