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Allergy to natural rubber latex (NRL, or latex), which contains a complex blend of «"^water-soluble plant proteins, has become a major source of concern in clinical practice. The Food and Drug Administration (FDA) has received incident reports of thousands of allergic reactions involving latex-containing medical products, including anaphylaxis, cardiac arrests and deaths. Latex is the inciting factor in at least 10 percent of the anaphylactic reactions reported under anesthesia. Anesthesiologists, nurse anesthetists, operating room and critical care nurses and surgeons are at high risk of developing hypersensitivity to latex as a result of occupational exposure.

Identification of High-Risk Groups_

1. Patients with a history of multiple surgical procedures, including those with myelomeningocoele (spina bifida) and congenital genitourinary tract anomalies. Patients with spina bifida have a 30-70 percent incidence of latex allergy.

2. Health care personnel with occupational exposure. Latex allergy is a major occupational health problem among health care personnel since the prevalence of latex sensitivity may be as high as 17 percent. Approximately 70 percent of adverse events to latex reported by the FDA involve health care workers.

3. Other individuals with occupational exposure to natural rubber latex, including hairdressers, greenhouse workers and those in latex product manufacturing.

4. Individuals with a history of atopy, hay fever, rhinitis, asthma or eczema.

5. Individuals with a history of food allergy to tropical fruits (such as avocado, kiwi, banana), chestnuts, stone fruits and additional specific foods.

Routes of Exposure

Sensitization to latex can occur as a result of contact via skin or mucous membranes or by inhalation, ingestion, and parenteral injection or wound inoculation. Latex gloves are the source of exposure and sensitization among most medical personnel. Gloves vary considerably in their latex content and ability to produce allergy. Powder in gloves, which is used to facilitate donning, enhances the potential for sensitization by transcu-taneous or inhalation exposure.

Signs and Symptoms

Three types of reactions can occur in individuals. The first two are generalized reactions and are not life-threatening:

1. Irritant contact dermatitis, usually due to drying and cracking of the skin.

2. Type IV (contact) hypersensitivity — also know as delayed type hypersensitivity.

Usually occurs over a 24-hour period, is cell mediated and is limited to the site of contact (for example, skin reactions similar to poison ivy).

3. Type I (IgE-mediated) hypersensitivity — also known as immediate type hypersensitivity. This is a true allergic reaction and can have localized or systemic symptoms that can include:

a. Hives, erythema, urticaria which may be localized or generalized.

b. Upper respiratory symptoms, including stuffy or runny nose, cough, asthma.

c. Red, itchy eyes, angioedema of eyelids.

d. GI symptoms, including diarrhea, nausea, vomiting, cramping.

e. Headache, anxiety, shortness of breath, itching.

g. Anaphylaxis, tachycardia, hypotension, cardiovascular collapse.

Operating Room Management of the Patient With Latex Allergy_

1. Identify each patient who is at risk. A careful history frequently will elicit episodes of previous allergic reactions or risk factors.

2. Patients who have a suggestive history and confirmatory laboratory findings must be managed with complete latex avoidance.

3. When possible, the patient should be scheduled for elective surgery as the first case of the day. Airborne latex-laden particles are presumed to be at their minimum levels at that time.

4. Signs displaying "Latex Allergy" should be posted on all O.R. doors. No one should enter the O.R. with latex gloves, without scrubbing after taking off latex gloves or while wearing latex-laden clothing from previous latex exposure.

5. Preview all equipment to be used, looking for possible latex-containing products.

6. A latex-free cart should accompany the patient throughout his/her hospital stay.

Treatment of a Latex Allergic Reaction

1. Contact dermatitis and Type IV reactions:

a. Avoid irritating skin cleansers.

b. Topical corticosteroids can be applied locally for rashes or hives.

2. Type I latex reactions:

a. Mild reactions respond well to antihistamines, and topical nasal steroids may be useful.

b. Hives are treated with antihistamines and systemic steroids.

c. A reaction with airway involvement may require the use of systemic steroids, bronchodilators, endotracheal intubation and epinephrine.

d. In the case of anaphylaxis, a formal anaphylaxis protocol is advisable.

3. Latex-free precautions must accompany the patient throughout the perioperative period (PACU, ICU and discharge unit).

4. The details of any allergic reaction should be clearly documented on the patient's chart. Report any latex-induced reactions to the FDA MedWatch program (1-800-FDA-1088).

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