Acute Management

Asthma Free Forever

Asthma Free Forever By Jerry Ericson

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Initial therapy

1. Stop administration/reduce absorption of offending agent

(Consider a variety of potential routes of exposure-administration, including mucosal contact and inhalation)

2. Remove all latex from the surgical field

3. Change gloves

4. Discontinue all antibiotic and blood administration

5. Maintain the airway and administer 100 percent O2

6. Intubate the trachea (as indicated)

7. Administer 25-50 ml/kg of crystalloid or colloid (as indicated)

8. Administer epinephrine

Intravenous: 0.1 mcg/kg or approximately 10 mcg in an adult Subcutaneous (in the absence of an I.V.): 300 mcg (0.3 mg) Endotracheal: five to 10 times the intravenous dose, or 50-100 mcg in an adult From a metered dose inhaler: 3 inhalations of 0.16 to 0.20 mg epinephrine/inhalation From a nebulizer: eight to 15 drops of 2.25 percent epinephrine in 2 ml normal saline

9. Discontinue all anesthetic agents

10. Consider use of Military Anti-Shock Trousers (MAST)

11. Display prominent signs such as "latex allergy" or "latex alert" on the inside of the operating room as well as on the entry doors for those entering

Secondary therapy

1. Administer antihistamine

Diphenhydramine 1 mg/kg I.V. or IM (maximal dose 50 mg) Ranitidine 1 mg/kg I.V. (maximal dose 50 mg)

2. Administer glucocorticoids

Hydrocortisone 5 mg/kg initially and then 2.5 mg/kg q 4-6 hours Methylprednisolone 1 mg/kg initially and 0.8 mg/kg q 4-6 hours

3. Administer aminophylline for bronchospasm (may be ineffective during anesthesia)

Loading dose 5 to 6 mg/kg

Continuous infusion 0.4-0.9 mg/kg/hr (check blood level)

4. Administer inhaled Beta-2 agonists for bronchospasm

5. Administer a continuous catecholamine infusion for blood pressure support

Epinephrine 0.02-0.05 mcg/kg/min (2-4 mcg/min) Norepinephrine 0.05 mcg/kg/min (2-4 mcg/min) Dopamine 5-20 mcg/kg/min Isoproterenol (same dosing as epinephrine)

6. Administer sodium bicarbonate

0.5 to 1 mg/kg initially, with titrations using arterial blood gas analysis

2. Hives may develop locally or systemically. Antihistamines and systemic steroids are used to treat these symptoms.

3. A more severe reaction, involving the airway, will require more aggressive treatment with antihistamines, systemic steroids, H2 blockers, oxygen and possibly bronchodilators, endotracheal intubation and epinepherine.

4. In the case of anaphylaxis, a formal anaphylaxis protocol is required. Anaphylaxis may require artificial airway support, intravascular volume expansion, administration of vasoactive medication and other life-support techniques. It is of critical importance to have previously created a latex-free crash cart.

5. The details of any allergic reaction should be clearly recorded, including a description of the anesthetic agents and techniques, surgical products used, resuscita-tive measures required, laboratory evaluation as well as the perioperative course. It is important to immediately initiate a laboratory workup because many of the pathog-nomonic findings of anaphylaxis, such as serum mast cell tryptase levels, complement C3 and C4, and histamine will be transiently altered but return to baseline within four hours. With a severe reaction, elevated tryptase levels may persist for longer, even several days. The patient should be referred to an allergist, and the patient's chart should be flagged in order to alert subsequent caregivers.

Management of the Health Care Worker With Latex Allergy

Health care workers who are regularly exposed to latex are at risk for sensitization. Personnel sensitized to latex must avoid all direct contact with latex-containing products. For anesthesiologists, the most frequent offending products are latex examination and surgical gloves. High-quality, powderless, non-latex gloves should be available at every anesthetizing location for individuals who prefer not to use latex products. Those affected should have proper allergy identification and should always carry an epinephrine autoinjector device. Latex allergic anesthesiologists with positive histories and/or confirmatory laboratory tests should be counseled on the risks of continued work in environments with high latex use and on strategies to limit exposure.

The wearing of powderless, low-latex-allergen gloves by co-workers is also critical because this simple step can reduce levels of latex aeroallergen by more than ten-fold in the operating room.34 Exposure to aerosolized latex occurs when gloves are changed as well as when powder in the room and on clothing is mobilized. The use of powderless gloves with low (or preferably no) allergen content will limit sensitiza-tion of health care workers and allow those who already manifest inhalant allergic reactions to return to work. Moreover, the wearing of nonlatex gloves by co-workers would eliminate this significant source of allergen.

Ultimately, the prevention of allergic reactions will occur only when institutions adopt strict policies to protect workers from unnecessary latex exposure. NIOSH has recommended that employers take specific steps to protect workers from latex exposure and allergy in the workplace.61

Management of Health Care Facilities

A successful strategy to manage latex allergies in health care settings requires facility-wide commitment.72 A multidisciplinary latex allergy task force should include broad representation from the hospital staff: medical, nursing, administration, pharmacy, occupational health, central supply, dietary services and housekeeping. Members from this committee can provide a useful latex allergy consultation service. In addition, this committee should have the responsibility to develop60:

1. a process to evaluate all glove selection and utilization;

2. a mechanism for reporting and evaluating all suspected latex reactions;

3. policies and protocols for management of the latex-sensitive patient and the latex-sensitive health care worker; and

4. educational programs for all hospital employees.

Even so, the task is difficult. Specific steps to be taken by employers and workers are found in the NIOSH Alert61 (Appendix C).

Future Directions and Implications for Anesthesiologists

Attention is now being turned to immunotherapy for latex-allergic patients, using the same principles of desensitization that have proven effective for patients with insect allergy. Strategies that have been applied include subcutaneous, percutaneous and sublingual desensitization. While the latter strategies may generally be safer and more effective,73 subcutaneous desensitization has been the more standard approach. Nevertheless, at this time, the benefits of immunotherapy include an improvement in cutaneous symptoms with a possible improvement in rhinitis and asthma. '

Conclusion

Latex allergy continues to be an important medical problem for health care workers and their patients. We have re-examined the definition of latex allergy, updated our understanding of the offending allergens, the factors that enhance sensitization, the threshold levels that sensitize and elicit reactions in sensitized individuals, current diagnostic techniques, avoidance measures, the barrier properties of non-latex alternatives and the roles of premedication and immunotherapy. Fifteen years after its emergence as an international concern in specific patient populations and ultimately in health care workers, latex allergy is a well-defined condition with established diagnostic criteria and rational treatment and prevention strategies. However, notwithstanding an expanding fund of knowledge and a suggestion of immunotherapy's efficacy, avoidance remains the only effective treatment.

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Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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