Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Assistant Professor Dept of...

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Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Tara Hata, MD Assistant Professor Assistant Professor Dept of Anesthesia, UIHC Dept of Anesthesia, UIHC March 27, 2001 March 27, 2001

Transcript of Latex Allergy: Diagnosis, Prevention, and Management Tara Hata, MD Assistant Professor Dept of...

Latex Allergy: Diagnosis, Prevention, and Management

Latex Allergy: Diagnosis, Prevention, and Management

Tara Hata, MDTara Hata, MD

Assistant ProfessorAssistant Professor

Dept of Anesthesia, UIHCDept of Anesthesia, UIHC

March 27, 2001March 27, 2001

History of Latex AllergyHistory of Latex Allergy

1933 Contact dermatitis to gloves1933 Contact dermatitis to gloves

1979 Contact urticaria1979 Contact urticaria

1982 Identified IgE antibodies to latex proteins1982 Identified IgE antibodies to latex proteins

1989 Anaphylaxis and death from latex exposure1989 Anaphylaxis and death from latex exposure

Association with spina bifida or severe GU Association with spina bifida or severe GU anomaliesanomalies

1997 Reports to FDA total 2300 allergic reactions 1997 Reports to FDA total 2300 allergic reactions (225 anaphylaxis, 53 cardiac arrests, 17 deaths) (225 anaphylaxis, 53 cardiac arrests, 17 deaths)

1998 FDA mandates labeling of medical products1998 FDA mandates labeling of medical products

Origin of LatexOrigin of Latex Latex is sap from rubber tree, Latex is sap from rubber tree, Hevea brasiliensisHevea brasiliensis 60% H60% H22O, 35% rubber, 5% proteinO, 35% rubber, 5% protein

Rubber molecule: cis-1,4-polyisopreneRubber molecule: cis-1,4-polyisoprene Chemicals added during productionChemicals added during production

Preservatives (ie: ammonia), accelerators (ie: thiurams), Preservatives (ie: ammonia), accelerators (ie: thiurams), antioxidants (phenylenediamine), vulcanizing compounds (ie: antioxidants (phenylenediamine), vulcanizing compounds (ie: sulfur) sulfur)

May elicit delayed hypersensitivityMay elicit delayed hypersensitivity

Proteins responsible for most generalized allergiesProteins responsible for most generalized allergies 7 sensitizing proteins identified to date7 sensitizing proteins identified to date

Manufacture of Latex GlovesManufacture of Latex Gloves

Protein content can vary 1000-fold among lotsProtein content can vary 1000-fold among lots May vary 3000-fold among manufacturersMay vary 3000-fold among manufacturers Powdered examination gloves have highest protein Powdered examination gloves have highest protein

content and allergen levelscontent and allergen levels Cornstarch particles adsorb latex allergensCornstarch particles adsorb latex allergens Particles aerosolized: assoc with respiratory symptomsParticles aerosolized: assoc with respiratory symptoms Particles also contaminate clothingParticles also contaminate clothing

Lowest levels in powderless gloves that undergo Lowest levels in powderless gloves that undergo additional washing and chlorinationadditional washing and chlorination

Mechanisms of ExposureMechanisms of Exposure

Cutaneous absorption, ie: from glovesCutaneous absorption, ie: from gloves Inhalation via aerosolized proteins on powderInhalation via aerosolized proteins on powder MucosalMucosal

Vaginal/rectal exams, dental procedures, surgeryVaginal/rectal exams, dental procedures, surgery

ParenteralParenteral IVs, surgical wounds, severe dermatitisIVs, surgical wounds, severe dermatitis

Hypersensitivity ClassificationHypersensitivity Classification

Type IType I ImmediateImmediate Type IIType II CytotoxicCytotoxic Type IIIType III Immune complexImmune complex Type IVType IV Delayed typeDelayed type

Types of Latex SensitivityTypes of Latex Sensitivity

Irritant contact dermatitisIrritant contact dermatitis Type IV -- Delayed HypersensitivityType IV -- Delayed Hypersensitivity Type I --Immediate HypersensitivityType I --Immediate Hypersensitivity

Irritant Contact DermatitisIrritant Contact Dermatitis

Most frequent reaction to latex productsMost frequent reaction to latex products Sxs/signs: scaling, drying, cracking of skinSxs/signs: scaling, drying, cracking of skin Results from direct action of latex and chemicalsResults from direct action of latex and chemicals Not a true allergy - no immunologic mechanismNot a true allergy - no immunologic mechanism

However breakdown in skin integrity enhances However breakdown in skin integrity enhances absorption of latex proteinsabsorption of latex proteins

Accelerates onset of sensitivity/allergyAccelerates onset of sensitivity/allergy

Rx: identify reaction, use alternative productRx: identify reaction, use alternative product

Type IV -- Delayed HypersensitivityType IV -- Delayed Hypersensitivity Synonyms: T-cell mediated contact dermatitis, Synonyms: T-cell mediated contact dermatitis,

allergic contact dermatitisallergic contact dermatitis Most common Most common immuneimmune response to gloves response to gloves Sxs/signs: mild to severe dermatitis (itching, Sxs/signs: mild to severe dermatitis (itching,

blistering, crusting); appears 6-72 hrs after contact blistering, crusting); appears 6-72 hrs after contact Cause: processing chemicals in gloves;Cause: processing chemicals in gloves;

mediated by T lymphocytes (not antibodies)mediated by T lymphocytes (not antibodies) Rx: Identify chemical and use alternative productRx: Identify chemical and use alternative product Patients may progress to Type I allergy Patients may progress to Type I allergy

Type I -- Immediate HypersensitivityType I -- Immediate Hypersensitivity Synonyms: IgE mediated anaphylactic reactionSynonyms: IgE mediated anaphylactic reaction Cause: proteins in latex Cause: proteins in latex

Antigen induces production of IgE; re-exposure to antigen Antigen induces production of IgE; re-exposure to antigen triggers cascade: release of histamine, arachidonic acid, triggers cascade: release of histamine, arachidonic acid, leukotrienes, prostaglandinsleukotrienes, prostaglandins

Onset within minutesOnset within minutes Varied response: local hives to anaphylactic shockVaried response: local hives to anaphylactic shock Rx: Antihistamines, steroids, anaphylaxis protocolRx: Antihistamines, steroids, anaphylaxis protocol Prevention: avoid latex and areas where powdered Prevention: avoid latex and areas where powdered

gloves usedgloves used

Type I MediatorsType I Mediators

Histamine and tryptase release common to type I and IVHistamine and tryptase release common to type I and IV Prostaglandins, leukotrienes, eosinophilic chemotactic Prostaglandins, leukotrienes, eosinophilic chemotactic

factor, platelet activating factorfactor, platelet activating factor potent bronchoconstrictors, vasodilatorspotent bronchoconstrictors, vasodilators

Cytokines released minutes later also cause inflammatory Cytokines released minutes later also cause inflammatory effectseffects

Cardiovascular Histamine ReceptorsCardiovascular Histamine Receptors

HeartHeart H1H1 coronary vasoconstrictioncoronary vasoconstriction

H2H2 coronary vasodilation, coronary vasodilation, tachycardia, inotropytachycardia, inotropy

ArteriesArteries H1H1 vasoconstrictionvasoconstriction

H1,H2H1,H2 vasodilation, hypotension vasodilation, hypotension

VeinsVeins H1H1 increased permeability, increased permeability, edemaedema

H1, H2H1, H2 vasodilation, poolingvasodilation, pooling

Pulmonary Histamine ReceptorsPulmonary Histamine Receptors

BronchiolesBronchioles H1H1 BronchoconstrictionBronchoconstriction

H2H2 Mucous secretionMucous secretion

VasculatureVasculature H1H1 Increased permeabilityIncreased permeability

Gastrointestinal Histamine ReceptorsGastrointestinal Histamine Receptors

Smooth muscleSmooth muscle H2H2 Constriction, crampingConstriction, cramping

MucosaMucosa H2H2 Acid secretionAcid secretion

Cutaneous Histamine ReceptorsCutaneous Histamine Receptors

H1, H2H1, H2 Vasodilation, increased permeabilityVasodilation, increased permeability

Pruritis, urticaria, angioedemaPruritis, urticaria, angioedema

Risk Groups for Latex AllergyRisk Groups for Latex Allergy

Patients with history of multiple surgeries Patients with history of multiple surgeries Meningomyelocele or severe urologic anomaliesMeningomyelocele or severe urologic anomalies

Health care workersHealth care workers Other occupational exposure Other occupational exposure

Rubber product workers, hair dressers, house cleanersRubber product workers, hair dressers, house cleaners

Individuals with atopyIndividuals with atopy Hay fever, rhinitis, asthma, or eczemaHay fever, rhinitis, asthma, or eczema

Patients with specific food allergiesPatients with specific food allergies Banana, kiwi, avocado, chestnut, etc.Banana, kiwi, avocado, chestnut, etc. Similar proteinsSimilar proteins

Myelodysplastic PatientsMyelodysplastic Patients

Prevalence of latex allergy is 18-64%Prevalence of latex allergy is 18-64% Type I reactions more commonType I reactions more common Predisposing factorsPredisposing factors

multiple surgeries multiple surgeries daily catheterizations / stoma caredaily catheterizations / stoma care presence of atopy is synergistic factorpresence of atopy is synergistic factor

Other children at high riskOther children at high risk multiple surgeries starting in neonatal periodmultiple surgeries starting in neonatal period those with spinal cord injuriesthose with spinal cord injuries

Health Care WorkersHealth Care Workers

Typically display a type IV reactionTypically display a type IV reaction Can include conjunctivitis, rhinitis, dermatitisCan include conjunctivitis, rhinitis, dermatitis

1998 study: prevalence of immediate sensitivity in 1998 study: prevalence of immediate sensitivity in anesthesiologists & CRNAs 12-16%anesthesiologists & CRNAs 12-16% Over 80% of those sensitized had no sxs yetOver 80% of those sensitized had no sxs yet Risk factors: hx atopy, skin sxs with latex gloves, Risk factors: hx atopy, skin sxs with latex gloves,

tropical fruit allergiestropical fruit allergies

Progression from type IV to type I unpredictableProgression from type IV to type I unpredictable

Diagnosis of Latex AllergyDiagnosis of Latex Allergy

*Clinical history (ask the right questions)*Clinical history (ask the right questions) Myelodysplasia / urologic anomaliesMyelodysplasia / urologic anomalies Multiple surgeriesMultiple surgeries Chronic occupational exposureChronic occupational exposure Previous reactions to latex products (type I)Previous reactions to latex products (type I) Certain food allergiesCertain food allergies AtopyAtopy

Refer to allergistRefer to allergist Skin testingSkin testing In vitro testingIn vitro testing

Diagnosis by Skin TestingDiagnosis by Skin Testing

Diagnose Type IV delayed hypersensitivityDiagnose Type IV delayed hypersensitivity Positive patch testPositive patch test Reaction appears anytime from 8 hours to 5 days laterReaction appears anytime from 8 hours to 5 days later

Diagnose Type I allergyDiagnose Type I allergy Skin prick test using antigens from glove productsSkin prick test using antigens from glove products

Gold standardGold standard Positive test: wheal and flare (c/t + and - controls)Positive test: wheal and flare (c/t + and - controls) Sensitivity and specificity around 98%Sensitivity and specificity around 98% May result in severe reactionMay result in severe reaction

Diagnosis by In Vitro TestingDiagnosis by In Vitro Testing No risk to patientNo risk to patient RAST (radioallergosorbent test)RAST (radioallergosorbent test)

Measures amount of IgE Ab to latex in serumMeasures amount of IgE Ab to latex in serum Most labs must send outMost labs must send out Takes 5-10 daysTakes 5-10 days Sensitivity 80-90%Sensitivity 80-90% Specificity 60-90%Specificity 60-90%

EAST (Enzymeallergosorbent Test)EAST (Enzymeallergosorbent Test) Does not utilize radioactivityDoes not utilize radioactivity Sensitivity & specificity of 80-85%Sensitivity & specificity of 80-85%

Prevention of Reactions in ORPrevention of Reactions in OR Identify latex sensitive patientsIdentify latex sensitive patients

Medic-alert braceletMedic-alert bracelet Signs on hospital bed, room, and ORSigns on hospital bed, room, and OR

Schedule as 1st start in ORSchedule as 1st start in OR Use latex free environmentUse latex free environment

For pts with hx of type I or type IV reactionsFor pts with hx of type I or type IV reactions Meningomyelocele or urologic anomaliesMeningomyelocele or urologic anomalies

Post list of latex-containing devices & alternativesPost list of latex-containing devices & alternatives FDA mandated labeling started February 1998FDA mandated labeling started February 1998

Pretreat pts with positive hxPretreat pts with positive hx

Non-latex EquipmentNon-latex Equipment

Disposable endotracheal tubesDisposable endotracheal tubes Esophageal stethoscopesEsophageal stethoscopes Oral airwaysOral airways Suction catheters, Nasogastric tubesSuction catheters, Nasogastric tubes ECG padsECG pads Temp probesTemp probes LMAsLMAs

Potential Latex-Derived ProductsPotential Latex-Derived Products

GlovesGloves Tape, dressingsTape, dressings

Catheters, drainsCatheters, drains Tourniquets, elastic bandagesTourniquets, elastic bandages

IV ports, central linesIV ports, central linesMedication vialsMedication vials

SyringesSyringes Nasal airways, masks, strapsNasal airways, masks, straps

Breathing bag, bellowsBreathing bag, bellows BP cuff tubingBP cuff tubing

Stethoscope tubingStethoscope tubing Oximeter probeOximeter probe

*Check labels!*Check labels!

Avoidance of Latex includes:Avoidance of Latex includes:

Avoiding skin contact: BP/stethoscope tubing, IV Avoiding skin contact: BP/stethoscope tubing, IV tourniquets tourniquets

Remove stoppers from multi-dose med vialsRemove stoppers from multi-dose med vials Tape latex injection ports on IV tubing, central Tape latex injection ports on IV tubing, central

lines, IV fluid bags lines, IV fluid bags Use latex free syringes (remember the epidural & Use latex free syringes (remember the epidural &

spinal trays)spinal trays)

PretreatmentPretreatment

Prophylaxis of anaphylaxis is controversialProphylaxis of anaphylaxis is controversial Efficacy unknownEfficacy unknown Anaphylaxis has occurred in pretreated ptsAnaphylaxis has occurred in pretreated pts May mask early signsMay mask early signs

Pretreat pts with hx of Type I sxsPretreat pts with hx of Type I sxs Start prophylaxis preop and continue x 24 hrStart prophylaxis preop and continue x 24 hr

Diphenhydramine 1 mg/kg q 6 hr IV or PODiphenhydramine 1 mg/kg q 6 hr IV or PO Methylprednisolone 1 mg/kg q 6 hr IV or POMethylprednisolone 1 mg/kg q 6 hr IV or PO Cimetidine 5 mg/kg q 6 hr IV or PO (up to 300 mg)Cimetidine 5 mg/kg q 6 hr IV or PO (up to 300 mg)

Recognition of AnaphylaxisRecognition of Anaphylaxis

CutaneousCutaneous UrticariaUrticaria FlushingFlushing DiaphoresisDiaphoresis Perioral / periorbital edemaPerioral / periorbital edema Conjunctival hyperemiaConjunctival hyperemia LacrimationLacrimation RhinitisRhinitis

Recognition of AnaphylaxisRecognition of Anaphylaxis RespiratoryRespiratory

Laryngeal edemaLaryngeal edema BronchospasmBronchospasm Pulmonary edemaPulmonary edema

CardiovascularCardiovascular Tachycardia, dysrhythmiasTachycardia, dysrhythmias HypotensionHypotension CV collapseCV collapse

Management of AnaphylaxisManagement of Anaphylaxis Remove antigenRemove antigen 100% oxygen100% oxygen IV volume expansion (up to 50 ml/kg)IV volume expansion (up to 50 ml/kg) D/C or adjust anesthesiaD/C or adjust anesthesia EpinephrineEpinephrine

Bronchospasm or hypotension: 0.1-5 ug/kg IVBronchospasm or hypotension: 0.1-5 ug/kg IV Cardiac arrest: peds: 10 ug/kg, adults: 0.5-2 mg IVCardiac arrest: peds: 10 ug/kg, adults: 0.5-2 mg IV

Antihistamine: diphenhydramine 1 mg/kg H2 Antihistamine: diphenhydramine 1 mg/kg H2 blocker optional blocker optional

Steroids: hydrocortisone 1-4 mg/kgSteroids: hydrocortisone 1-4 mg/kg

Again…...Again…...

Identify those pts at high riskIdentify those pts at high risk For myelodysplastic & GU anomaly pts, as well as For myelodysplastic & GU anomaly pts, as well as

those with hx of type I sxs:those with hx of type I sxs: Label pt, chart, pt room, OR as latex freeLabel pt, chart, pt room, OR as latex free Use latex precautionsUse latex precautions

Prophylax pts with hx of type I reactionProphylax pts with hx of type I reaction Be prepared to treat anaphylaxisBe prepared to treat anaphylaxis

ConclusionConclusion

Most important step is avoidance of exposure in Most important step is avoidance of exposure in susceptible patientssusceptible patients

With universal precautions, the problem will likely With universal precautions, the problem will likely worsenworsen

Hospitals should strive for low allergen environmentsHospitals should strive for low allergen environments Powderless gloves with low extractable protein contentPowderless gloves with low extractable protein content

Protect yourselfProtect yourself Treat dermatitisTreat dermatitis Cover hand wounds with tegadermCover hand wounds with tegaderm