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Latex Allergy A GUIDELINE FOR PERIOPERATIVE NURSES Mary Ann Young, RN; Margie Meyers, RN; Lee Desotell McCulloch, FW;Lesley J. Brown, RN Thirty minutes into a surgical procedure, the patient exhibited urticaria, hypotension, tachycardia, and increased airway pressure related to bronchospasm-an intraoperative anaphylactic reaction of unknown cause was in progress once again. The anesthesiologist administered epinephrine, steroids, and isoproterenol and was able to stabilize the patient somewhat; but within minutes, the patient’s vital signs again indicated anaphylaxis. Doses of the appropriate medications were repeated, and the surgeon closed the operative site. The surgical team focused on stabilizing the patient, and the patient’s surgery was postponed indefinitely.
B
efore 1988, these life-threatening reactions caused concern among anesthesiologists, surgeons, and nurses because
Mary Ann Young, RN, BSN, is a level II staff nurse in the operating room at Children’s Hospital, Boston. She earned her bachelor of science degree in nursing at Salve Regina University, Newport, RI. Margie Meyers, RN, is a level 11 staff nurse in the operating room at Children’s Hospital, Boston. She earned her diploma in nursing at Children’s Hospital School of Nursing, Boston. Lee Desotell McCulloch, RN, is a level I I staff nurse i n the operating room at Children’s Hospital, Boston. She earned her associate degree in nursing at Howard 488
the reason for the anaphylaxis remained a mystery. Patients were tested for allergies to the medications and anesthetic agents that had been used, but results were not definitive. In fact, some patients were allergic to several substances. When these medications were avoided in future surgeries, however, anaphylaxis still occurred. In 1988, members of the Anesthesiology Department at Children’s Hospital, Boston, linked a number of anaphylactic reactions to the use of latex products during surgery. Through laboratory research and a review of the literature describing similar cases throughout the world, Robert S. Holnan, MD, and Navil Sethna, MD, learned that intraoperative exposure to latex causes an anaphylactic reaction in certain patients.’ This reaction is known as an immunoglobulin E
Community College, Columbia, Md.
Lesley J. Brown, UN, is a level 11 staff nurse in the operating room at Children’s Hospital, Boston. She earned her diploma in nursing at Children’s Hospital School of Nursing, Boston. The authors wish to thank Judith S . Mitiguy, RN, MS; Carole Bardsdale, RN, BS, CNOR; Stella Harrington, RN, BSN, CNOU; Jackie Hamblet, RN, M S , CNOR; Gayle Gildea, RN, BSN; Anne Jenks Micheli, U N ,BSN, M S ; Navil Sethna, MD; and Robert Holzman, MD for their assistance with this manuscript.
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Nurses must understand the latex IgE-mediated response and follow strict guidelines when caring for allergic patients. (IgE) mediated allergic response to latex. No epidemiological studies to date have reported on the incidence of latex reactions. To ensure safe perioperative practice, nurses must understand the latex IgE-mediated response and follow strict guidelines when caring for allergic patients. Educating all health care workers, the community, patients, and their families about this newly reported allergy is important to prevent life-threatening anaphylaxis associated with latex exposure.
Allergic Response to Latex -atural latex is the milky sap obtained from the Havea brasifiensis plant, commonly known as the rubber tree. In the manufacturing process, the sap is filtered to remove particulate debris and then preserved by adding either ammonia or sodium sulfite.? The antigen that triggers an allergic response is believed to be a water-soluble protein that occurs naturally in the latex. Liquid latex is useful for products such as surgical gloves. condoms, balloons, elastic thread, and rubber adhesives. Frequent use of latex by patients or health care workers can result in sensitization that may place some people at increased risk for an allergic reaction. Allergic reactions can be classified into two types: local and systemic (ie, anaphylactic ). Systemic reactions are immunologically mediated and occur when patients are exposed to an allergen to which they have been sensitized (Fig 1). This re-exposure to a specific allergen stimulates production of IgE. During a reaction. IgE binds to high-affinity receptors on basophils and mast cells, and the combination of antigen with IgE causes degranulation o f these cells. The secretory products of basophils and mast cells are histamine, heparin, serotonin, and arachidonic acid, which is converted
by other cells into prostaglandins and leukotrienes. These products are responsible for the symptoms of allergic reactions.3 Allergic manifestations vary with the route of exposure. Urticaria develops when latex comes in contact with the skin. Airborne latex particles may cause allergic rhinitis, conjunctivitis, wheezing, and bronchospasm. Systemic reactions (eg, hypotension, tachycardia, bronchospasm) may occur when latex gloves come in contact with the patient’s peritoneal lining, mucosa, or serosal surfaces. ln the United States, allergic reactions from a variety of substances occur in approximately 200,000 patients each year during hospitalization. Approximately one million patients experience milder reactions but do not require hospital admi~sion.~ The most common allergenic agents in health care settings are antibiotics and radiographic contrast material^.^ An individual may have a sensitivity to latex that manifests itself as contact urticaria, but when the latex comes in contact with mucous membranes or with organs in the peritoneal cavity during surgery or when airborne antigens are inhaled, that same individual may suffer a severe anaphylactic reaction. For several years, there have been multiple medical reports of latex sensitivity to gloves resulting in contact dermatitis. Recently, however, reports of severe reactions to latex, including anaphylaxis and even death, have increased.6 Latex hypersensitivity seems to be a fairly recent occurrence. In 1979, a researcher reported contact urticaria to rubber; and in 1984, it was confirmed by skin prick testing as an IgEmediated anaphylaxis.g From 1981 to 1983, serological studies were performed in three surgical nurses with contact urticaria to latex gloves. Their responses also were found to be IgE-mediated.’ Anaphylaxis, caused by mucosa1 exposure during rectal manometry, was 489
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cross-linking IgE antibody by allergen vasomotor col-
t early release of histamine and serotonin I.)
late release of leukotrienes and prostagkzndins
smooth muscle contraction (bronchoconstriction) increased blood jlow (vasodikztion)
increased mucus secretion (rhinitis. bronchid obstruction) mast cell degranulation
Fig I . Reaction sequence of an allergic response. (Reprintedfrom Immunology, Immunopathology and Immunity, Stewart Sell,fourth ed, with permission from Elsevier Science Publishing Co, Inc, New York City,1987)
reported in an 18-year-old woman with a history of contact urticaria to latex following the insertion and inflation of a balloon fashioned from a latex glove.'O One researcher reported five patients with intraoperative anaphylactic responses. Three were hypersensitive to fruit, three had worked in a hospital setting, and all had contact urticaria to latex. When skin-prick tested, five had a positive reaction to latex." Contact urticaria and anaphylaxis also were reported in one patient with oral and vaginal exposure to condoms and one with rectal exposure to a latex glove.12 In October 1990, the company that manufactured latex balloon enema tips voluntarily recalled all of its latex-containing products.'3 A correlation between the latex balloons and anaphylactic responses had become evident when 148 incidents related to barium enema examinations were reported during a 22-month period. Nine fatalities occurred, and three of these patients succumbed to anaphylaxis before the 490
instillation of barium.14 At Children's Hospital, we have seen an increased incidence of anaphylactic reactions under anesthesia when patients are exposed to latex gloves during surgery. Following exposure, anaphylaxis is characterized by hypotension, tachycardia, increased airway pressures with bronchospasm, and generalized erythema. In almost all cases, it has been necessary to end the procedure because of the patient's unstable condition.
High Risk Populations
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ertain groups appear to be at higher risk for latex sensitivity. One group that routinely uses latex gloves is health care professionals, including nurses, physicians, and dentists. The US Food and Drug Administration (FDA) reports that 6% to 7% of surgical personnel are sensitive to latex.I5 Other groups identified at high risk are those with spinal cord
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injuries, myelodysplasia, and chronic illness. The frequent use of latex for catheterization and multiple surgical procedures is thought to be the cause for the increased incidence of latex hypersensitivity. The New England Myelodysplasia Association has reported an 18% to 28% incidence of sensitivity to latex from a survey of five myelodysplasia clinics.I6One prospective study suggests that 41 % of spina bifida patients have the IgE antibody specific for the rubber proteins." In a study conducted from January 1989 to January 1991 at another facility, 11 cases were reported; these patients developed an anaphylactic reaction (ie, hypotension and at least one other symptom including rash, angioedema, stridor, wheezing, or bronchospasm). Ten patients had myelodysplasia, and one had a congenital abnormality of the genitourinary tract. l8 At Children's Hospital, we care for many patients with myelodysplasia. Like staff members in other medical facilities, we have noted an increased sensitivity to latex in these patients.Ig Our hospital researchers have observed 29 cases of suspected intraoperative anaphylaxis related to latex exposure. Of this number, 28 patients had myelodysplasia, and one had Mayer-Rokitansky-Kuster Syndrome (ie, agenesis of the vagina) and was selfcatheterized for three years before a vaginal reconstruction. Several of these patients had a positive history of localized cutaneous reactions or systemic hypersensitivity to latex objects (eg, rubber balls, balloons, urethral catheters, latex gloves).20
Preoperative Assessment
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he most effective way to avoid an intraoperative hypersensitivity response to latex is through preventive measures. A complete assessment before patients enter the operating room is crucial to identify those who are sensitive to latex. The first step in this assessment is to identify the high-risk patients (eg, patients with
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myelodysplasia, spinal cord injury, chronic illness. a history of multiple reconstructive surgical procedures, a history of occupational contact with latex products). All of these patients have had an opportunity to become latex-sensitive from multiple exposures to products containing latex proteins. Several reports indicate that patients with a history of atopic dermatitis, eczema, and fruit allergies also may be at increased risk.21In addition, patients with a history of intraoperative anaphylactic reaction for unknown reasons may be suspect for latex allergy and should be evaluated carefully by the health care team. Another useful preoperative tool is allergy testing with latex extract. When allergy testing can be done, it may provide patient reassurance and clear documentation. The most common tests for allergies are the skin prick test (SPT), the intrademal test (IDT), and the radio-allergosorbent test (RAST). Skin prick test. The SPT involves taking a drop of the latex extract (ie, antigen) diluted in saline, placing it on the skin, and gently scratching the skin with a needle. The whealand-flare response is measured after 10 minutes and then measured against a control group reaction.'* Intradermal test. The IDT is similar to the SPT, except that the latex antigen is more diluted with saline. A minute quantity of the diluted allergen is injected intradermally into the patient's lower arm.After 10 minutes, localized erythema is measured and compared with the control group reaction. In the event of a systemic reaction, a non-latex tourniquet can be applied proximal to the injection site. lntradermal testing is approximately 1,000 times more sensitive than SPT and is performed in patients with suspected IgE-mediated diseases who have demonstrated a 0 to 1+ response to SPT. 21 Radio-allergosorbent test. The RAST measures latex-specific IgE antibodies and the potency of allergy extracts. It is a two-phase (ie. solid, liquid) test system using an insolubilized allergen that first is incubated in the patient's serum to react with allergen-specific 491
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Table 1
The ChiMren’s Hospital PeriOperQtve Nursing Policy latex. A preoperative nursing assessment should look for a history of an allergy to latex.
Safe nursing care of the patient will be implemented perioperatively to minimize the risk of an allergic/anaphylacticreaction to
Purpose To provide guidelinesto ensure consistent, safe pexioperative nursing care of the latex allergic patient. Adhering to these aids in
the successful completionof the patient’s surgery with no occurrenceof an allergic/ anaphylacticreaction to latex.
General information
3. Topical sensitivityto latex may indicate the patient is at increasedrisk of intraoperative systemicanaphylacticreaction to latex.
Implementation
Rationale
1. The presence of latex allergy will be docu-
mented on the p p e r a t i v e assessment.
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in cardiorespiratoryarrest within minutes.
1. Exposure to latex products may cause a hypersensitivity response either locally at the site of the contact (ie, contact dermatitis; cell-mediated reaction), or systemic reaction (ie, anaphylaxis; IgEmediated hypersensitivity). The later reaction may manifest as breathing difficulty (ie, bronchospasm), cutaneous erythemia and urticaria, anxiety, palpitations, chest tightness and pain, hypotension, facial and peripheral edema, and shock. This reaction can occur even with trivial exposure to latex and may result
2. Patients known to have an increased exposure to latex (eg, patients with myelodysplasia, or urological deformitiesor those who have had multiple surgicalp m dures), are predisposed to having a hypersensitivity response to latex.
1. These assessments should include any known allergies or sensitivities.
2. Patient will wear a latex allergy-alert ID bracelet; foot of bed and operating room doors will have visible allergy warning signs; and the allergy will be clearly documented in the patient’s chart.
2. Identification of an allergy is crucial in ensuring safe patient care.
3. Non-latex gloves must be worn in place of latex gloves when caring for the patient.
3. Contact with latex gloves can increase the risk of an IgE-mediated allergic response in a patient with a latex allergy.
4. Patient contact with any latex products must be avoided during penoperative care.
4. Contact with any latex product can increase the risk of an Ig-E mediated allergic response in a patient with a latex allergy-
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Care and Management of the Patient with U e x Allergy Implementation
Rationale
5. Rubber medication stoppers and IV rubber
5. Three-way stopcocks for administration of medication prevent systemic introduction of latex thus minimizing the risk of an IgEmediated response.
injection ports will not be used.
6. The master list of commonly used latex containing items will be available to those providing perioperative care to the patient.
6. Knowledge of latex items minimizes the risks of patient contact with products containing latex.
7. Substitutes for latex will be available.
7. Non-latex substitutes lower risk of patient reaction and minimize anesthesia time.
8. Communication will occur among staff
8. Communication among staff members is a way to maintain consistent, safe, quality patient care.
members regarding the patient's allergic response to latex.
9. The post anesthesia care unit nurse will be notified by phone of the latex allergy before the patient's arrival.
9. Preparations can be made in advance to provide non-latex items for a patient with latex allergy.
Evaluation mized, and statistics will be gathered by the Department of Anesthesia.
The incidence of allergic/anaphylactic reactions in patients with IgE-mediated allergic response to latex will be mini-
Planning Objectives I. All OR nursing personnel caring for the latex-allergic patient perioperatively will adhere to the guidelines specific to the care of these patients.
2. Perioperative nurses caring for the latex-
allergic patient will ensure that the patient does not come in contact with any latex products while in their care.
3. Latex products will not be used. Non-latex products will be substituted when needed.
Resources 1. A master list of commonly used latex items will be available to personnel responsible for the care of the latex-allergicpatient.
2. Non-latex items and substitutes for most latex items can be found on the master list.
3. An allergy-alert bracelet will be placed on
the patient, and the patient's chart will be documented clearly with the latex allergy. 4. A perioperative nursing check-off list for the care of the latex-allergic patient can be used.
5. Contact Drs Holvnan or Sethna about patient responses to latex. U 493
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Table 2
Common Items Containing Latex, Latex items Aces (brown tensor) Catheters Coude Foley Malecot Blue paper towel drapes with adhesive strips, instrument mats Bite blocks Blood pressure cuff tubing Self adheringtape (ie, elasticfabric, adhesive) Cyst0 tubing with rubber tip
Cloth towels
Rolled cotton batting on areas of contact with patient’s skin Plastic tape, paper tape,one-inch rolled cotton gauze Cut off rubber tip and either attach remaining plastic tubing to cyst0 stopcock or, in arthroscopies, attach irrigation port to scope sheath Aces (white cotton) Non-latex glove finger
Esmarch bandages Finger cots Fogarty catheters Irrigation 3L NaCL with rubber stopper IV bag and burrette rubber stoppers IV tubing rubber stoppers
Do not puncture with needle Three-way stopcocks on IV tubing
Molded surgicalface masks with elastic band
Other types of surgical masks
antibodies and then incubated with radiolabeled heterologous antihuman IgE to detect the allergen-specific antibodies of the IgE isotype.24At the present time, the RAST is only 53% sensitive, but is by far the most specific test for IgE antibody.= The advantages of IDT and SPT are their availability, low cost, quick results, and sensitivity. One disadvantage, however, is the potential for a full systemic reaction with both tests; therefore, it is advisable to have an anesthesiologist standing by and emergency drugs available when performing these two tests. Also, both tests may be unacceptable to the pediatric population who may be needle phobic; to patients receiving specific medications that may interfere with testing 4%
Non-latex alternatives Aces (white cotton) Silastic Foley catheters
(eg, anti-inhibitory drugs); and to patients with severe dermatitisF6When the SPT and IDT are contraindicated, the RAST may be useful, although it is not as sensitive or readily available and is much more costly. Routine testing of all patients is expensive and, unless the patient is in a high-risk group or a latex allergy is suspected, unnecessary. Careful screening of all patients by health care workers to identify patients at risk and further test those patients is more cost effective.27At present, we do not use prophylactic medication for latex-sensitive patients. We provide these patients with a latex-free environment and they do quite well. Prophylactic medications that could be administered preoperatively include
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Alternative Non-latex Products Latex items Medication vial rubber stoppers Mouth gags Nephrostomy catheter Penrose drains
Chest tube drainage system tubing Red rubber catheters Rubber bands Rubber dams Rubber shods or suture bolsters Specimen trap Syringes, with rubber plungers
Tourniquet cuff tubing Urine drainage system port Rubber nipples ~
~
Non-latex glove for IV tourniquet, JacksonPratt drains or Hemovacs for drains; vessel loops for vessels, tendon retraction. Wrap tubing with rolled cotton batting, rolled cotton gauze, tape, etc. Feeding tubes, nasogastric tubes, silastic Foley catheter, Stamey suprapubic catheters Vessel loops, small pieces of non-latex glove Sterile plastic bags (eg, bowel bags) Cut pieces of silastic catheter Prevent contact with patient, or use black top tubes No premixed medications (should be freshly drawn up): check with anesthesiologist Rolled cotton batting on areas of skin contact Prevent any patient contact; cover with tape Polyvinyl chloride or silicone nipples
~
prednisone, diphenhydramine, and ranitidine, with or without ephedrine (an alpha-adrenergic agent); however, there are no studies that document the effectiveness of this approach.**
Perioperative Patient Care
G
Non-latex alternatives Remove rubber stoppers to withdraw medications Replace rubber with silastic
ood communication between health care workers and clear, consistent documentation is crucial to patient safety. Each individual responsible for the latex-sensitive patient should make this a priority to minimize the risks of causing a hypersensitive reaction. Intraoperatively, the patient relies on the health care team to be aware, responsible, and knowledgeable about the possible effects of
contact with latex products. At our hospital, a policy and procedure for perioperative care and management of latexsensitive patients has been developed recently and put into practice by perioperative nurses (Table 1). A list of items containing latex and those that are latex-free is available to members of the health care team (Table 2 ) . Because many companies do not list the components found in patient care products on their packaging, we contacted the manufacturers for this information. We have researched suggested alternatives to latex and have formulated a list of commonly used items that are latex-free. (See “Latex-free Items Used at the Children’s Hospital.”) This list is not all inclu497
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sive. Manufacturers should be consulted about their specific products to determine if the products contain latex and whether a latex-free alternative is available. We have based our perioperative nur\ing checklist on this information (Table 3). It serves as a patient safety inventory and assists in preventing latex exposure. We also place strategically located signs on doors, beds, and anesthesia machines to clearly identify the patient u ith a latex allergy.
Increasing Awai-eness
P
ublic awareness and education is a vital component of safe care when latex allergy exists or is suspected. Patients and families must be advised to notify all health care, school, and day care professionals about any latex sensitivity. Our physicians r e c u m mend that anyone suspected of this sensitivity should consider immunology testing and wear an allergy-alert bracelet identifying the latex allergy. Patients also should be aware that unintentional exposure to rubber may trigger a life-threatening systemic reaction. Some common settings i n which latex products may be present include birthday parties, fairs, circuses (eg. halloons, play jewelry), school buses, rubber raincoats, boots, and condoms, diaphragms. Respiratory exposure alone (eg, blowing up ;L balloon) may cause an allergic response in a child with latex allergy.” Physicians may prescribe auto-injectable epinephrine for patients to administer to themselves in the event of a reaction. Patients and families should receive appropriate literature explaining all signs, symptoms, and 1-isk areas for latex allergy. After a patient has been labeled “latex allergic,” his or her life may be affected in many ways. The patient must be aware of his or her environment and take steps to see that it is latex free. He or she should wear an allergyidentification bracelet and carry epinephrine for treatment of accidental exposure reactions. A letter
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Latex-free Items Used at The Children’s Hospital” Ace bandages, white cotton (Conco ECotton) Aseptos (Medline, Superior) Back table drape (Boundry) C-arm drapes (Xomed) Catheters; ureteral, suction, silastic Foleys (Argyle, Bard, Surgicath, Mentor) Cautery cords (Olsen, Valley Lab) Cautery pads (3M) Cell Saver tubing (Haemonetic) DermaciIDermaclear tape (Johnson & Johnson) Ear tubes (Richard, Xomed) Extremity sheet (Convertor) Filiforms and followers (Bard) Gel pads (Allen Medical) Glassman “fish’ retainers (Adept-Med) Jackson-Pratt drains (Heyer Schulte) Mayo covers (Boundry) Microfoam/Micropore tape (3M) Microscope drapes (Xomed) Oximeter probes (Nelcor) Raytex sponges (Johnson & Johnson) Rest-on foam with adhesive (3M) Silk tape (Johnson & Johnson) Split sheet, adhesive (Johnson & Johnson) Steri drapes, regular and Ioban (3M) Steri strips (3M) Suture booties (Scanlan International) Tegaderm (3M) Testicular implants (Dow Coming) Ureteral catheter (Surgicath) Vessiloops (Devon Industries) Vidrape spray (Becton Dickinson) Warming blanket (Seebrook) Xeroform (Sherwood Medical) $‘4riypatient care item may contain late.\-. This iitt is not all inclusilv and represents items idenrlfied by Children’s Hospital as being latexpee. .%fun?companies produce non-latex items. #Munujucturersshould be contacted to determine if’specific. products contain latex and what nonIutm alternutives the manufacturer recommends.
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Table 3
Perioperative Nursing Care Plan for the Patient with Latex Allergy Preoperative Identify if patient has a latex allergy Ensure that patient has a visible latex-allergy bracelet on. Ensure that chart clearly documents that a latex allergy is present. Wear latex-free gloves for any patient contact. Remove unsterile boxes of latex gloves from the room. Ensure that all members of the health care team are aware of the patient’s latex allergy. Refer to the list of latex and latexfree items and have alternatives available. Intraoperative Ensure that clear, visible signs indicating that there is a latex-allergy patient in the room are on OR doors. Have a quantity of latex-free gloves are available in every size for both
from a physician explaining latex allergy, reaction signs and symptoms, and appropriate treatment should be circulated to all facilities that care for latex-sensitive children (eg, school, scout troop, day care). The patient or family should carry nonlatex gloves in a convenient place (eg, the car) in the event a situation which requires the use of gloves occurs. Many offices and health care settings do not carry non-latex gloves and may not be aware of this problem. Children and adults will have restrictions of activity placed upon them and will be subj e c t to certain added financial burdens. Insurance companies and hospitals may require patients to share the increased costs of care related to this latex phenomenon. Currently, many non-latex products are more
sterile and nonsterile use. Do not use Penrose drains to start IV lines or as drains in a wound. Use a silastic Foley if a Foley is ordered for a procedure. Do not puncture rubber medication stoppers with a needle. Remove rubber stoppers to draw up medications. Wrap rolled cotton batting around the patient’s arm and/or leg to prevent blood pressure cuff tubing and/or tourniquet cuff tubing from coming in contact with the patient’s skin. Assess the sterile fieldback table with the scrub nurse to ensure a latex-free setup. Ensure there is a latex allergy sign affixed to the foot of the patient’s bed. Communicate with the post anesthesia care unit nurse regarding the patient’s latex allergy before the patient arrives in the unit.
expensive than latex products; for example, a pair of sterile, non-latex gloves is approximately three times more expensive than a pair of sterile, latex gloves.
Questions
M
any questions regarding latex allergy remain unanswered; however, it is imperative that all health care professionals become educated about the facts regarding IgE-mediated responses to latex. We have found that a hospital-wide task force is needed to communicate findings from recent literature and develop a consistent, safe standard of care for patients who are allergic to latex. In our hospital, the task force consists of representatives from a11
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departments in which these high-risk patients receive care. It includes nurses from the inpatient units (eg, orthopedics, urology. neurology), perioperative nurses, ambulatory care nurses, allergy clinic staff, surgeons. and anesthesiologists. Although many studies are being done to improve allergy testing, the most valuable tool in caring f o r allergic patients is the a s s u r a n c e of a l a t e x - f r e e e n v i r o n m e n t . Obtaining careful, complete patient histories. identifying high-risk groups, teaching families and involved health care professional\. and communication and collaboration of the health care team are key elements in succeshful and safe patient care. The increased occurrence of hypersensitivity to latex is not fully understood, but there are many theories. Universal precautions and the increased use of gloves has been suggeated as contributing to the exposure of more people to latex and possible sensitization. The concern about bloodborne contamination has increased the use of gloves in most health care settings. For example, in our operating room, spinal fusion procedures routinely use 40 pairs of gloves per case. Before universal precautions were implemented, that number was approximately 10 pairs of gloves pelcase. Glove manufacturing industries now are faced with increased demands for their products. This raises questions about whether changes in production methods have occurred that affect the quality of gloves being produced. The increased occurrence of latex sensitivity is being investigated by the FDA and other researchers. Researchers also are studying the effects of the manufacturing process and shortened shelf-life of gloves to determine whether latex collection methods. pre s e r v at i on, rn a n u f a c t ur i n g methods . o r changes in latex protein account for these increases in sensitivity.20 Because the potential for a life-threatening situation exists, all p a t i e n t s in h i g h - r i s k g r o u p s s h o u l d be assessed carefully, and when latex allergy i \ suspected, the F D A recommends that all
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latex products be a ~ o i d e d . ~ ’
Conclusion
L
atex allergy has been identified, and its life-threatening risks have been documented. Perioperative nurses, therefore, have an obligation to educate patients, familie\, and peers on this subject. Knowledge, communication, and prevention are key elements ensuring safe health care for this new high-risk population of patients. Our policy of creating a latex-free environment for all patients who are allergic or sensitive to latex and those who are potentially at risk has been successful. This measure is worth the effort and expense, considering the possible danger to the patient. Of the 29 patients at our hospital with suspected latex-related anaphylaxis described earlier, 11 have returned for surgical procedures, and they have been treated with latex-free precautions penoperatively. N o prophylactic medications were administered, and no anaphylaxis occurred. Latex-free precautions were implemented by the health care team, and all patients experienced an uneventful and successful hospital stays. Notes I . R S Holzman, N F Sethna, S Sockin, “Hypotension. flushing and bronchospasm in myelodysplasia
patients,” abstract presented at the American Society of Anesthesiologists annual meeting. 2. D Spaner et al, “Hypersensitivity to natural latex.“ Journal of Allergy and Clinical Immunology 83 (June 1989) 1136. 3. S Sell, Immunology, Immunopathology and Irrrrnuni/y, fourth ed (New York City: Elsevier, 1987) 89,440. 3 . P P Van Arsdel, Jr, “Diagnosing drug allergy,” Journal of American Medical Association 247 (May 1982) 2576-2581. 5. M M Fisher, D G More, “The epidemiology
and clinical features of anaphylactic reactions in anesthesia,” Anesthesia Intensive Care 9 (August 1981 226-234. 6. D W Gelfand, “Barium enemas, latex balloons, and anaphylactic reactions,” (Commentary) American ./ourno/ of Roentgenobgy 156 (January 1991) 1-2; D Kong. “Link of latex to allergy, deaths spurs US inquiry.” The Boston Globe 27 May 1991, 1,7. 501
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7. A F Nutter, “Contact urticaria to rubber,” British Journal of Dermatology 101 (November 1979) 597-598. 8. K Turjanmaa, T Reunala, R Tuimala, “Severe IgE-mediated allergy to surgical gloves,” abstract, XV Nordic Congress of Allergology, Turku, Finland, Allergy Supplement 2 (June 1984) 35. 9. P J Frosch et al, “Contact urticaria to rubber gloves is IgE-mediated,” Contact Dermatitis 14 (April 1986) 241-245. 10. J M Sondhehner, P S Pearlman, W C Bailey, “Systemic anaphylaxis during rectal manometry with a latex balloon,” American Journal of Gastroenterology 84 (August 1989) 975-977. 11. F Leynadier, C Pecquet, J Dry, “Anaphylaxis to latex during surgery,” Anesthesia 44 (July 1989) 547550. 12. J S Taylor et al, “Contact urticaria and anaphylaxis to latex,” Journal of the American Academy of Dermatology 21 (October 1989) 874-877. 13. E-ZEM Co, Inc, Urgent:Medical Device Recall (Westbury, New York: E-ZEM Co, Inc, Oct 5,1990). 14. Gelfand, “Barium enemas, latex balloons, and anaphylactic reactions,” 1-2. 15. US Food and Drug Administration, Medical Alert Bulletin (Washington, DC: US Food and Drug Administration,March 29, 1991). 16. E Meeropol et al, “Allergic reactions to rubber in patients with myelodysplasia,” New England Journal of Medicine 323 (Oct 11,1990) 1072. 17. J E Slater et al, “Type 1 hypersensitivity to rubber,” Annals of Allergy 65 (November 1990) 412. 18. Centers for Disease Control “Anaphylactic reactions during general anesthesia Among pediatric patients-United States, January 1990-January 1991,” in Morbidity and Mortality Weekly Report 40 (July 5, 1991)437. 19. M Gold, B M Braude, F S Swartz, “Intraoperative anaphylaxis: an association with latex sensitivity,” Journal of Allergy and Clinical Immunology 87 (March 1991) 268, 270; R Slater, “Latex antigens,” Journal of Allergy and Clinical Immunology 85 (January 1991) 268; G G Shapiro, F S Virant, M W Burns, “Intraoperative cardiovascular collapse due to latex allergy,” Journal of Allergy and Clinical Immunology 85 (January 1991) 268,270. 20. Navil Sethna, MD, personal conversation with authors, 5 March 1992. 21. K Tujanmaa, “Incidence of immediate allergy to latex gloves in hospital personnel,” Contact Dermatitis 17 movemkr 1987) 270-275; Leynadier, Pecquet, Dry, ‘‘Anaphylaxista latex during Surgery,’’ 547-550. 22. D P Stites, A I Terr, Basic and Clinical immunology, sixth ed (Norwalk,Conn: Appleton & Lange, 1987) 373. 23. Ibid, 375. 24. ibid, 376; G Gleitch, J Yunginger, “The radioallergosorbent test: A method to measure IgE anti-
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bodies, IgG blocking antibodies, and the potency of allergy extracts,” Bulletin of the New York Academy of Medicine 57 (September 1981) 559-560. 25. K Turjanmaa, T Reunala, L Rasanen, “Comparison of diagnostic methods in latex surgical glove contact urticaria,” Contact Dermatitis 19 (October 1988) 241-247. 26. Stites, Terr, Basic and Clinical Immunology, 373. 27. Turjanmaa, Reunala, Rasanen, “Comparison of diagnostic methods in latex surgical glove contact urticaria,” 246: J Slater, L Mostello, “Routine testing for latex allergy in patients with spina bifida is not recommended,” Anesthesiology 74 (February 1991) 391; J Slater, L Mostello, C Shaer, “Type I hypersensitivity to rubber,” Annals of Allergy 65 (November 1990) 413. 28. K J Kelly, “Complications of latex allergy,” Dialogues in Pediatric Urology 15 (March 1992) 4. 29. Slater, Mostello, Shaer, “Type I hypersensitivity to rubber,” 413. 30. Kelly, “Complicationsof latex allergy,” 4. 31. US Food and Drug Administration, Medical Bulletin, Allergic Reactions (Washington, Dc: US Food and Drug Administration, July 1991). Suggested reading Axelsson, I G; Eriksson M; Wrangsjo, K. “Anaphylaxis and angioedema due to rubber allergy in children.” Acta Pediatrica Scandinavica (March 1988) 314-316. Axelsson, I G ; Johansson, S G ; Wrangsjo, K.“IgEmediated anaphylactoid reactions to rubber.” Allergy 42 (January 1987) 42,46-50. Bochner, B S ; Lichtenstein, L M. “Anaphylaxis.” New England Journal of Medicine 324 (June 20, 1991) 1785-1790. Morales, C, et al. “Anaphylaxis produced by rubber glove contact: Case reports and immunological identification of the antigens involved.” Clinical and Experimental Allergy 19 (July 1989) 425430. Slater, J. “Rubber anaphylaxis.” The New England Journal of Medicine 320 (April 27, 1989) 11261129. Swartz, J, et al. “Intraoperative anaphylaxis to latex.” Canadian Journal of Anaesthesia 37 (July 1990) 589-592. Turjanmaa, K; Laurila, K; Makinen-Kiliunen, S. “Rubber contact urticaria: Allergic properties of 19 brands of latex gloves.” Contact Dermatitis 19 (November 1988) 362-367. Wrangsjo, K; Wahlberg, J E; Axelsson, I G “IgEmediated allergy to natural rubber in 30 patients with contact urticaria.” Contact Dermatitis 19 (October 1988) 264-271.
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Ijxammation LATEXALLERGY
1. When an individual has an allergic response to latex, he or she is reacting to what? a. anantigen b. anantibody c. anantibiotic d. anantihistamine 2. Researchers believe that the antigen that triggers an allergic response to latex is a. a water-soluable protein that occurs naturally in latex b. particulate debris in the sap of the Havea brasiliensis plant c. ammonia sulfite used to process the sap d. sodium sulfite used to process the sap 3. Allergic reactions can be classified into two types. They are a. immunologic and systemic b. systemic and local c. local and secretory d. airborne and local 4. Local reactions (ie, those caused by contact with skin or inhalation) manifest which symptoms? a. urticaria, allergic rhinitis b. conjunctivitis, wheezing c. bronchospasm d. all of the above 5. Systemic reactions (ie, those occuring when latex comes in contact with the patient’s peritoneal lining, mucosa, or serosal surfaces) cause what symptoms? 1. hypotension 2. tachycardia 3. urticaria 4. bronshospasm a. 1 and2 504
6.
7.
8.
9.
b. 1,2, and3 c. 1 , 2 , a n d 4 d. 3 a n d 4 Certain groups appear to be at high risk for sensitivity to latex. What is a common factor for all groups? a. They are all female. b. They are all under 18 years of age. c. They all have frequent exposure to latex products. d. They all have physical disabilities. One group who routinely use latex and may be at high risk for latex sensitivity is health professionals. a. true b. false Patients who must frequently use latex catheters are at risk for latex sensitivity. Why? a. Frequent mucosal contact with latex products increases the risk for allergic sensitization. b. Frequent catheterization traumatizes the urethra and causes latex reactions. c. Lubrication used during catheterization alters the composition of the latex and this is thought to increase the chance of sensitization. d. all of the above Which of the following are high-risk groups for latex allergy? 1. chronically ill patients. 2. patients with spina bifida 3 patients with spinal cord injuries 4. patients with atopic dermatitis, eczema, or fruit allergies a. all of the above
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b. 1,2, and4 c. 2 a n d 3 d. 1,2, and3 10. A patient who has experienced an intraoperative anaphylactic reaction f o r unknown reasons should be suspected of latex allergy. a. true b. false 11. Allergy testing is a useful tool for identifying patients with latex allergy. What are the three tests that are performed? a. EKG, CBC, stress test b. skin prick test, RUST, and PPD c. skin prick test, RAST, and IDT d. RAST, IDT, and PPD 12. What are the advantages of the IDT and skin prick test? 1. can be done by anyone, n o risk to patient 2. acceptable to all patients, moderate cost 3. easily available, low cost 4. quick results, very sensitive a. 1 b. 2 c. 2 a n d 4 d. 3 and 4 13. One disadvantage to testing patients by skin prick or IDT to identify or confirm latex allergy is the potential for a a. result that is inconclusive b. full systemic reaction c. needle phobic patient d. false negative reaction 14. For some patients, IDT and skin prick testing may be inappropriate. Why? a. Children who are needle phobic may be uncooperative. b. Patients with severe dermatitis are not good candidates for these tests. c. Certain anti-inhibitory medications may interfere with the tests d. all of the above 15. Part of the preoperative assessment on all patients should include the possibility of latex allergy. Which of the following would be good questions to routinely ask
16.
17.
18.
19.
a patient scheduled for surgery? 1. “How many surgical procedures have you had?” 2. “What type of work do you do?” 3. “Do you have any allergies or sensitivities?” 4. “What type of procedure are you having today?” a. 1 and4 b. 1, 3, and4 c. 2 a n d 3 d. 1, 2, and3 Once identified as “latex allergic,” what basic change must the perioperative nurse make in the care for these patients? a. provide resuscitative equipment in the OR b. replace all latex containing items with non-latex items. c. be aware of the allergy d. see that the surgery is cancelled with all units and personnel is imperative to ensure that these patients are not exposed to latex. a. socializing b. communication c. professionalism d. friendliness Where would be strategic spots to post Figns warning personnel about the patient’s latex allergy? 1 . the main entrance to the OR department and on the surgical schedule 2. the door to the OR suite and the anesthesia machine to be used on the patient 3. the patient’s bed and chart 4. the patient’s room and on the front of his or her gown a. 1 and 2 b. 2 a n d 3 c. 3 and4 d. 1 and4 The best way to determine if a product is latex-free is by a. checking on the package b. checking with purchasing c. checking with the manufacturer 505
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d. checking with the patient 20. Creating a latex-free environment is more expensive and more work for the surgical team, however, this can result in n o occurring and no being given in the majority of patients.
Position on HIV and Nursing Students Defined In support of strong, ongoing, comprehensive education for nursing students about acquired immune deficiency syndrome (AIDS) and the human immunodeficiency virus (HIV), the American Nursing Association (ANA) issued a position statement on HIV infection and nursing students. According to the recent position statement, the ANA believes that nursing curriculums that include current HIV information should be provided at the beginning of academic programs by a faculty member with expertise in the field. Education should continue throughout the students’ course of study. Also, all nursing students, with informed consent, should be immunized against hepatitis B virus (HBV) unless there are medical contraindications. Each nursing school also should provide a post-exposure management program for students who sustain exposure to blood and body fluids in clinical settings. Each school should provide health care services to students during their enrollment. Nursing schools also should develop a means for providing disabilitycoverage for students in the event of HIV or HBV exposure in clinical settings. Nursing students or nursing school applicants should not be deprived of access to schools or dismissed from their educationalprogram based solely on HIV-positive status. All HIV-related information should be confidentialto safeguard nursing students’rights to privacy. Finally, nurs-. ing students should be assured of protections consistent with those of employees covered under the Occupational Health and Safety Act.
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a. b. c. d.
deaths, inappropriate medications anaphylaxis, prophylactic medications latex contact errors, medications interrupted surgeries, therapeutic medications.
New Publications Help with Survey Preparation Two new publications designed to help nurses prepare for hospital accreditation surveys are now available from the Joint Commission on Accreditation of Healthcare Organizations, according to a June 29, 1992, news release. The first guide, Defining Nursing Care in Your Hospital, will help nurses define their organization’s nursing care as required by the nursing standards, which were revised significantly in the 1991 accreditation manual. The guide divides the process of defining an organization’s nursing care into a seven-step plan. It also provides examples that staff members can use in writing their own definitions. The second publication, How to Prepare for a Survey: Nursing, explains the entire accreditation process. Topics include what nurses should expect from the survey, what needs to be done 3 to 6 months before the survey, and what needs to be done immediately before the surveyors’ arrive. A series of checklists also is provided to help organize information for the survey. Both guides can be ordered by writing to Cashier, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, Ill. Credit card orders can be placed by calling the customer service center at (708) 9 16-580.
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A O R N JOGRNAL
Answer Sheet bTEX
ALLERGY
P
lease fill out the application and a n s b c ' r form below and the evaluation on the back of this page. Tear out the page from the . l o i ~ m ~ / or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 8023 1 Event # 935003
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Program offered September 1992 The deadline for this program is Feb 28, 1993. 1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicate. your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete thc program -~ 5. Enclose fee: Members $7; Nonmembers $14.
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1to 5. 1. Objectives.To what extent were the following objectives of this home study programachieved? (1) Describe the allergic response to latex. (2) Iden@ populations at high risk for latex allergy. (3) Describe the perioperative assessment of patients with latex allergy. (4) Identify actions the perioperative nurse can take when caring for a patient with latex allergy.
2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individualobjectivesmet? (5) Was the content of the article relevant to the objectives?
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3. Test questionslanswers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address impomnt points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
Topic(s):
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Latex Allergy A GUIDELINE FOR PERIOPERATIVE NURSES Mary Ann Young, RN; Margie Meyers, RN; Lee Desotell McCulloch, FW;Lesley J. Brown, RN Thirty minutes into a surgical procedure, the patient exhibited urticaria, hypotension, tachycardia, and increased airway pressure related to bronchospasm-an intraoperative anaphylactic reaction of unknown cause was in progress once again. The anesthesiologist administered epinephrine, steroids, and isoproterenol and was able to stabilize the patient somewhat; but within minutes, the patient’s vital signs again indicated anaphylaxis. Doses of the appropriate medications were repeated, and the surgeon closed the operative site. The surgical team focused on stabilizing the patient, and the patient’s surgery was postponed indefinitely.
B
efore 1988, these life-threatening reactions caused concern among anesthesiologists, surgeons, and nurses because
Mary Ann Young, RN, BSN, is a level II staff nurse in the operating room at Children’s Hospital, Boston. She earned her bachelor of science degree in nursing at Salve Regina University, Newport, RI. Margie Meyers, RN, is a level 11 staff nurse in the operating room at Children’s Hospital, Boston. She earned her diploma in nursing at Children’s Hospital School of Nursing, Boston. Lee Desotell McCulloch, RN, is a level I I staff nurse i n the operating room at Children’s Hospital, Boston. She earned her associate degree in nursing at Howard 488
the reason for the anaphylaxis remained a mystery. Patients were tested for allergies to the medications and anesthetic agents that had been used, but results were not definitive. In fact, some patients were allergic to several substances. When these medications were avoided in future surgeries, however, anaphylaxis still occurred. In 1988, members of the Anesthesiology Department at Children’s Hospital, Boston, linked a number of anaphylactic reactions to the use of latex products during surgery. Through laboratory research and a review of the literature describing similar cases throughout the world, Robert S. Holnan, MD, and Navil Sethna, MD, learned that intraoperative exposure to latex causes an anaphylactic reaction in certain patients.’ This reaction is known as an immunoglobulin E
Community College, Columbia, Md.
Lesley J. Brown, UN, is a level 11 staff nurse in the operating room at Children’s Hospital, Boston. She earned her diploma in nursing at Children’s Hospital School of Nursing, Boston. The authors wish to thank Judith S . Mitiguy, RN, MS; Carole Bardsdale, RN, BS, CNOR; Stella Harrington, RN, BSN, CNOU; Jackie Hamblet, RN, M S , CNOR; Gayle Gildea, RN, BSN; Anne Jenks Micheli, U N ,BSN, M S ; Navil Sethna, MD; and Robert Holzman, MD for their assistance with this manuscript.
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Nurses must understand the latex IgE-mediated response and follow strict guidelines when caring for allergic patients. (IgE) mediated allergic response to latex. No epidemiological studies to date have reported on the incidence of latex reactions. To ensure safe perioperative practice, nurses must understand the latex IgE-mediated response and follow strict guidelines when caring for allergic patients. Educating all health care workers, the community, patients, and their families about this newly reported allergy is important to prevent life-threatening anaphylaxis associated with latex exposure.
Allergic Response to Latex -atural latex is the milky sap obtained from the Havea brasifiensis plant, commonly known as the rubber tree. In the manufacturing process, the sap is filtered to remove particulate debris and then preserved by adding either ammonia or sodium sulfite.? The antigen that triggers an allergic response is believed to be a water-soluble protein that occurs naturally in the latex. Liquid latex is useful for products such as surgical gloves. condoms, balloons, elastic thread, and rubber adhesives. Frequent use of latex by patients or health care workers can result in sensitization that may place some people at increased risk for an allergic reaction. Allergic reactions can be classified into two types: local and systemic (ie, anaphylactic ). Systemic reactions are immunologically mediated and occur when patients are exposed to an allergen to which they have been sensitized (Fig 1). This re-exposure to a specific allergen stimulates production of IgE. During a reaction. IgE binds to high-affinity receptors on basophils and mast cells, and the combination of antigen with IgE causes degranulation o f these cells. The secretory products of basophils and mast cells are histamine, heparin, serotonin, and arachidonic acid, which is converted
by other cells into prostaglandins and leukotrienes. These products are responsible for the symptoms of allergic reactions.3 Allergic manifestations vary with the route of exposure. Urticaria develops when latex comes in contact with the skin. Airborne latex particles may cause allergic rhinitis, conjunctivitis, wheezing, and bronchospasm. Systemic reactions (eg, hypotension, tachycardia, bronchospasm) may occur when latex gloves come in contact with the patient’s peritoneal lining, mucosa, or serosal surfaces. ln the United States, allergic reactions from a variety of substances occur in approximately 200,000 patients each year during hospitalization. Approximately one million patients experience milder reactions but do not require hospital admi~sion.~ The most common allergenic agents in health care settings are antibiotics and radiographic contrast material^.^ An individual may have a sensitivity to latex that manifests itself as contact urticaria, but when the latex comes in contact with mucous membranes or with organs in the peritoneal cavity during surgery or when airborne antigens are inhaled, that same individual may suffer a severe anaphylactic reaction. For several years, there have been multiple medical reports of latex sensitivity to gloves resulting in contact dermatitis. Recently, however, reports of severe reactions to latex, including anaphylaxis and even death, have increased.6 Latex hypersensitivity seems to be a fairly recent occurrence. In 1979, a researcher reported contact urticaria to rubber; and in 1984, it was confirmed by skin prick testing as an IgEmediated anaphylaxis.g From 1981 to 1983, serological studies were performed in three surgical nurses with contact urticaria to latex gloves. Their responses also were found to be IgE-mediated.’ Anaphylaxis, caused by mucosa1 exposure during rectal manometry, was 489
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cross-linking IgE antibody by allergen vasomotor col-
t early release of histamine and serotonin I.)
late release of leukotrienes and prostagkzndins
smooth muscle contraction (bronchoconstriction) increased blood jlow (vasodikztion)
increased mucus secretion (rhinitis. bronchid obstruction) mast cell degranulation
Fig I . Reaction sequence of an allergic response. (Reprintedfrom Immunology, Immunopathology and Immunity, Stewart Sell,fourth ed, with permission from Elsevier Science Publishing Co, Inc, New York City,1987)
reported in an 18-year-old woman with a history of contact urticaria to latex following the insertion and inflation of a balloon fashioned from a latex glove.'O One researcher reported five patients with intraoperative anaphylactic responses. Three were hypersensitive to fruit, three had worked in a hospital setting, and all had contact urticaria to latex. When skin-prick tested, five had a positive reaction to latex." Contact urticaria and anaphylaxis also were reported in one patient with oral and vaginal exposure to condoms and one with rectal exposure to a latex glove.12 In October 1990, the company that manufactured latex balloon enema tips voluntarily recalled all of its latex-containing products.'3 A correlation between the latex balloons and anaphylactic responses had become evident when 148 incidents related to barium enema examinations were reported during a 22-month period. Nine fatalities occurred, and three of these patients succumbed to anaphylaxis before the 490
instillation of barium.14 At Children's Hospital, we have seen an increased incidence of anaphylactic reactions under anesthesia when patients are exposed to latex gloves during surgery. Following exposure, anaphylaxis is characterized by hypotension, tachycardia, increased airway pressures with bronchospasm, and generalized erythema. In almost all cases, it has been necessary to end the procedure because of the patient's unstable condition.
High Risk Populations
C
ertain groups appear to be at higher risk for latex sensitivity. One group that routinely uses latex gloves is health care professionals, including nurses, physicians, and dentists. The US Food and Drug Administration (FDA) reports that 6% to 7% of surgical personnel are sensitive to latex.I5 Other groups identified at high risk are those with spinal cord
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injuries, myelodysplasia, and chronic illness. The frequent use of latex for catheterization and multiple surgical procedures is thought to be the cause for the increased incidence of latex hypersensitivity. The New England Myelodysplasia Association has reported an 18% to 28% incidence of sensitivity to latex from a survey of five myelodysplasia clinics.I6One prospective study suggests that 41 % of spina bifida patients have the IgE antibody specific for the rubber proteins." In a study conducted from January 1989 to January 1991 at another facility, 11 cases were reported; these patients developed an anaphylactic reaction (ie, hypotension and at least one other symptom including rash, angioedema, stridor, wheezing, or bronchospasm). Ten patients had myelodysplasia, and one had a congenital abnormality of the genitourinary tract. l8 At Children's Hospital, we care for many patients with myelodysplasia. Like staff members in other medical facilities, we have noted an increased sensitivity to latex in these patients.Ig Our hospital researchers have observed 29 cases of suspected intraoperative anaphylaxis related to latex exposure. Of this number, 28 patients had myelodysplasia, and one had Mayer-Rokitansky-Kuster Syndrome (ie, agenesis of the vagina) and was selfcatheterized for three years before a vaginal reconstruction. Several of these patients had a positive history of localized cutaneous reactions or systemic hypersensitivity to latex objects (eg, rubber balls, balloons, urethral catheters, latex gloves).20
Preoperative Assessment
T
he most effective way to avoid an intraoperative hypersensitivity response to latex is through preventive measures. A complete assessment before patients enter the operating room is crucial to identify those who are sensitive to latex. The first step in this assessment is to identify the high-risk patients (eg, patients with
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myelodysplasia, spinal cord injury, chronic illness. a history of multiple reconstructive surgical procedures, a history of occupational contact with latex products). All of these patients have had an opportunity to become latex-sensitive from multiple exposures to products containing latex proteins. Several reports indicate that patients with a history of atopic dermatitis, eczema, and fruit allergies also may be at increased risk.21In addition, patients with a history of intraoperative anaphylactic reaction for unknown reasons may be suspect for latex allergy and should be evaluated carefully by the health care team. Another useful preoperative tool is allergy testing with latex extract. When allergy testing can be done, it may provide patient reassurance and clear documentation. The most common tests for allergies are the skin prick test (SPT), the intrademal test (IDT), and the radio-allergosorbent test (RAST). Skin prick test. The SPT involves taking a drop of the latex extract (ie, antigen) diluted in saline, placing it on the skin, and gently scratching the skin with a needle. The whealand-flare response is measured after 10 minutes and then measured against a control group reaction.'* Intradermal test. The IDT is similar to the SPT, except that the latex antigen is more diluted with saline. A minute quantity of the diluted allergen is injected intradermally into the patient's lower arm.After 10 minutes, localized erythema is measured and compared with the control group reaction. In the event of a systemic reaction, a non-latex tourniquet can be applied proximal to the injection site. lntradermal testing is approximately 1,000 times more sensitive than SPT and is performed in patients with suspected IgE-mediated diseases who have demonstrated a 0 to 1+ response to SPT. 21 Radio-allergosorbent test. The RAST measures latex-specific IgE antibodies and the potency of allergy extracts. It is a two-phase (ie. solid, liquid) test system using an insolubilized allergen that first is incubated in the patient's serum to react with allergen-specific 491
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Table 1
The ChiMren’s Hospital PeriOperQtve Nursing Policy latex. A preoperative nursing assessment should look for a history of an allergy to latex.
Safe nursing care of the patient will be implemented perioperatively to minimize the risk of an allergic/anaphylacticreaction to
Purpose To provide guidelinesto ensure consistent, safe pexioperative nursing care of the latex allergic patient. Adhering to these aids in
the successful completionof the patient’s surgery with no occurrenceof an allergic/ anaphylacticreaction to latex.
General information
3. Topical sensitivityto latex may indicate the patient is at increasedrisk of intraoperative systemicanaphylacticreaction to latex.
Implementation
Rationale
1. The presence of latex allergy will be docu-
mented on the p p e r a t i v e assessment.
492
in cardiorespiratoryarrest within minutes.
1. Exposure to latex products may cause a hypersensitivity response either locally at the site of the contact (ie, contact dermatitis; cell-mediated reaction), or systemic reaction (ie, anaphylaxis; IgEmediated hypersensitivity). The later reaction may manifest as breathing difficulty (ie, bronchospasm), cutaneous erythemia and urticaria, anxiety, palpitations, chest tightness and pain, hypotension, facial and peripheral edema, and shock. This reaction can occur even with trivial exposure to latex and may result
2. Patients known to have an increased exposure to latex (eg, patients with myelodysplasia, or urological deformitiesor those who have had multiple surgicalp m dures), are predisposed to having a hypersensitivity response to latex.
1. These assessments should include any known allergies or sensitivities.
2. Patient will wear a latex allergy-alert ID bracelet; foot of bed and operating room doors will have visible allergy warning signs; and the allergy will be clearly documented in the patient’s chart.
2. Identification of an allergy is crucial in ensuring safe patient care.
3. Non-latex gloves must be worn in place of latex gloves when caring for the patient.
3. Contact with latex gloves can increase the risk of an IgE-mediated allergic response in a patient with a latex allergy.
4. Patient contact with any latex products must be avoided during penoperative care.
4. Contact with any latex product can increase the risk of an Ig-E mediated allergic response in a patient with a latex allergy-
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Care and Management of the Patient with U e x Allergy Implementation
Rationale
5. Rubber medication stoppers and IV rubber
5. Three-way stopcocks for administration of medication prevent systemic introduction of latex thus minimizing the risk of an IgEmediated response.
injection ports will not be used.
6. The master list of commonly used latex containing items will be available to those providing perioperative care to the patient.
6. Knowledge of latex items minimizes the risks of patient contact with products containing latex.
7. Substitutes for latex will be available.
7. Non-latex substitutes lower risk of patient reaction and minimize anesthesia time.
8. Communication will occur among staff
8. Communication among staff members is a way to maintain consistent, safe, quality patient care.
members regarding the patient's allergic response to latex.
9. The post anesthesia care unit nurse will be notified by phone of the latex allergy before the patient's arrival.
9. Preparations can be made in advance to provide non-latex items for a patient with latex allergy.
Evaluation mized, and statistics will be gathered by the Department of Anesthesia.
The incidence of allergic/anaphylactic reactions in patients with IgE-mediated allergic response to latex will be mini-
Planning Objectives I. All OR nursing personnel caring for the latex-allergic patient perioperatively will adhere to the guidelines specific to the care of these patients.
2. Perioperative nurses caring for the latex-
allergic patient will ensure that the patient does not come in contact with any latex products while in their care.
3. Latex products will not be used. Non-latex products will be substituted when needed.
Resources 1. A master list of commonly used latex items will be available to personnel responsible for the care of the latex-allergicpatient.
2. Non-latex items and substitutes for most latex items can be found on the master list.
3. An allergy-alert bracelet will be placed on
the patient, and the patient's chart will be documented clearly with the latex allergy. 4. A perioperative nursing check-off list for the care of the latex-allergic patient can be used.
5. Contact Drs Holvnan or Sethna about patient responses to latex. U 493
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Table 2
Common Items Containing Latex, Latex items Aces (brown tensor) Catheters Coude Foley Malecot Blue paper towel drapes with adhesive strips, instrument mats Bite blocks Blood pressure cuff tubing Self adheringtape (ie, elasticfabric, adhesive) Cyst0 tubing with rubber tip
Cloth towels
Rolled cotton batting on areas of contact with patient’s skin Plastic tape, paper tape,one-inch rolled cotton gauze Cut off rubber tip and either attach remaining plastic tubing to cyst0 stopcock or, in arthroscopies, attach irrigation port to scope sheath Aces (white cotton) Non-latex glove finger
Esmarch bandages Finger cots Fogarty catheters Irrigation 3L NaCL with rubber stopper IV bag and burrette rubber stoppers IV tubing rubber stoppers
Do not puncture with needle Three-way stopcocks on IV tubing
Molded surgicalface masks with elastic band
Other types of surgical masks
antibodies and then incubated with radiolabeled heterologous antihuman IgE to detect the allergen-specific antibodies of the IgE isotype.24At the present time, the RAST is only 53% sensitive, but is by far the most specific test for IgE antibody.= The advantages of IDT and SPT are their availability, low cost, quick results, and sensitivity. One disadvantage, however, is the potential for a full systemic reaction with both tests; therefore, it is advisable to have an anesthesiologist standing by and emergency drugs available when performing these two tests. Also, both tests may be unacceptable to the pediatric population who may be needle phobic; to patients receiving specific medications that may interfere with testing 4%
Non-latex alternatives Aces (white cotton) Silastic Foley catheters
(eg, anti-inhibitory drugs); and to patients with severe dermatitisF6When the SPT and IDT are contraindicated, the RAST may be useful, although it is not as sensitive or readily available and is much more costly. Routine testing of all patients is expensive and, unless the patient is in a high-risk group or a latex allergy is suspected, unnecessary. Careful screening of all patients by health care workers to identify patients at risk and further test those patients is more cost effective.27At present, we do not use prophylactic medication for latex-sensitive patients. We provide these patients with a latex-free environment and they do quite well. Prophylactic medications that could be administered preoperatively include
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Alternative Non-latex Products Latex items Medication vial rubber stoppers Mouth gags Nephrostomy catheter Penrose drains
Chest tube drainage system tubing Red rubber catheters Rubber bands Rubber dams Rubber shods or suture bolsters Specimen trap Syringes, with rubber plungers
Tourniquet cuff tubing Urine drainage system port Rubber nipples ~
~
Non-latex glove for IV tourniquet, JacksonPratt drains or Hemovacs for drains; vessel loops for vessels, tendon retraction. Wrap tubing with rolled cotton batting, rolled cotton gauze, tape, etc. Feeding tubes, nasogastric tubes, silastic Foley catheter, Stamey suprapubic catheters Vessel loops, small pieces of non-latex glove Sterile plastic bags (eg, bowel bags) Cut pieces of silastic catheter Prevent contact with patient, or use black top tubes No premixed medications (should be freshly drawn up): check with anesthesiologist Rolled cotton batting on areas of skin contact Prevent any patient contact; cover with tape Polyvinyl chloride or silicone nipples
~
prednisone, diphenhydramine, and ranitidine, with or without ephedrine (an alpha-adrenergic agent); however, there are no studies that document the effectiveness of this approach.**
Perioperative Patient Care
G
Non-latex alternatives Remove rubber stoppers to withdraw medications Replace rubber with silastic
ood communication between health care workers and clear, consistent documentation is crucial to patient safety. Each individual responsible for the latex-sensitive patient should make this a priority to minimize the risks of causing a hypersensitive reaction. Intraoperatively, the patient relies on the health care team to be aware, responsible, and knowledgeable about the possible effects of
contact with latex products. At our hospital, a policy and procedure for perioperative care and management of latexsensitive patients has been developed recently and put into practice by perioperative nurses (Table 1). A list of items containing latex and those that are latex-free is available to members of the health care team (Table 2 ) . Because many companies do not list the components found in patient care products on their packaging, we contacted the manufacturers for this information. We have researched suggested alternatives to latex and have formulated a list of commonly used items that are latex-free. (See “Latex-free Items Used at the Children’s Hospital.”) This list is not all inclu497
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sive. Manufacturers should be consulted about their specific products to determine if the products contain latex and whether a latex-free alternative is available. We have based our perioperative nur\ing checklist on this information (Table 3). It serves as a patient safety inventory and assists in preventing latex exposure. We also place strategically located signs on doors, beds, and anesthesia machines to clearly identify the patient u ith a latex allergy.
Increasing Awai-eness
P
ublic awareness and education is a vital component of safe care when latex allergy exists or is suspected. Patients and families must be advised to notify all health care, school, and day care professionals about any latex sensitivity. Our physicians r e c u m mend that anyone suspected of this sensitivity should consider immunology testing and wear an allergy-alert bracelet identifying the latex allergy. Patients also should be aware that unintentional exposure to rubber may trigger a life-threatening systemic reaction. Some common settings i n which latex products may be present include birthday parties, fairs, circuses (eg. halloons, play jewelry), school buses, rubber raincoats, boots, and condoms, diaphragms. Respiratory exposure alone (eg, blowing up ;L balloon) may cause an allergic response in a child with latex allergy.” Physicians may prescribe auto-injectable epinephrine for patients to administer to themselves in the event of a reaction. Patients and families should receive appropriate literature explaining all signs, symptoms, and 1-isk areas for latex allergy. After a patient has been labeled “latex allergic,” his or her life may be affected in many ways. The patient must be aware of his or her environment and take steps to see that it is latex free. He or she should wear an allergyidentification bracelet and carry epinephrine for treatment of accidental exposure reactions. A letter
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Latex-free Items Used at The Children’s Hospital” Ace bandages, white cotton (Conco ECotton) Aseptos (Medline, Superior) Back table drape (Boundry) C-arm drapes (Xomed) Catheters; ureteral, suction, silastic Foleys (Argyle, Bard, Surgicath, Mentor) Cautery cords (Olsen, Valley Lab) Cautery pads (3M) Cell Saver tubing (Haemonetic) DermaciIDermaclear tape (Johnson & Johnson) Ear tubes (Richard, Xomed) Extremity sheet (Convertor) Filiforms and followers (Bard) Gel pads (Allen Medical) Glassman “fish’ retainers (Adept-Med) Jackson-Pratt drains (Heyer Schulte) Mayo covers (Boundry) Microfoam/Micropore tape (3M) Microscope drapes (Xomed) Oximeter probes (Nelcor) Raytex sponges (Johnson & Johnson) Rest-on foam with adhesive (3M) Silk tape (Johnson & Johnson) Split sheet, adhesive (Johnson & Johnson) Steri drapes, regular and Ioban (3M) Steri strips (3M) Suture booties (Scanlan International) Tegaderm (3M) Testicular implants (Dow Coming) Ureteral catheter (Surgicath) Vessiloops (Devon Industries) Vidrape spray (Becton Dickinson) Warming blanket (Seebrook) Xeroform (Sherwood Medical) $‘4riypatient care item may contain late.\-. This iitt is not all inclusilv and represents items idenrlfied by Children’s Hospital as being latexpee. .%fun?companies produce non-latex items. #Munujucturersshould be contacted to determine if’specific. products contain latex and what nonIutm alternutives the manufacturer recommends.
499
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Table 3
Perioperative Nursing Care Plan for the Patient with Latex Allergy Preoperative Identify if patient has a latex allergy Ensure that patient has a visible latex-allergy bracelet on. Ensure that chart clearly documents that a latex allergy is present. Wear latex-free gloves for any patient contact. Remove unsterile boxes of latex gloves from the room. Ensure that all members of the health care team are aware of the patient’s latex allergy. Refer to the list of latex and latexfree items and have alternatives available. Intraoperative Ensure that clear, visible signs indicating that there is a latex-allergy patient in the room are on OR doors. Have a quantity of latex-free gloves are available in every size for both
from a physician explaining latex allergy, reaction signs and symptoms, and appropriate treatment should be circulated to all facilities that care for latex-sensitive children (eg, school, scout troop, day care). The patient or family should carry nonlatex gloves in a convenient place (eg, the car) in the event a situation which requires the use of gloves occurs. Many offices and health care settings do not carry non-latex gloves and may not be aware of this problem. Children and adults will have restrictions of activity placed upon them and will be subj e c t to certain added financial burdens. Insurance companies and hospitals may require patients to share the increased costs of care related to this latex phenomenon. Currently, many non-latex products are more
sterile and nonsterile use. Do not use Penrose drains to start IV lines or as drains in a wound. Use a silastic Foley if a Foley is ordered for a procedure. Do not puncture rubber medication stoppers with a needle. Remove rubber stoppers to draw up medications. Wrap rolled cotton batting around the patient’s arm and/or leg to prevent blood pressure cuff tubing and/or tourniquet cuff tubing from coming in contact with the patient’s skin. Assess the sterile fieldback table with the scrub nurse to ensure a latex-free setup. Ensure there is a latex allergy sign affixed to the foot of the patient’s bed. Communicate with the post anesthesia care unit nurse regarding the patient’s latex allergy before the patient arrives in the unit.
expensive than latex products; for example, a pair of sterile, non-latex gloves is approximately three times more expensive than a pair of sterile, latex gloves.
Questions
M
any questions regarding latex allergy remain unanswered; however, it is imperative that all health care professionals become educated about the facts regarding IgE-mediated responses to latex. We have found that a hospital-wide task force is needed to communicate findings from recent literature and develop a consistent, safe standard of care for patients who are allergic to latex. In our hospital, the task force consists of representatives from a11
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departments in which these high-risk patients receive care. It includes nurses from the inpatient units (eg, orthopedics, urology. neurology), perioperative nurses, ambulatory care nurses, allergy clinic staff, surgeons. and anesthesiologists. Although many studies are being done to improve allergy testing, the most valuable tool in caring f o r allergic patients is the a s s u r a n c e of a l a t e x - f r e e e n v i r o n m e n t . Obtaining careful, complete patient histories. identifying high-risk groups, teaching families and involved health care professional\. and communication and collaboration of the health care team are key elements in succeshful and safe patient care. The increased occurrence of hypersensitivity to latex is not fully understood, but there are many theories. Universal precautions and the increased use of gloves has been suggeated as contributing to the exposure of more people to latex and possible sensitization. The concern about bloodborne contamination has increased the use of gloves in most health care settings. For example, in our operating room, spinal fusion procedures routinely use 40 pairs of gloves per case. Before universal precautions were implemented, that number was approximately 10 pairs of gloves pelcase. Glove manufacturing industries now are faced with increased demands for their products. This raises questions about whether changes in production methods have occurred that affect the quality of gloves being produced. The increased occurrence of latex sensitivity is being investigated by the FDA and other researchers. Researchers also are studying the effects of the manufacturing process and shortened shelf-life of gloves to determine whether latex collection methods. pre s e r v at i on, rn a n u f a c t ur i n g methods . o r changes in latex protein account for these increases in sensitivity.20 Because the potential for a life-threatening situation exists, all p a t i e n t s in h i g h - r i s k g r o u p s s h o u l d be assessed carefully, and when latex allergy i \ suspected, the F D A recommends that all
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latex products be a ~ o i d e d . ~ ’
Conclusion
L
atex allergy has been identified, and its life-threatening risks have been documented. Perioperative nurses, therefore, have an obligation to educate patients, familie\, and peers on this subject. Knowledge, communication, and prevention are key elements ensuring safe health care for this new high-risk population of patients. Our policy of creating a latex-free environment for all patients who are allergic or sensitive to latex and those who are potentially at risk has been successful. This measure is worth the effort and expense, considering the possible danger to the patient. Of the 29 patients at our hospital with suspected latex-related anaphylaxis described earlier, 11 have returned for surgical procedures, and they have been treated with latex-free precautions penoperatively. N o prophylactic medications were administered, and no anaphylaxis occurred. Latex-free precautions were implemented by the health care team, and all patients experienced an uneventful and successful hospital stays. Notes I . R S Holzman, N F Sethna, S Sockin, “Hypotension. flushing and bronchospasm in myelodysplasia
patients,” abstract presented at the American Society of Anesthesiologists annual meeting. 2. D Spaner et al, “Hypersensitivity to natural latex.“ Journal of Allergy and Clinical Immunology 83 (June 1989) 1136. 3. S Sell, Immunology, Immunopathology and Irrrrnuni/y, fourth ed (New York City: Elsevier, 1987) 89,440. 3 . P P Van Arsdel, Jr, “Diagnosing drug allergy,” Journal of American Medical Association 247 (May 1982) 2576-2581. 5. M M Fisher, D G More, “The epidemiology
and clinical features of anaphylactic reactions in anesthesia,” Anesthesia Intensive Care 9 (August 1981 226-234. 6. D W Gelfand, “Barium enemas, latex balloons, and anaphylactic reactions,” (Commentary) American ./ourno/ of Roentgenobgy 156 (January 1991) 1-2; D Kong. “Link of latex to allergy, deaths spurs US inquiry.” The Boston Globe 27 May 1991, 1,7. 501
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7. A F Nutter, “Contact urticaria to rubber,” British Journal of Dermatology 101 (November 1979) 597-598. 8. K Turjanmaa, T Reunala, R Tuimala, “Severe IgE-mediated allergy to surgical gloves,” abstract, XV Nordic Congress of Allergology, Turku, Finland, Allergy Supplement 2 (June 1984) 35. 9. P J Frosch et al, “Contact urticaria to rubber gloves is IgE-mediated,” Contact Dermatitis 14 (April 1986) 241-245. 10. J M Sondhehner, P S Pearlman, W C Bailey, “Systemic anaphylaxis during rectal manometry with a latex balloon,” American Journal of Gastroenterology 84 (August 1989) 975-977. 11. F Leynadier, C Pecquet, J Dry, “Anaphylaxis to latex during surgery,” Anesthesia 44 (July 1989) 547550. 12. J S Taylor et al, “Contact urticaria and anaphylaxis to latex,” Journal of the American Academy of Dermatology 21 (October 1989) 874-877. 13. E-ZEM Co, Inc, Urgent:Medical Device Recall (Westbury, New York: E-ZEM Co, Inc, Oct 5,1990). 14. Gelfand, “Barium enemas, latex balloons, and anaphylactic reactions,” 1-2. 15. US Food and Drug Administration, Medical Alert Bulletin (Washington, DC: US Food and Drug Administration,March 29, 1991). 16. E Meeropol et al, “Allergic reactions to rubber in patients with myelodysplasia,” New England Journal of Medicine 323 (Oct 11,1990) 1072. 17. J E Slater et al, “Type 1 hypersensitivity to rubber,” Annals of Allergy 65 (November 1990) 412. 18. Centers for Disease Control “Anaphylactic reactions during general anesthesia Among pediatric patients-United States, January 1990-January 1991,” in Morbidity and Mortality Weekly Report 40 (July 5, 1991)437. 19. M Gold, B M Braude, F S Swartz, “Intraoperative anaphylaxis: an association with latex sensitivity,” Journal of Allergy and Clinical Immunology 87 (March 1991) 268, 270; R Slater, “Latex antigens,” Journal of Allergy and Clinical Immunology 85 (January 1991) 268; G G Shapiro, F S Virant, M W Burns, “Intraoperative cardiovascular collapse due to latex allergy,” Journal of Allergy and Clinical Immunology 85 (January 1991) 268,270. 20. Navil Sethna, MD, personal conversation with authors, 5 March 1992. 21. K Tujanmaa, “Incidence of immediate allergy to latex gloves in hospital personnel,” Contact Dermatitis 17 movemkr 1987) 270-275; Leynadier, Pecquet, Dry, ‘‘Anaphylaxista latex during Surgery,’’ 547-550. 22. D P Stites, A I Terr, Basic and Clinical immunology, sixth ed (Norwalk,Conn: Appleton & Lange, 1987) 373. 23. Ibid, 375. 24. ibid, 376; G Gleitch, J Yunginger, “The radioallergosorbent test: A method to measure IgE anti-
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bodies, IgG blocking antibodies, and the potency of allergy extracts,” Bulletin of the New York Academy of Medicine 57 (September 1981) 559-560. 25. K Turjanmaa, T Reunala, L Rasanen, “Comparison of diagnostic methods in latex surgical glove contact urticaria,” Contact Dermatitis 19 (October 1988) 241-247. 26. Stites, Terr, Basic and Clinical Immunology, 373. 27. Turjanmaa, Reunala, Rasanen, “Comparison of diagnostic methods in latex surgical glove contact urticaria,” 246: J Slater, L Mostello, “Routine testing for latex allergy in patients with spina bifida is not recommended,” Anesthesiology 74 (February 1991) 391; J Slater, L Mostello, C Shaer, “Type I hypersensitivity to rubber,” Annals of Allergy 65 (November 1990) 413. 28. K J Kelly, “Complications of latex allergy,” Dialogues in Pediatric Urology 15 (March 1992) 4. 29. Slater, Mostello, Shaer, “Type I hypersensitivity to rubber,” 413. 30. Kelly, “Complicationsof latex allergy,” 4. 31. US Food and Drug Administration, Medical Bulletin, Allergic Reactions (Washington, Dc: US Food and Drug Administration, July 1991). Suggested reading Axelsson, I G; Eriksson M; Wrangsjo, K. “Anaphylaxis and angioedema due to rubber allergy in children.” Acta Pediatrica Scandinavica (March 1988) 314-316. Axelsson, I G ; Johansson, S G ; Wrangsjo, K.“IgEmediated anaphylactoid reactions to rubber.” Allergy 42 (January 1987) 42,46-50. Bochner, B S ; Lichtenstein, L M. “Anaphylaxis.” New England Journal of Medicine 324 (June 20, 1991) 1785-1790. Morales, C, et al. “Anaphylaxis produced by rubber glove contact: Case reports and immunological identification of the antigens involved.” Clinical and Experimental Allergy 19 (July 1989) 425430. Slater, J. “Rubber anaphylaxis.” The New England Journal of Medicine 320 (April 27, 1989) 11261129. Swartz, J, et al. “Intraoperative anaphylaxis to latex.” Canadian Journal of Anaesthesia 37 (July 1990) 589-592. Turjanmaa, K; Laurila, K; Makinen-Kiliunen, S. “Rubber contact urticaria: Allergic properties of 19 brands of latex gloves.” Contact Dermatitis 19 (November 1988) 362-367. Wrangsjo, K; Wahlberg, J E; Axelsson, I G “IgEmediated allergy to natural rubber in 30 patients with contact urticaria.” Contact Dermatitis 19 (October 1988) 264-271.
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Ijxammation LATEXALLERGY
1. When an individual has an allergic response to latex, he or she is reacting to what? a. anantigen b. anantibody c. anantibiotic d. anantihistamine 2. Researchers believe that the antigen that triggers an allergic response to latex is a. a water-soluable protein that occurs naturally in latex b. particulate debris in the sap of the Havea brasiliensis plant c. ammonia sulfite used to process the sap d. sodium sulfite used to process the sap 3. Allergic reactions can be classified into two types. They are a. immunologic and systemic b. systemic and local c. local and secretory d. airborne and local 4. Local reactions (ie, those caused by contact with skin or inhalation) manifest which symptoms? a. urticaria, allergic rhinitis b. conjunctivitis, wheezing c. bronchospasm d. all of the above 5. Systemic reactions (ie, those occuring when latex comes in contact with the patient’s peritoneal lining, mucosa, or serosal surfaces) cause what symptoms? 1. hypotension 2. tachycardia 3. urticaria 4. bronshospasm a. 1 and2 504
6.
7.
8.
9.
b. 1,2, and3 c. 1 , 2 , a n d 4 d. 3 a n d 4 Certain groups appear to be at high risk for sensitivity to latex. What is a common factor for all groups? a. They are all female. b. They are all under 18 years of age. c. They all have frequent exposure to latex products. d. They all have physical disabilities. One group who routinely use latex and may be at high risk for latex sensitivity is health professionals. a. true b. false Patients who must frequently use latex catheters are at risk for latex sensitivity. Why? a. Frequent mucosal contact with latex products increases the risk for allergic sensitization. b. Frequent catheterization traumatizes the urethra and causes latex reactions. c. Lubrication used during catheterization alters the composition of the latex and this is thought to increase the chance of sensitization. d. all of the above Which of the following are high-risk groups for latex allergy? 1. chronically ill patients. 2. patients with spina bifida 3 patients with spinal cord injuries 4. patients with atopic dermatitis, eczema, or fruit allergies a. all of the above
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b. 1,2, and4 c. 2 a n d 3 d. 1,2, and3 10. A patient who has experienced an intraoperative anaphylactic reaction f o r unknown reasons should be suspected of latex allergy. a. true b. false 11. Allergy testing is a useful tool for identifying patients with latex allergy. What are the three tests that are performed? a. EKG, CBC, stress test b. skin prick test, RUST, and PPD c. skin prick test, RAST, and IDT d. RAST, IDT, and PPD 12. What are the advantages of the IDT and skin prick test? 1. can be done by anyone, n o risk to patient 2. acceptable to all patients, moderate cost 3. easily available, low cost 4. quick results, very sensitive a. 1 b. 2 c. 2 a n d 4 d. 3 and 4 13. One disadvantage to testing patients by skin prick or IDT to identify or confirm latex allergy is the potential for a a. result that is inconclusive b. full systemic reaction c. needle phobic patient d. false negative reaction 14. For some patients, IDT and skin prick testing may be inappropriate. Why? a. Children who are needle phobic may be uncooperative. b. Patients with severe dermatitis are not good candidates for these tests. c. Certain anti-inhibitory medications may interfere with the tests d. all of the above 15. Part of the preoperative assessment on all patients should include the possibility of latex allergy. Which of the following would be good questions to routinely ask
16.
17.
18.
19.
a patient scheduled for surgery? 1. “How many surgical procedures have you had?” 2. “What type of work do you do?” 3. “Do you have any allergies or sensitivities?” 4. “What type of procedure are you having today?” a. 1 and4 b. 1, 3, and4 c. 2 a n d 3 d. 1, 2, and3 Once identified as “latex allergic,” what basic change must the perioperative nurse make in the care for these patients? a. provide resuscitative equipment in the OR b. replace all latex containing items with non-latex items. c. be aware of the allergy d. see that the surgery is cancelled with all units and personnel is imperative to ensure that these patients are not exposed to latex. a. socializing b. communication c. professionalism d. friendliness Where would be strategic spots to post Figns warning personnel about the patient’s latex allergy? 1 . the main entrance to the OR department and on the surgical schedule 2. the door to the OR suite and the anesthesia machine to be used on the patient 3. the patient’s bed and chart 4. the patient’s room and on the front of his or her gown a. 1 and 2 b. 2 a n d 3 c. 3 and4 d. 1 and4 The best way to determine if a product is latex-free is by a. checking on the package b. checking with purchasing c. checking with the manufacturer 505
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d. checking with the patient 20. Creating a latex-free environment is more expensive and more work for the surgical team, however, this can result in n o occurring and no being given in the majority of patients.
Position on HIV and Nursing Students Defined In support of strong, ongoing, comprehensive education for nursing students about acquired immune deficiency syndrome (AIDS) and the human immunodeficiency virus (HIV), the American Nursing Association (ANA) issued a position statement on HIV infection and nursing students. According to the recent position statement, the ANA believes that nursing curriculums that include current HIV information should be provided at the beginning of academic programs by a faculty member with expertise in the field. Education should continue throughout the students’ course of study. Also, all nursing students, with informed consent, should be immunized against hepatitis B virus (HBV) unless there are medical contraindications. Each nursing school also should provide a post-exposure management program for students who sustain exposure to blood and body fluids in clinical settings. Each school should provide health care services to students during their enrollment. Nursing schools also should develop a means for providing disabilitycoverage for students in the event of HIV or HBV exposure in clinical settings. Nursing students or nursing school applicants should not be deprived of access to schools or dismissed from their educationalprogram based solely on HIV-positive status. All HIV-related information should be confidentialto safeguard nursing students’rights to privacy. Finally, nurs-. ing students should be assured of protections consistent with those of employees covered under the Occupational Health and Safety Act.
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a. b. c. d.
deaths, inappropriate medications anaphylaxis, prophylactic medications latex contact errors, medications interrupted surgeries, therapeutic medications.
New Publications Help with Survey Preparation Two new publications designed to help nurses prepare for hospital accreditation surveys are now available from the Joint Commission on Accreditation of Healthcare Organizations, according to a June 29, 1992, news release. The first guide, Defining Nursing Care in Your Hospital, will help nurses define their organization’s nursing care as required by the nursing standards, which were revised significantly in the 1991 accreditation manual. The guide divides the process of defining an organization’s nursing care into a seven-step plan. It also provides examples that staff members can use in writing their own definitions. The second publication, How to Prepare for a Survey: Nursing, explains the entire accreditation process. Topics include what nurses should expect from the survey, what needs to be done 3 to 6 months before the survey, and what needs to be done immediately before the surveyors’ arrive. A series of checklists also is provided to help organize information for the survey. Both guides can be ordered by writing to Cashier, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, Ill. Credit card orders can be placed by calling the customer service center at (708) 9 16-580.
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Answer Sheet bTEX
ALLERGY
P
lease fill out the application and a n s b c ' r form below and the evaluation on the back of this page. Tear out the page from the . l o i ~ m ~ / or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 8023 1 Event # 935003
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Program offered September 1992 The deadline for this program is Feb 28, 1993. 1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicate. your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete thc program -~ 5. Enclose fee: Members $7; Nonmembers $14.
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AORN (ID) # If nonmember, please provide Social Securit) #
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1to 5. 1. Objectives.To what extent were the following objectives of this home study programachieved? (1) Describe the allergic response to latex. (2) Iden@ populations at high risk for latex allergy. (3) Describe the perioperative assessment of patients with latex allergy. (4) Identify actions the perioperative nurse can take when caring for a patient with latex allergy.
2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individualobjectivesmet? (5) Was the content of the article relevant to the objectives?
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(High)
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(4)
(5)
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(1) (1) (1)
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(5) (5) (5) (5)
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3. Test questionslanswers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address impomnt points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
Topic(s):
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