2009 Japanese Society of Latex Allergy guidelines for the safe management of latex allergy

Latex allergy is an IgE-mediated reaction to natural latex antigen. Operating room equipment frequently includes medical devices, such as surgical gloves, intravenous lines, and urinary catheters, which are made from latex or contain latex. These products can trigger an allergic reaction that can result in anaphylactic shock. Removal of natural rubber and latex-containing products from the operating room and avoidance of external and internal exposure of patients to latex antigen will prevent such allergic reactions. Updated guidelines for the safe management of latex allergy were published in 2009 by the Japanese Society of Latex Allergy. The previous guidelines regarding this topic were published in 2006. The new guidelines consist of 11 chapters that deal with background, exposure to latex antigen and development of sensitization, high-risk groups, natural rubber products, allergic reactions triggered by natural rubber products, diagnosis, latex-fruit syndrome, countermeasures and treatments in emergencies, prevention and safe management in the hospital, countermeasures in daily life, and limits for application of the guidelines. We had a case that required management according to the 2009 guidelines. A 49-year-old male doctor with a history of allergy to latex gloves was scheduled for laparoscopic cholecystectomy under general and epidural anesthesia for recurrent, acute cholecystitis. The anesthesia and operation were performed uneventfully with latex-free medical devices and machines in a latex-safe environment in the operating room under the new guidelines. Safe anesthetic management under the 2009 guidelines should be available for all operations in Japan on patients with latex allergy.     

Latex allergy. An not rare intraoperative event

Latex allergy has become a real problem among both surgical staff (paramedics and physicians) and patients especially pediatric patients with urogenital malformations and spina bifida. Latex allergy is produced from both natural molecules which compose the substance produced from Hevea brasiliensis (rubber tree) and industrial additives contents in latex devices. Diagnosis of latex allergy may be carried out through a preoperative Prik-test. A characteristic of latex allergy reaction is the starting of symptoms (more than 15 minutes after allergen contact). Pathophysiology of latex allergy is the same of all allergic reactions; it is an antigen-antibody reaction and type I or II reaction may occur. There are a lot of devices that surgeons and anesthesists use in the operative theatre and that should not be used in presence of a patient with latex allergy. Guaranteed latex-free devices should always be present in store.     

Rezidivierende Ergussbildung und granulomatöse Synovitis nach Knietotalendoprothesenimplantation bei Latexallergie

An increasing number of articles report about allergic reactions in association with total knee arthroplasty. While most studies focus on allergic reactions to metallic components, few reports exist about reactions to bone cement or its ingredients. Allergy to natural rubber latex is a major occupational problem in the health care sector and a problem even in other occupations in which protective gloves are used. The allergic reaction to latex ranges from a minor skin rash to anaphylactic shock. Preventing exposure to latex is the key to managing and preventing this allergy. We report about a patient who developed recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy.     

Latex allergy in children: modalities and prevention

Allergic or immediate hypersensitivity reactions to latex have been reported in children with increasing frequency in the past. The reported prevalence varies greatly depending upon the population studied and the methods used to detect sensitization. Children's subpopulations at particular risk include: atopics, individuals with spina bifida, children undergoing surgical procedure during the neonatal period and individuals who required frequent surgical instrumentations. Latex allergy is also an important medical issue, particularly for healthcare personnel. Sensitization mainly occurs by wound or mucosal contact with latex devices during surgery or by inhalation of airborne allergens released from powdered latex gloves. Regarding diagnosis, the medical history, skin prick test and search for specific serum IgE are crucial but cost effective. The development of a guide listing latex-containing drugs is essential for the primary prevention of allergic reactions. Immunotherapy or specific premedication seems not effective in preventing the risk of anaphylaxis during the perioperative course. The most effective strategy to decrease the incidence of latex sensitization is complete avoidance. This strategy is efficient in patients and also in health care workers and has been applied since 2002 in our pediatric surgical hospital. One of major problem with the latex-free gloves was that surgeons find them considerably more difficult to work with. But today, manufacturers made considerable effort and free-latex gloves with an equal tactile sensation than the latex-gloves are now available. The extra cost of free latex gloves is well counterbalanced as allergen test, long stay hospital for allergic reaction, and worker's compensation are no longer needed. Since the introduction of this program in our institution, no allergic reaction to latex has been reported in 25000 anesthetized children or with the health care workers.     

Latex allergen levels of injectable collagen stored in syringes with rubber plungers

Objectives

To assess the latex allergen content of glutaraldehyde cross-linked injectable bovine collagen stored in rubber plunger syringes.

Methods

Extracts of syringe plungers and collagen solutions before and after storage in syringes with natural rubber latex plungers were tested for latex protein allergens. Thirty-nine patients known to be allergic to latex underwent skin prick testing with extracts of the latex plungers, collagen solutions before and after storage in syringes, standard latex skin test reagents, four extracts from commercially available gloves, and positive (histamine) and negative (diluent) control solutions. Thirty-one control patients not known to be latex allergic were similarly tested.

Results

No latex proteins were detected using in vitro immunochemical techniques. Only 1 of 39 (2.5%) latex allergic patients reacted to the syringe extract and the collagen stored in the syringe. No reactions were recorded to collagen that had no contact with latex.

Conclusions

The level of latex antigens in injectable collagen is very low. The low prevalence of skin test reactivity in these highly latex allergic individuals suggests that type 1 hypersensitivity reactions as a result of latex contamination would be unlikely.     

Latexerkrankungen

This article presents the development of glove purchasing in all acute hospitals insured by the employers’ liability insurance association for the health service and promotion of wellbeing (BGW) since the duty of substitution was introduced and since suspicion of occupational illnesses caused by allergies to natural latex became notifiable. A significant positive correlation was statistically documented between the use of powdered natural latex gloves and the number of cases in which an occupational illness attributable to natural latex allergy was notified. The results show that prevention by means of substitution of unpowdered gloves low in natural latex for powdered gloves with a high allergen content is of decisive importance. This simple countermeasure is easy to implement, and when it is consistently applied it significantly reduces the development of occupational allergies to natural latex and makes it possible for even sensitised members of staff to stay in their workplace.     

Anästhesiologische Besonderheiten bei Patienten mit Latexallergie

Immediate-type hypersensitivity due to natural rubber (latex) products is an increasing problem for the anaesthetist, because a major part of products used for anaesthesia contains natural rubber. If the patient has a positive history of allergic symptoms after contact to natural rubber like urticaria, bronchospasm or anaphylaxis, preoperative skin tests, in vitro-tests, and if necessary even latex-glove wearing-test should be performed. If preoperative diagnosis of natural latex allergy is established, latex free anaesthesia is strictly recommended, otherwise life-threatening complications may ensue. Accordingly, we report on a patient who developed intraoperative anaphylactic shock following exposure to natural latex. In addition to the treatment with drugs, latex-containing products should be immediately replaced by latex free ones, in particular all persons should put on latexfree gloves. For prevention of anaphylactic episodes in sensitized patients the reader is provided an examplary list of latexfree products for anaesthesia. Because the incidence of immediate-type reactions to latex is still increasing, intraoperative occurence of an anaphylactic reaction to an unknown agent is likely to be due to allergy to natural rubber.     

Intraoperative anaphylaxis to latex

This case report describes intraoperative anaphylaxis occurring in a fourteen-year-old female with spina bifida in which latex surgical gloves were incriminated as the aetiologic agent. The patient was non-atopic but since eight years of age she had developed localized angioedema and urticarial skin reactions on exposure to rubber. She had previously undergone several uneventful surgical procedures. Forty-five minutes following induction of anaesthesia and during laparotomy for elective cholecystectomy she experienced sudden onset of increased airway pressure, oxygen desaturation, tachycardia, profound hypotension and erythema consistent with an anaphylactic reaction. Resuscitation with manual ventilation and oxygen, intravenous fluids and an epinephrine infusion was successful. Subsequent investigations for allergies demonstrated a strongly positive skin prick test and RAST to latex antigen, with negative results to anaesthetic agents, antibiotics and inhalant allergens. During two later operations prophylaxis consisting of diphenhydramine, ranitidine and hydrocortisone appeared to prevent further reactions. Latex should be considered as a cause of life-threatening intraoperative allergic reactions in patients with a history of rubber allergy or frequent exposure to latex products.     

Prevalence of allergic reactions to implant materials in total hip and knee arthroplasty

INTRODUCTION: Several case reports have been published on allergic reactions like eczema, urticaria, persistent swelling, sterile osteomyelitis or aseptic implant loosening in the context of orthopaedic implants. There is, however, a lack of data concerning incidence or prevalence of allergies in this special group of patients. The aim of this study was to analyse a consecutive series of patients with a total hip or knee arthroplasty to gain information about prevalence of allergic reactions to constituents of the alloys or bone cement. MATERIAL AND METHOD: Between February and September 2005, a consecutive series of 300 patients after total hip (THA) or total knee (TKA) arthoplasty were interviewed during regular follow-up using the standardised questionnaire of the working group 20 "Implant and Allergy" of the DGOOC with respect to allergies, especially to different metals or constituents of bone cement. In this study 100 males and 200 females with 214 THA and 86 TKA were included. The mean follow-up time was 33.3 months (min: 3, max: 174). RESULTS: Different allergies were found in 39 patients. In 12 cases (4 %) allergic reactions against nickel, in 4 cases (1.3 %) against cobalt, in 2 cases (0.7 %) against chromium and in 2 cases (0.7 %) against benzoyl peroxide were detected by means of epicutaneous testing. One patient each suffering from a nickel allergy showed signs of osteolysis or recurrent effusion after THA with a metal-on-metal bearing. One patient each suffering from recurrent effusion or eczema following TKA showed allergic reactions to benzoyl peroxide. In all the other patients with allergies to the alloy constituents, the follow-up was uneventful. CONCLUSION: The prevalence of allergic reactions in an unselected group of orthopaedic patients is significantly lower in comparison to that in dermatological studies. Most patients suffering from allergies tolerated the implant uneventfully. Further studies are needed to identify those groups of patients with allergies who may not tolerate the implant in order to provide better care or use special implants.     

Hetastarch allergy and positive latex radioallergosorbent test in a patient suffering cardiovascular decompensation during multiple perioperative periods

The cause of sudden cardiovascular collapse in the perioperative period can be elusive. Allergy may be overlooked as a cause. When allergy is considered, latex is often suspected. Because hetastarch is frequently used in situations involving hypovolemia and hypotension, and because allergic reactions to it are rare, it may be overlooked as a possible allergen. We report a case of a patient suffering cardiovascular decompensation during four nonconsecutive perioperative periods before it was determined that she was allergic to hetastarch. She also had a very highly positive latex radioallergosorbent test, suggesting a latex allergy.     

LATEX ALLERGY IN NON-SPINA BIFIDA PATIENTS: UNFAMILIAR INTRA-OPERATIVE ANAPHYLAXIS

Background : The medical literature has described the prevalence of latex allergy in the spina bifida population and its implications for surgical intervention. We report three cases of severe and unexpected intra-operative anaphylaxis secondary to latex exposure in non-spina bifida patients. Methods : A retrospective review of case notes identified three non-spina bifida patients who suffered intra-operative anaphylaxis due to latex allergy. Personal and telephone interview and patient chart review was performed to detail a past history of multiple latex exposure, atopy, the anaphylaxis event and the postoperative outcome. Results : Three non-spina bifida patients are described. One suffered a cardiopulmonary arrest, the remaining two patients had severe vascular hypotension and airway resistance that was only relieved after administration of vasoconstrictors and bronchodilators. Postoperatively, all three tested strongly positive to latex allergen testing. Each patient had a history of multiple surgical latex exposure and specific allergies or allergic-type symptoms pre-operatively. Conclusion : We believe that the predictors of a severe allergic reaction to latex with surgical exposure in non-spina bifida patients may be similar to those predictors known in the spina bifida population. Identification of such at-risk patients will reduce the risk of significant intra-operative morbidity and possible mortality by the introduction of a latex-free operating environment.     

Latex allergy: diagnostic pitfalls

A 44-year-old woman, native of Martinique, with a history of multiple allergies and severe asthma, sustained an unexplained cardiovascular collapse during surgery under general anaesthesia. The patient recovered normally. Postoperatively, neither additional explorations were undertaken nor informations given to the patient. Later on she had to undergo cholecystectomy. Data obtained from preanaesthetic assessment (history, analysis of medical files) were in favour of a past intraoperative allergic accident. Allergological tests confirmed a latex allergy. This case substantiates the importance of a careful preanaesthetic consideration of patient's history and the value of a systematic allergologic exploration after an unexplained intraoperative event compatible with an anaphylactoid reaction. All such events should be clearly explained and a written document handed to the patient.     

Latex allergy: a strategy for management

Latex is a ubiquitous part of life today. It is a constituent of many household products and medical devices, although not always obvious on examination. The increase in incidence of potentially life-threatening allergic reactions to latex has been a cause for mounting concern over recent years. Although there have been recent reviews of the general problem of latex allergy, there is little advice available to anaesthetists on how to develop an effective strategy to implement within their own hospitals. The aim of this article is to improve awareness of latex allergy and by describing the development of our strategy to identify and safely manage those at risk in the peri-operative period, facilitate the process for other departments.     

A case of anaphylaxic shock due to latex glove used on internal examination and on the probe of intrauterine echogram

A 15 year old female with uterus bicornis bicollis was admitted for operation. She had a history of atopic dermatitis and allergy to buckwheat, raw egg and latex. Two months previously she had developed whole body flushing during dental treatment, and latex glove used by the dentist had been suspected as the cause. Prior to the operation she underwent internal examination and intrauterine echogram in which a latex glove was carelessly used by another gynecologist who had not confirmed her past history. After 30 minutes, dyspnea and urticaria without itching, appeared suddenly. Blood pressure decreased to 80/50 mmHg and heart rate increased to 120 beats.min-1. She was then transferred to our ICU. Methylprednisolone was administered intravenously for dyspnea and circulatory collapse. After 3 hours, the patient made an uneventful recovery. The increased plasma latex protein-specific IgE levels confirmed anaphylaxis to latex. The increasing incidence of potentially life-threatening allergic reactions to latex has caused mounting concern over recent years. We may suspect latex allergy when an anaphylaxic reaction or shock of unknown origin occurs. In hospitals, latex free products must be prepared for use with latex allergic patients and for protection of medical staff with this allergy.     

Recognition and management of the latex-allergic patient in the ambulatory plastic surgical suite

Allergic (IgE antibody-mediated) reactions to proteins retained in natural rubber latex (NRL), although decreasing in prevalence, are still a concern in many clinical practices due to possible sensitization of healthcare workers exposed to latex in the office setting and patients with histories of latex allergy who present in the office. In this article, the authors outline the risk factors for latex allergy, describe the symptoms of latex allergy, and provide direction on how to create an environment safe for medical care of latex-allergic patients. In addition, treatment of anaphylaxis to NRL is outlined, including precrisis steps in preparation for anaphylactic reactions in the office surgery setting. Many of the precautions outlined in this article could be extrapolated for a healthcare worker with known or suspected latex allergy.     

Latex allergy at Groote Schuur Hospital--prevalence, clinical features and outcome.

BACKGROUND: The incidence of latex allergy is increasing worldwide but there is very little information available on the clinical outcome for affected individuals. OBJECTIVE: To determine the prevalence of latex allergy at Groote Schuur Hospital, a large teaching hospital in Cape Town, and to study the outcome for affected individuals. METHOD: Using a questionnaire, we screened 2,316 hospital workers for the presence of work-related symptoms. Workers who were symptomatic had Immunocap RAST (CAP RAST) or skin-prick tests to confirm latex sensitivity. Latex-avoidance measures were implemented in positive subjects. One hundred symptomatic, sensitised individuals were followed up 3 months after intervention to assess their clinical status. A further cohort of 25 individuals with ongoing nasal symptoms were studied in detail. RESULTS: Latex sensitisation was confirmed in 182 of 717 symptomatic workers (25.3%). Sensitised symptomatic workers were significantly more likely to have had a previous history of urticaria (P = < 0.001), oral allergy syndrome (P = < 0.001), or allergic conjunctivitis (P = 0.001), but not hay fever, perennial rhinitis, eczema or insect allergies. Latex sensitisation occurred among all classes of health care workers. Ocular and cutaneous symptoms were significantly associated with positive latex sensitisation (P = < 0.001). After latex intervention, ocular symptoms (P = < 0.001), skin rashes (P = < 0.001) and wheezing (P = 0.001) reduced significantly. Nasal symptoms did not improve. Undiagnosed and untreated underlying allergies to common aero-allergens were present in the majority of latex-sensitised patients with ongoing nasal symptomatology. CONCLUSION: The prevalence of symptomatic sensitisation to latex allergy at Groote Schuur Hospital is between 9.2 and 11.2%. Ocular and cutaneous symptoms are the most prevalent in sensitised workers, and unlike nasal symptoms are significantly reduced when latex-avoidance measures are introduced. Ongoing nasal symptoms after intervention is instituted are probably due to other allergic sensitivities in latex-sensitised health care workers.     

Sublingual desensitization: a new approach to latex allergy problem

The prevalence of latex allergy has rapidly increased. Clinical manifestations range from contact urticaria-angioedema and rhinoconjunctivitis to more severe bronchial asthma and anaphylactic shock. The only effective therapy is desensitization. We studied 24 patients allergic to latex: 12 of them underwent a rush (4-day) sublingual desensitization to latex, performed by putting increasing doses of latex extract under the patients' tongues for 3 min every 20 min, followed by a maintenance therapy. The other 12 patients were considered controls. The sublingual rush desensitization protocol was successfully completed in all patients with no side effects. After 3 mo, all patients underwent an allergological evaluation, which showed a significant improvement of symptoms scores after challenges in the treated group as compared with the controls. All the desensitized patients can now wear latex gloves and undergo medical procedures without any symptoms. IMPLICATIONS: We present 12 cases of latex allergy in patients who underwent desensitization by a sublingual exposure protocol. This study provides evidence that a safe therapeutic approach to latex allergy is possible.     

Latex-related allergy in hemodialysis patients

Abstract

Background: Incidence of allergic reactions is increased in hemodialysis (HD) patients. However, the prevalence of latex allergy is not exactly known in HD patients. The aim of this present study is to determine the prevalence of latex allergy in HD patients. Methods: A total of 205 adult HD patients were included in the study. Questionnaires were completed during patient interviews, and their consents were provided. Latex prick test and latex specific IgE test (HY-TEC, K82) were performed. Mean age of the patients was 52?±?14 (25–79) years, and 61% was male. Mean dialysis duration was 38 months, and 21% of them were diabetics. Only five patients had allergic complaints in their histories, and none of them had severe anaphylaxis history. Latex prick test was positive in two patients. Latex specific IgE test was positive in five patients. Overall latex sensitivity was defined as 3.4%. Conclusion: No increased prevalence in latex allergy was determined in HD patients. Latex allergy incidence may be increased in atopic HD patients. Therefore, the use of latex products should be avoided as much as possible especially in atopic HD patients.     

Drug allergies in the surgical population

Many patients claim to have drug allergies. However, the signs and symptoms of “allergic reactions” are seldom documented and the drug allergies are rarely properly assessed. The goal of this study was to determine the incidence of claimed “drug allergies” in a surgical population. After obtaining institutional approval, the study was carried out at five hospitals affiliated with Dalhousie University. Patients were interviewed by the investigators during the preoperative anaesthetic evaluation over six months and all signs and symptoms of drug reactions were recorded. The validity of the claimed allergy was based on the history. The allergies were assigned to one of three groups: (1) High probability of an allergic reaction: one or more of the signs and symptoms typical of an immunological reaction, with or without a family history, or a history of atopy: (ii) Low probability of an allergic reaction: signs and symptoms of the reaction were predictable reactions or side effects of the drug, without the occurrence of reactions mentioned above; or (iii) Unknown status. no information concerning the reaction of history was available. Of 1818 adult and paediatric patients (914 female/904 male) interviewed, 511 (28.1%) claimed to have one or more drug allergies (a total of 671 allergies). More women than men claimed to have drug allergies (60.3% vs 39.7%) and there was a positive correlation between age, number of medications and reported drug allergies. Antibiotics (50%), opioids (27%), nonsteroidal antiinflammatory agents (10%), and sedatives (5%) accounted for 92% of all claimed drug allergies. Overall, 50% of claimed allergies had a high probability of true allergic reactions. The majority of antibiotics (75%) were associated with a high probability for true allergic reactions, but most of the other drug classes, such as opioids (83%), NSAIDs (64%) and sedatives (67%), were associated with a low probability for true allergic reactions. Our findings suggest a serious problem in the “labelling” of our patients as having drug allergies. Patients and health care personnel should be educated in the differentiation between predictable adverse drug reactions and true allergic drug reactions.     

Latex allergy--a clinical perspective

Latex allergy has been increasingly recognized in the past 6 years. Defined risk groups are health-care workers, spina bifida children, and possibly food allergy patients. Powdered latex gloves and latex barium enema tips are products most commonly associated with allergy. Clinically, patients present with contact urticaria, allergic rhinoconjunctivitis, asthma, and anaphylaxis. At least 15 deaths are reported to have occurred because of latex allergic reactions. Severe occupational latex allergy can result in removal of the affected individual from the workplace. This will have important cost implications. The only presently available treatment of latex allergy is avoidance.