Chapter 15

Latex Allergy
Concern about lat ex al l ergy in t he medi cal communi t y has increased as heal th care
personnel have seen an increase i n reacti ons among bot h pati ents and themsel ves.
Latex i s the second most common cause of i ntraoperati ve anaphyl axis, preceded
onl y by muscl e rel axants (1).
Origin of Sensitivity
Natural l atex is obtai ned f rom the sap of a rubber t ree. Duri ng the manufacturi ng
process, many chemi cals are added to the l at ex, dependi ng on the desi gn and
t echnical requi rements of the fi ni shed product . These substances may al so be
al l ergeni c. There may be as many as 240 potenti al l y al l ergeni c substances i n
processed l atex products (2).
The i ncreased i nci dence of l atex al l ergy i s bel ieved to be due bot h to changes i n
t he manuf act uring processes and i ncreased use of l atex-contai ni ng products.
Adopti on of uni versal and standard precauti ons (Chapter 34) has greatl y increased
l atex exposure.
Latex sensi t izati on can occur as a resul t of contact vi a the ski n or mucous
membranes, i nhal at i on, i ngesti on, parent eral i nject ion, or wound inocul at i on.
Latex-containing Products
Latex i s ubi qui tous i n the home, workpl ace, and heal t h care set ti ng but is not
al ways obvi ous. In the operat ing room sui te, i t i s f ound in gl oves; t racheal tubes;
Combi t ubes; f ace masks; mask straps; ai rways; wrappers on t rays; l aryngoscope
bul b gaskets; ski n temperat ure moni tors; rubber sucti on catheters; arm boards; bi te
bl ocks; teeth protectors; breathing t ubes; oxygen tubi ng; reservoi r bags; venti l ator
hoses and bel l ows; resusci tat ion bags (black or bl ue, reusable); bl ood pressure
cuff s and tubi ng; stethoscope tubi ng; intravenous tubi ng injecti on ports;
t ourniquets; syri nge plungers; rubber-shod clamps; i nt ravenous bag and t ubi ng
ports; medi cati on vi al needl e ports; tape and other adhesives (e.g. , Esmarch
bandages, adhesi ve bandages); dental dams; elast ic bandages (Ace wraps);
dressi ngs (e.g. , Coban, Mol eski n, Micropore); rubber pads; prot ective sheets;
drai ns; electrode pads; rubber aprons; ci rcul ati ng f l ui d warmi ng blankets; some cast
materi al ; goggl es; pul monary art ery cat heter bal l oons; epidural catheter adapters;
i ntravenous (IV) medi cat ion pump casset tes; el ect rocardi ogram (ECG) el ectrodes
and pads; f i nger cots; ostomy bags; i nt est i nal and stomach t ubes; rubber bands;
chest t ube drai nage system tubi ng; condom uri nals; uri nary and nephrost omy
catheters; gast rostomy tubes; bulb syri nges; adhesi ve drapes; ni ppl es; inst rument
mats; speci men traps; catheter bag st raps; di l ati ng catheters; and
P. 432

t he el ast ic i n i t ems rangi ng f rom surgi cal masks, head coverings, hats, and booti es
t o di apers. Al l ergi c react ions have been at tri but ed to drugs that had been prepared
i n a l at ex-contai ni ng syri nge f or a consi derabl e t i me before use or a bot tl e wi t h a
l atex stopper bet ween t he drug and the di l uent (3,4).
Products made of dry, mol ded, or ext ruded rubber such as wheel chai r t i res, tool
handl es, rubber seals, vi al stoppers, and syri nge plungers cont ai n much l ess
al l ergen than do i tems such as gloves, condoms, and bal loons t hat are formed by
di ppi ng f orms i nt o l i qui d l atex (5).
Wel l -washed rubber products such as vent il at or bell ows pose l ess ri sk than new
i tems (2). There is a decrease i n l atex prot ei ns in gl oves that are autocl aved (6).
Products t hat are st eri l i zed by usi ng ethylene oxi de may i ncrease the ri sk of l at ex
sensi ti zati on (7).
Gl oves have very hi gh al lergen l evels compared wi th most other l atex-contai ni ng
medi cal products. Latex gl oves are the bi ggest cont ributors to the aeroal l ergens
i nsi de the operati ng room. Many gl oves cont ain powder. Lat ex protei ns f rom the
gl oves bond wi th t hi s powder. When a gl ove i s put on or removed, the powder may
spray i nto t he ai r. It can then be inhal ed by personnel , i noculat e an open wound,
and cont ami nat e the i nst ruments on t he surgi cal f i el d (8). The highest l evels of
ai rborne l at ex al l ergen are f ound i n the operati ng rooms where powdered l atex
gl oves are f requentl y donned and removed (9, 10, 11). The powder can remai n
suspended i n the ai r f or hours. Even i n operat ing rooms where l ami nar ai rf l ow
devices are used, latex aeroal l ergens are present i n hi gh quant i t i es. Al l ergens are
carri ed t hroughout t he envi ronment by venti l ati on ai r exchange systems as wel l as
by sett l i ng on clothi ng and equi pment . Swi tchi ng to l ow-al l ergen gl oves has been
f ound t o reduce the level s of these aeroall ergens (12).
Latex i s found in many products outsi de the heal th care sett i ng. These i ncl ude toys;
condoms; expandable f abrics (wai stbands); di aphragms; bal l oons; hot water
bot tl es; erasers; rubber bands; shoe soles; motorcycl e and bi cycl e handgri ps;
bathi ng sui ts, caps, and goggles; racquet handl es; paci f i ers; baby bot tl e ni ppl es;
bungee cords; chewi ng gum; cosmet ic appl i cator sponges; f i sh tanks; bi ke hel mets;
automobil e ti res; rai ncoats; computer mouse pads; earphones; household rubber
gl oves; and carpet paddi ng to name but a few (8, 13).
Clinical Signs and Symptoms
Reacti ons t o l atex i nclude a spect rum of non-i mmune and i mmune-medi ated
responses. Si gns and sympt oms may be local or systemi c and vary wi del y i n
severi t y and t he ti me of occurrence. Most adverse reacti ons t o l atex occur 30 to 60
mi nutes af ter i nduct ion (14, 15). Symptoms can progress qui ckl y f rom mi ld t o
severe. I n some cases, l i f e-threatening reacti ons are the f i rst to appear.
There are three t ypes of reacti ons t o l atex: i rri t ant contact dermati tis, Type IV
del ayed hypersensi t ivi ty, and Type 1 i mmedi ate hypersensi ti vi ty (2,8,16).
Irritant Contact Dermatitis
Thi s i s t he most common t ype of gl ove-rel ated reacti on. I t resul ts f rom t he di rect
acti on of l atex and other i rri tant chemical s and consists of i tchi ng, redness, scali ng,
dryi ng, and ski n cracki ng. The rash is usual l y l i mi ted to t he exposed ski n area.
Soaps, mechanical i rri t at ion f rom scrubbi ng, and excessi ve sweati ng of ten
exacerbate i t . Whi le t hi s is not a true al lergy, di srupti on i n ski n int egri ty may
enhance absorpt ion of latex al l ergens and accelerate the onset of al lergi c
react i ons.
Type IV Delayed Hypersensitivity
Hypersensi t ivi ty is an i mmune response t hat l eads to ti ssue damage. Once
sensi ti zed, an i ndi vi dual ' s exposure to an ant i gen can cause a reacti on. I t may take
several years f or l atex sensi t i vi ty t o develop. When i t does, most develop as a Type
I V (del ayed) react i on.
A Type I V reacti on (all ergi c cont act dermati t i s, del ayed hypersensi ti vi t y) i s a T-
cell medi ated response characteri zed by a ski n rash that appears up to 72 hours
af ter ini t ial contact and may progress to oozi ng ski n bl i st ers. Unl i ke i rri t ant cont act
dermat i ti s, al l ergic contact dermat i ti s of t en spreads beyond the area of contact wi t h
t he al l ergen. Fl ushi ng, i tchi ng, rhi ni t is, di zzi ness, si nus symptoms, conj uncti vi ti s,
and eyel id edema may al so be present.
Not al l i ndividual s who devel op Type IV hypersensi t ivi ty progress to Type I , but
most i ndividual s wi t h Type I sensi tivi t y have previousl y had Type IV symptoms
(2,16,17).
Type I Immediate Hypersensitivity
Thi s i s t he most severe react i on and may l ead to signi f i cant morbidi t y and mortal i ty
(18). Sympt oms usual l y appear shortl y af ter exposure but can occur hours later.
They run t he ent i re spectrum f rom mi l d (skin redness, hives, i tchi ng, rhi ni ti s,
scratchy throat , i tchy or swol l en eyes) t o more severe (faci al edema, f ai ntness,
nausea, abdominal cramps, di arrhea, cough, hoarse voi ce, chest ti ghtness) t o l i fe
t hreateni ng (l aryngeal edema, bronchospasm, anaphylaxi s). A survey of
anaphylaxis duri ng anesthesi a showed that cardi ovascular symptoms, cutaneous
symptoms, and bronchospasm were the most common cl i ni cal features (19).
Anaphyl axis i s an i mmediate, severe, l i fe-t hreateni ng al lergi c response. There are a
number of report s i n the l i terature of anaphyl acti c react ions to l atex
(1,2,4,7,20,21, 22,23,24,25,26,27,28,29,30,31,32, 33,34).
P. 433

Latex al l ergy should be hi gh on t he li st of possi bi l i ti es when anaphyl axi s occurs
duri ng anesthesi a and surgery. I t may not be apparent that l atex is the causat ive
f act or. If medicati ons have been i nj ected i n cl ose proxi mi ty to t he anaphylacti c
react i on, t he anesthesi a provi der may suspect t hat medicati on caused t he react ion
(32). Fai lure t o recogni ze l atex all ergy can del ay removal of lat ex-containing
products and del ay ef f ecti ve t reatment.
Individuals at Risk
I dent i f yi ng pati ents at hi gh risk f or havi ng an al lergi c l atex reacti on al l ows
preventi ve measures to be t argeted (17). Hi gh-ri sk groups can be i dent i f i ed by
knowi ng the risk factors and appropri ate questi oni ng. Latex anaphyl axis may be
decreased by i denti fying at-ri sk pati ents (19).
The report ed preval ence of latex all ergy vari es greatl y dependi ng on the popul ati on
studi ed and the met hods used to detect sensi ti zati on. Anyone wi t h f requent
exposure to l at ex-contai ni ng materi al s i s at i ncreased ri sk of devel opi ng l atex
al l ergy. The greater t he exposure to l atex i n a popul ati on, the greater the number of
sensi ti zed i ndi vi duals. Ext ended or massive exposure i n and of i tsel f i s nei ther
necessary nor suf f icient to cause sensi ti zati on i f the person is not geneti cal l y
predi sposed (35).
Chi l dren and younger adul ts are more l ikel y to become latex sensi t ive t han t he
general popul ati on. Some but not al l studi es have found that women and members
of non-Caucasi an races are more l ikel y to have l at ex al l ergi es (17,35, 36,37,38).
The maj ori t y of l atex-sensi ti ve i ndi vi dual s have a history of at opy (predi sposi t i on to
mul ti pl e al lergi c condi t i ons) or posi t ive tests i n atopy screening
(2,17,25,27,35,39, 40,41,42, 43). Many have a hi story of an anaphyl act ic reacti on i n
t he past (8, 36,43). Some studies have f ound a connecti on bet ween an al l ergy to an
anesthesi a-relat ed agent and l atex (43,44).
Many pati ents wi th Type I latex al l ergy have a hi st ory of al l ergy t o certain f oods,
i ncl udi ng bananas, mangoes, watermel ons, avocados, peaches, f i gs, appl es,
chest nuts, pi neappl es, ki wi , passi on f rui t , apri cots, nectari nes, papaya, cel ery,
peanuts, cherri es, strawberri es, pl ums, pot atoes, and tomatoes
(2,5,25,35,37,45,46). There may be cross sensi ti vi ty between l atex and f i cus,
grasses, and ragweed (47). Pat ients wi th mi l k protei n al l ergi es may exhibi t all ergi c
react i ons to l atex products containing casei n (48).
I ndi vi dual s wi th hand dermati ti s who wear latex gloves are at i ncreased ri sk (35). A
hi story of gl ove-related symptoms does not rel i abl y i ndi cat e latex al l ergy;
conversel y, absence of symptoms does not rul e out sensi ti zat i on (42).
Many l atex-sensi ti ve i ndi vi dual s report swel l i ng or i t chi ng on the hands or other
areas af ter contact wi th rubber gloves, condoms, diaphragms, toys, or other rubber
products. Other symptoms i ncl ude swel l i ng or i t chi ng at t he l ips or mouth f rom
bl owi ng up bal l oons or af ter dental exami nat i ons (2).
Latex al l ergy i ncidence i s hi ghest for pat ient s requi ri ng mul t i ple operati ons al ong
wi th repet i ti ve uri nary catheteri zat ion. This i ncl udes pat ients wi th myelodyspl asi a,
congeni tal ort hopedic defects, and congeni tal geni touri nary tract abnormal i ti es
(49). Spi na bi fi da pati ents have a parti cularl y high i ncidence. However, adul ts wi t h
spinal cord injuri es have a l ow ri sk of l atex sensi ti zati on (50). Ot her hi gh ri sk
groups i nclude pati ents who undergo repeated esophageal dil ati ons, pati ents who
have f requent vagi nal exams (part i cul arl y those going t hrough an i n vi tro
f ert i l i zat i on program) and are exami ned wi t h a l atex-covered ul t rasound probe (51),
and pati ents undergoi ng bari um enema procedures wi th a l atex bal loon ti p (17).
Ot her at -ri sk pat i ents f or l at ex al lergy i ncl ude those who use gl oves i n thei r dai l y
acti vi ti es: farmers, f ood-servi ce workers, gardeners, pai nters, mort uary workers,
auto techni ci ans, l aw enf orcement personnel , wast e removal workers, hai rdressers,
i ndi vi dual s i nvolved i n the manuf acture of latex products, and those wi t h pri or
react i ons to l atex-contai ni ng devices.
Approximatel y 70 percent of adverse events t o l atex report ed to t he Food and Drug
Admi ni st rat i on (FDA) invol ve heal th care workers. Wi t hi n the medical prof essi on,
i ndi vi dual s who f requent l y use di sposabl e gl oves, i ncl udi ng surgeons; anesthesi a
provi ders; operati ng room, postanesthesi a care uni t (PACU), and emergency room
personnel ; denti sts and dental assistants; and l aboratory t echni ci ans are more
l ikel y to become latex sensi ti ve t han other heal th care workers. Adul t
anesthesi ol ogi sts change gl oves more of ten t han pedi at ri c anesthesi ol ogi sts and
have an increased prevalence of l atex sensi ti zati on (52).
Diagnosing Latex Allergy
Latex al l ergy is di agnosed by history and conf i rmatory t ests (53).
History
St andard quest ions to screen f or l atex al lergy shoul d be devel oped. There are
exampl es of screeni ng tools f or pati ents in the l i terature that can be of assistance
i n devel oping a questi onnai re (46,54). The history should i ncl ude the ri sk f actors
and occupati ons where l atex exposure i s common, as discussed previ ousl y i n thi s
chapter.
P. 434


Confirmatory Tests
A pat ient wi th a hi st ory suspi ci ous f or l atex al lergy may be a candi dat e for
confi rmatory testi ng.
I mmunol ogi c testi ng i s not f ool proof , part i cul arl y in t he case of l atex, because of
t he numerous di f f erent latex prot ei ns. Testing requi res a variety of l atex anti gens,
and there can be no certai nt y t hat a part i cul ar anti gen wi l l be i ncl uded i n the t est
solut i on (17). Because fal se negat ives can occur, pati ents wi t h a strong suspi ci on
of l at ex al l ergy shoul d be managed i n a l atex-saf e envi ronment even i f i mmunol ogi c
t est ing i ndicates a negative reacti on (17).
Skin-prick Test
The ski n-pri ck test (SPT) i s used to detect Type I l at ex al l ergy (38). A di l ut e
solut i on of l atex al lergen i s pl aced on the skin, and the ski n is pri cked or scratched.
A wheal -and-f l are react ion i s consi dered posi tive f or l atex sensi tivi ty. Thi s test i s
i nexpensive and easy to admi ni ster and i nterpret . I t of fers reasonabl y good
sensi ti vi ty and specif i ci ty. Retrospecti ve studi es show t hat pati ents wi th
i ntraoperati ve l atex anaphyl axi s are almost i nvari abl y lat ex-SPT posi t i ve (42).
Drawbacks to t he SPT i ncl ude absence of an accepted test soluti on (2,5,9, 17,55).
The risk of a systemi c anaphylacti c react ion exi sts, but i t i s less than wi t h
i ntradermal testi ng.
Intradermal Test
Wi th intradermal testi ng, a smal l amount of a suspension or al lergen i s injected into
t he ski n. This method i s more sensi t ive t han ski n pri cki ng, but t he chance of
anaphylaxis i s greater (17,56).
Patch Test
The patch t est is avai labl e f or di agnosi s of Type IV delayed hypersensi tivi t y (8,38).
A standardi zed patch or a f ragment of t he latex product i s appl i ed to t he ski n and
checked over several days. A posi ti ve reacti on incl udes i tchi ng, redness, swel l i ng,
or bl i st eri ng where the patch covers the skin.
In Vitro Measurement of Antibodies
I n vi t ro tests are used t o measure specif i c ant ibodi es agai nst l atex al l ergens i n
bl ood sampl es (57). These tests are expensi ve, and the cl i ni cal si gnif i cance of a
posi t i ve serol ogi c test i s uncl ear. Subjects wi t h anti l atex ant ibodi es are termed
l atex sensi t i ve, al t hough many are not symptomati c and may never become so.
Chall enge Tests
Chall enge (provocati on, use, wear) tests may be used i f t he resul ts of other tests
are equi vocal or if t he person has a cl ini cal hi story hi ghl y consi stent wi t h l at ex
al l ergy but resul ts of other t ests are negat ive (5, 35,58). The pot ent ial l y al l ergi c
person handl es, wears, or inhal es l atex protei ns and i s observed for reacti ons.
However, there may be discrepanci es i n chal l enge test resul ts, and no chall enge
method has become broadl y accepted by cl i ni ci ans.
Preventing Reactions
Successful preventi on of l atex react ions requi res a f aci l i t y-wi de strat egy. Heal th
care faci li ti es shoul d appoint a mul t i disci pl inary task f orce that incl udes
representati ves f rom every prof essi onal component of t he i nst i tut ion. I t should
i ncl ude an al l ergist or i mmunol ogi st as consul tant. I t may be a good idea to have a
l atex-sensi ti ve empl oyee on the t eam (9). Among t he dut i es of t hi s t ask f orce
shoul d be gl ove sel ecti on, a mechani sm f or reporti ng latex reacti ons, formul ati ng
pol i ci es and protocols f or management of t he latex-sensi t ive pati ent , and heal th
care worker and educati onal programs (2,59,60).
Medi cal products that cont ai n l atex wi l l need t o be i denti f ied and al t ernat ives
establ i shed bef ore an emergency arises. Manuf acturers have made great stri des in
decreasi ng l atex i n a variety of products (57). I f i t i s not possi bl e to remove a l atex
product, barri ers shoul d be pl aced between the l atex i tem and the pat i ent .
Successful preventi on of all ergi c reacti ons wi l l occur onl y when i nsti tuti ons adopt
st ri ct pol icies to protect at -ri sk pat ients f rom unnecessary latex exposure. At -ri sk
chil dren in a l atex-contai ni ng envi ronment are more l i kely t o have an al l ergic
react i on than t hose in an envi ronment where l atex-contai ni ng arti cl es have been
removed (3,61).
I t i s i mpossi ble t o tot al l y el i minat e l atex exposure. The goal is to create a l at ex-
saf e envi ronment, that is, one i n whi ch the presence of lat ex anti gens i s mi ni mi zed.
The need for educati on cannot be overemphasi zed. The maj ori t y of l at ex reactions
i n a center wi th an establi shed protocol were at tributed t o human error (61).
Usi ng powderl ess gl oves shoul d be a hi gh pri ori t y (5,62,63). I t hel ps t o mini mi ze
react i ons to l atex at l i tt le added expense and decreases the amount of
aeroal l ergens i n the worki ng envi ronment. Oi l -based hand creams or l ot ions should
be avoi ded. They can break down l atex and make the protei n more l i kel y to st i ck to
t he hands. When gl oves are powdered, pul li ng them on and of f gentl y wi l l mi ni mize
aerosol i zi ng the latex prot ei ns.
Pat i ents wi t h known or suspect ed l atex al l ergy shoul d have thei r records fl agged
and wear l atex-al l ergy wri st bands. Drug prophylaxi s is someti mes undert aken (56).
Al l ergi c react ions, i ncludi ng anaphyl axi s, may occur even when prophyl acti c agents
are used (3,64). Whi l e having t hese drugs al ready on board may lessen t he
P. 435

severi t y of a react ion, they may mask the earl y si gns of anaphylaxi s, delaying
recogni t i on and i mplementat ion of more aggressi ve t reatment (17). Using H
2

bl ockers may i ncrease the ri sk of heart bl ock for pati ents who develop anaphylaxi s
(65).
I f pat ients requi ri ng surgery have conf i rmed l atex sensi ti vi t y or convi nci ng hi stori es
of l at ex react ions, avoi di ng latex-contai ning products is t he onl y ef fective therapy.
Thi s i s not al ways easy, as l atex al l ergens permeate t he hospi tal . Even i n the
absence of known l atex al l ergy, some procedures i nvol vi ng pati ents wi t h syndromes
such as spi na bi f ida shoul d be performed i n a l at ex-saf e area (66). For hi gh-ri sk
pati ent groups, avoi di ng l atex products should begin at bi rt h (67).
The FDA requi res that al l medi cal products t hat cont ai n l atex that may di rect l y or
i ndi rectl y come i nt o contact wi t h the body duri ng use to bear l abels stat ing t hat the
product contains l at ex and that l atex may cause al l ergic react i ons i n some
i ndi vi dual s (68) (Fi g. 15.1). Governmental agenci es i n many other countri es have
si mi l ar requi rements (68). If a product does not have this warni ng, i t i s l ikel y t hat
t he product is l atex-f ree unl ess i t i s a pharmaceuti cal or i s not regul at ed by t he
FDA. Drug manufacturers are exempt f rom t he l abel i ng requi rement (69).
Manuf acturers f requent l y l abel devices as latex-f ree (Fi g. 15.2).
The t erm hypoal l ergeni c is no l onger used for devi ces that cont ai n l atex. At
present, there i s no test that can adequately determi ne the l evel of l at ex proteins i n
a product, and there i s no manuf acturing process t hat can reduce t he level bel ow
t he mini mum requi red t o produce a react i on i n some peopl e. Al so, the t otal protei n
content i s not anal ogous t o al l ergi c ri sk.
The l at ex-sensi ti ve pati ent shoul d be schedul ed as the fi rst case of the day wi th al l
l atex-cont ai ni ng materi al s removed the precedi ng ni ght to mi ni mi ze exposure t o
ai rborne l at ex-l aden part i cl es (2). No one shoul d ent er that operati ng room wi t h
l atex gl oves wi thout scrubbi ng af ter taking of f l atex gl oves or whi l e weari ng cl othi ng
f rom previ ous l at ex exposure.

View Figure

Figure 15.1 Thermodilution catheter clearly marked as
containing latex.

Si gns sayi ng Latex Al l ergy or Lat ex Al ert (f or pat ients wi t h signi f i cant ri sk
f act ors f or l atex al lergy but no overt signs or symptoms) shoul d be posted i nsi de
and outside the operati ng room as wel l as in peri operat ive care areas (Fi g. 15.3).

View Figure

Figure 15.2 Device labeled latex-free.

P. 436



View Figure

Figure 15.3 A sign indicating possible latex allergy should
be placed outside the operating room door.

Latex products shoul d be l i mi ted t o si tuati ons where i t i s thought that they are
superior to nonlatex-cont ai ni ng products. Latex-f ree gl oves wi th i mproved f i t and
f eel are avail abl e (70).
A ki t/cart contai ni ng l atex-f ree products shoul d accompany the pat i ent t hroughout
hi s or her stay. Latex precauti on sti ckers shoul d be pl aced on doct ors' order sheets
and the l ike. Si gns stat ing Latex Precauti ons or Latex Al lergy should be pl aced
on the wal ls and doors of t he pat ient' s room. Any department that i s to recei ve a
pati ent wi t h l atex al l ergy or sensi ti vi ty shoul d be noti f i ed pri or t o transfer t o that
department .
Peri operat ive care areas where mul t ipl e pati ents are managed i n proxi mi t y (e. g. ,
preoperat ive hol di ng areas and PACUs) shoul d be re-eval uated. If powdered gloves
are used i n these areas, pat ients may be admi t ted di rectl y to the operat ing room
and remai n there duri ng thei r recovery f rom anesthesi a. I f PACUs have isol ati on
rooms, t hey may be converted t o l atex-saf e envi ronments f or pat i ents recoveri ng
f rom surgery (71).
Some heal th care f aci l i ti es have establ i shed a speci fi c operat i ng room where al l
l atex-cont ai ni ng materi al s are banned. Si gns shoul d be posted on al l entrances to
t hat operati ng room, reminding medi cal personnel of t he si tuati on (72). Traff ic i n
t he room shoul d be kept to a mi ni mum (2).
No l atex-contai ni ng i t ems (i . e., gowns, hats, boots, and compressi on stocki ngs)
shoul d be pl aced on the pat ient . Cords and t ubes f or al l moni t ori ng devi ces shoul d
be pl aced in st ockinettes and secured wi th non-l at ex tape (73).
Latex-f ree i nt ravenous st art ki ts contai ni ng t ourniquet , bandages, dressings, t apes,
and gloves are avai l abl e. Intravenous t ubi ng wi thout l atex injecti on ports should be
used or al l l atex i nj ecti on ports shoul d be t aped to prevent i nadvertent puncture.
St opcocks or one-way valves should be used for push and pi ggyback medi cati ons.
I ntravenous f l uid or commerci al l y prepared medicati on bags shoul d be pi erced
t hrough the int ravenous tubi ng port, not the l atex i nj ect ion port.
Al though react i ons to rubber syri nge pl ungers have been report ed, no problems
have so far been described i n medicati ons f reshl y drawn and i mmedi ately
admi ni stered (74). I f l atex-cont ai ni ng syringes are used, drugs shoul d be f reshl y
prepared i n the syri nge i mmedi atel y bef ore use. Gl ass syri nges off er an at t racti ve
al ternati ve, and total l y pl astic syri nges and speci al needl es are avai l abl e
(75,76,77). It i s best to use medi cati on f rom glass ampul es, if avai l abl e. Al though i t
has been advocated t hat t he contents of a vi al shoul d be drawn up af t er t he rubber
stopper has been removed (17,47, 78), t his may not be benef ici al and may resul t i n
i ncreased microbi al contami nati on and waste (79). Lyophi l i zed drugs i n contai ners
wi th l at ex shoul d be reconsti t uted by usi ng a syri nge, not shaken i n a mul t i dose vial
and wi t hdrawn by usi ng a f i l ter. Vi al s should be kept upri ght and not shaken (4).
A f i l ter shoul d be used at t he breathing system pat ient port t o protect agai nst
ai rborne l at ex al l ergens (80,81).
I t may not be possi bl e to enti rel y avoi d some rubber-contai ning anestheti c
equipment -rubber bel l ows, di aphragms, val ves, and tubi ngs (82). However, when
t hese part s of equipment do not come i nto contact wi t h the pati ent and have been
previ ousl y washed, no compli cat i ons have resul ted (83).
Latex-f ree equi pment i ncludi ng f ace masks, ai rways, mask straps, tracheal t ubes,
bag-valve-mask uni ts, reservoi r bags, ECG el ect rodes and pads, st ethoscopes
(tubing or di aphragm), pul se oximet ry sensors, esophageal stethoscopes,
nasogastri c and sucti on tubes, tape, gas hoses, and breathi ng t ubes shoul d be
used. Unfortunatel y, some l atex-f ree reservoi r bags have such poor di stensi bi li t y
t hat thei r use may compromise pati ent saf ety (84).
I f an epi dural cathet er adaptor contai ns l atex, i t shoul d be replaced wi th a bl unt ,
l atex-f ree adaptor.
Latex-f ree reusabl e blood pressure i nst ruments and accessori es are avai l abl e i n a
vari et y of si zes and model s. These i ncl ude i nf lati ng tubing, coil ed t ubi ng,
sphygmomanomet ers, and i nf l ati on bl adders. Wrappi ng the area under t he cuf f wi th
sof t cotton can prevent contact wi t h any l atex i n these devi ces.
I n some cases, some i mprovi si ng may be necessary, as wi th a pulmonary artery
catheter (85,86).
From the surgi cal poi nt of vi ew, using non-l at ex gl oves, drai ns, and cat heters is
mandatory. Special precaut i ons shoul d be undert aken t o avoid l atex-based
equipment such as i nst rument mats, rubber-shod cl amps, vascular tags, bulb
syri nges, rubber bands, and adhesive bandages. A non-l at ex gl ove can be used as
a
P. 437

Penrose drai n, which can be a source of latex hypersensi ti vi ty (86A).
When l at ex-sensi t ive pat ients or staff have been ident if i ed, i t is i mport ant to
provi de l atex-f ree i tems. These shoul d be col l ected i nto a cart t hat can be cal l ed
i nto acti on as t he need ari ses. The Ameri can Soci et y of Anesthesiol ogists and
ot hers have made recommendati ons f or t he contents of a l atex-saf e cart (2,59,86).
Suggest ed i tems are l isted i n Tabl e 15. 1. Each i t em shoul d gi ve i nf ormati on on
l atex content and shoul d be reviewed for t hi s informati on pri or t o addi ng the i tem to
t he l atex-safe cart or bef ore use.
TABLE 15.1 Suggested Contents of a Latex-safe Cart
Latex-free or glass syringes
Syringe needles
Intravenous catheters
Intravenous tubing and extensions made from polyvinylchloride
Stopcocks (in-line, three-way, and single)
Latex-free heparin lock caps and T-pieces with side port
Alcohol wipes in a new box
Latex-safe adhesive tape from a new box
Latex-free intravenous tourniquets
Sterile gauze pads
Esophageal thermometer
Disposable blood pressure cuffs of various sizes
Isolation stethoscope
Sterile case padding
Latex-free disposable pulse oximetry finger sensors
Latex-free ECG electrodes
Latex-free resuscitation bags sized for infants, children, and adults
Nasal oxygen cannula
Oxygen extension tubing
Latex-free tracheal tubes, double-lumen tubes, and stylets
Latex-free oral and nasal airways
Silicone supraglottic device
Plastic face masks and head straps (elastic strap may have latex)
Medications for cardiac arrest and emergency situations
Vinyl gloves for any size staff
Sterile nonlatex gloves, sizes 6 to 9
Silicone urinary catheter in assorted sizes
Urimeter
Epidural and spinal trays
Polyvinylchloride suction catheters, sizes 8 to 14 French
Anesthesia breathing circuits without latex components
Anesthesia medications in vials
In-line high efficiency particulate gas filter
Policy binder with all latex policies and protocols
Reference guide for latex-containing materials
Brightly colored signs that warn of latex allergy

Treating Latex Reactions
The symptoms of i rri t ant contact dermati tis can of ten be control led by removing the
i rri t ant . Measures incl ude weari ng a sof t gl ove l iner and reducing exposure to other
i rri t ants (e.g. , soaps). Treatment wi t h t opical cort ico-steroi ds may be hel pf ul . Use
of protective hand creams, however, i s contrai ndicated (2).
For all ergi c reacti ons, t he most i mportant step i s t o stop admi ni st rat i on and/or
reduce absorpt ion of the off ending agent . Al l pot ent i al routes of exposure, i ncl udi ng
mucosal and i nhal at ional , must be considered.
Topical cort icost eroids can be used f or a rash or hives. Topi cal nasal st eroi ds may
be used for rhi ni ti s (2). Anti hi st ami nes and systemi c steroi ds can be used to t reat
ot her mi l d reacti ons (2). If the symptoms are more severe, more aggressi ve
t reatment is i ndi cated, incl udi ng ant ihistami nes, systemic st eroi ds, H
2
bl ockers,
oxygen, intravenous f luids, bronchodi l ators, and epi nephri ne (2,36,87). If
anaphylaxis occurs, art if i ci al ai rway support may be needed as wel l as
i ntravascular vol ume expansi on, admi ni strati on of vasoacti ve medi cat i ons, and
ot her l i fe-support t echniques. The crash cart must not cont ai n l atex-contai ni ng
i tems (2).
Latex precaut ions should accompany the pati ent throughout the remai nder of t he
postoperati ve peri od (PACU, i ntensi ve care uni t, and di scharge uni t).
The detai l s of any all ergi c reacti on shoul d be cl earl y documented i n the pati ent ' s
chart . Thi s shoul d i nclude a descri pti on of the anest het i c agents and techni ques,
surgi cal products used, resusci tati ve measures requi red, l aboratory eval uati on, and
t he peri operati ve course. The pati ent should be ref erred to an al l ergist and the
pati ent 's record f lagged t o alert subsequent caretakers.
Desensi t izati on by using progressi ve contact has been descri bed (88). I t consi sts of
i ncreasi ng exposure to lat ex by weari ng l atex gloves dail y f or increasi ng peri ods.
Subl i ngual desensi t i zat ion may resul t i n si gni f icant i mprovement in sympt oms (89).
Latex Allergy and Medical Personnel
Numerous studies show a hi gh inci dence of l atex al l ergy in heal th care workers
(2,8,9,10, 11,35,40,41,42,56,90,91,92, 93,94, 95). Medi cal personnel who wear l atex
gl oves on a regul ar basi s (surgeons, anesthesi a provi ders, operati ng room staff ,
radi ol ogi sts, housekeepi ng staf f , and l aboratory personnel ) are at hi gher ri sk f or
devel opi ng l atex all ergi es than are other heal th care workers (41,42, 72).
Occupat i onal asthma has been report ed i n an admi nistrat ive employee who was
exposed t o ai rborne l atex al lergens (96).
P. 438


Health Care Institution Responsibilities
I nst i tut ions should provide educati on programs and trai ni ng mat eri al s about latex
al l ergy (71). Thi s i ncl udes educati ng al l st af f members, not j ust prof essional heal th
care provi ders. For example, envi ronmental and nut ri t ional service workers are
requi red t o wear gl oves; theref ore, they shoul d be knowl edgeable about thei r gl ove
choices.
St af f shoul d be encouraged to report al l ergi c symptoms and be peri odical l y
screened f or l atex-al l ergy symptoms. Det ecti ng symptoms earl y and protecti ng
symptomati c workers f rom l at ex exposure are essenti al f or prevent ing l ong-t erm
heal th ef fects. Prevent i on st rat egi es shoul d be re-evaluated whenever a worker i s
di agnosed wi t h l at ex al l ergy. Studi es have shown t hat economical l y feasi bl e
i ntervent ions to reduce l atex exposure can successf ul l y al l ow l atex-al l ergic
i ndi vi dual s to cont inue worki ng as wel l as decrease the number of new cases of
occupati onal latex al l ergy (5).
The use of powderl ess gl oves (Fi g. 15.4) shoul d be encouraged. In a study i n whi ch
heal th care workers used bot h powdered and powder-f ree gl oves, the rate of
conversi on to l atex sensi ti vi ty was the same i n each group, but the convert ers usi ng
powdered gl oves were symptomati c whereas the ones usi ng powderl ess gl oves
showed no symptoms (92).
Usi ng non-l atex gl oves f or activi t ies t hat are not l i kel y t o i nvolve contact wi th
i nfect ious materi al s (f ood handl i ng, housekeepi ng, t ransport ) shoul d be
encouraged. Thi s can great l y reduce the level s of l atex ant igens in the
envi ronment.
Wearing non-latex gl oves or usi ng some type of barri er bet ween t he latex gl oves
and the skin shoul d be encouraged. Non-lat ex gl oves are usual l y more expensive
t han gl oves contai ni ng latex (97). It is l ikel y, however, t hat t he price dif ferenti al can
be decreased i f t he f aci l i ty were to choose a si ngle vendor of l atex-f ree gloves. If a
worker must move to another job to avoi d l atex-cont ai ni ng materi al s and the new
j ob pays l ess, t hat worker may be el i gi bl e for workers' compensati on. It is al so
possi bl e t hat workers coul d become so sensi ti zed that empl oyment i s not possibl e.
Very l ow l evels of permanent di sabi l i t y are needed to make t he conversion t o l atex-
f ree gl oves cost ef f ecti ve (97).

View Figure

Figure 15.4 Gloves that are both powderless and latex-free
will help to prevent latex allergy.

Faci l i ti es shoul d ensure that good housekeepi ng pract ices are perf ormed to remove
l atex-cont ai ni ng dust f rom the workpl ace. Thi s can be accompli shed by ident if yi ng
areas t hat are contami nated wi th l at ex dust (carpets, uphol stery, and venti l ati on
ducts) for f requent cl eani ng and changi ng venti lati on f i l ters and vacuum bags
f requent l y.
Some heal th care inst i tut ions requi re that bal l oons t hat of ten accompany f l ower
arrangements be non-l atex (98).
For sensi ti zed heal t h care workers, the Ameri cans wi t h Disabi li t ies Act guarantees
workers reasonable modi f icati on of the workpl ace to accommodat e the di sabil i ty.
The Occupati onal Saf ety and Heal th Admini st rati on (OSHA) rules stat e that i n
addi ti on to gl oves that are normal l y provi ded, non-l atex gloves, glove li ners,
powderless gl oves, or other si mi l ar al ternati ves shal l be readi l y accessi bl e t o those
empl oyees who are al l ergi c to l atex gl oves (9).
Health Care Worker Responsibilities
Workers i n heal t h care need to take advantage of l atex al l ergy educat i on and
t rai ni ng to become f amil i ar wi th ways to prevent l atex al l ergy and t o learn t o
recogni ze the symptoms.
Workers should prot ect themselves f rom latex exposure i nsi de and outsi de the
workpl ace. Non-l atex gloves shoul d be used f or acti vi ti es that are not l i kely t o
i nvol ve cont act wi t h i nf ect i ous materi al s. I ntact ski n is an ef f ect ive barri er, and i t is
i mportant to mai nt ai n good hand care. Cuts and open sores shoul d be covered wi th
a pl astic barri er dressi ng pri or to weari ng l atex gl oves (99). Oi l -based hand creams
or l ot ions should be avoi ded, as they may enhance t he release of l atex protei ns
f rom the gloves (54). Af ter removi ng l at ex gl oves, hands should be washed wi t h a
mi ld soap and dri ed thoroughl y. Thi s wi l l decrease t he l oad of al l ergen.
Heal th care workers shoul d avoid weari ng work cl othes (scrubs) home af ter worki ng
i n the operati ng room (99). I ndi rect exposures have caused l atex al l ergy i n chi l dren
and spouses.
I f si gns and symptoms of l atex al lergy devel op, the person shoul d avoid contact
wi th l at ex-contai ni ng products unti l he or she can be seen by a physici an who is
experienced i n diagnosing and treati ng latex al l ergy. A di ary of symptoms shoul d be
kept. Del ay and
P. 439

self -t reatment can delay diagnosis, al lowi ng t he probl em to become more seri ous.
The Health Care Worker with Latex Sensitivity
Dependi ng on the severi t y of the reacti on, lat ex sensi ti vi t y i n heal t h care workers
can be an i nconveni ence or a l i fe-t hreatening hazard. I t can mean the end of a
career (100,101). Of ten, heal t h care personnel are unaware of thei r sensi ti zat i on,
as t he symptoms can be nonspeci f ic (99). The onl y cl ue mi ght be t he t emporal
rel ati onshi p wi t h working. Deni al can be a probl em.
Latex-al l ergic anest hesia provi ders shoul d be counsel ed on the ri sks of cont i nued
work i n envi ronments wi t h hi gh l atex use and on st rategi es t o li mi t exposure. They
shoul d have proper al l ergy i dent i f i cat i on, i ncl uding a medical al ert device, and
shoul d i nf orm t hei r heal th care provi ders (i ncl udi ng denti st and local hospi t al ). They
may want to carry an al lergy ki t , i ncl udi ng an epi nephri ne auto-i njector device, non-
l atex gl oves to wear or give to others to wear i f they must care f or them, and a
compl ete l ist of medicati ons t aken. Friends and f ami l y shoul d be gi ven i nformati on
about l at ex al l ergy. The i ndi vi dual must be on the l ookout f or hi dden l atex.
Consi derati on shoul d be given to avoi di ng foods that may contain prot ei ns si mi l ar
t o t hose in l atex.
Once l at ex al l ergy i s di agnosed, the onl y opti on i s to avoid cont act wi t h l atex and to
t ry t o cont rol the sympt oms. Al most al l the products that heal th care workers
encounter i n thei r dai l y work can be made latex-f ree. A l atex-safe envi ronment al so
prevents exposure of other workers.
There are many non-l atex gl oves avai labl e, both steri l e and nonsteri l e. These
i ncl ude vi nyl , ni t ri l e, st yrene butadiene, and neoprene (2,53, 97,102). Unf ortunat el y,
t hese may not match the physi cal characteri stics of l atex gloves such as hi gh
el ast i ci ty, st rength, fl exi bi l i t y, t ear resi stance, t act i le sensat i on, and barri er
i ntegri t y (5,53, 103). Latex gloves are bi odegradabl e and do not produce hazardous
and toxi c emi ssi ons when inci nerated, as do synt het ic gl oves. Non-l atex gl ove
l i ners and l at ex gl oves wi t h i ntegral non-latex l ayers are avai l abl e (9). Co-workers
shoul d wear powderl ess, l ow-l atex al l ergen gl oves. Thi s reduces the exposure to
l atex by those who are not yet sensi ti zed and may decrease symptoms i n sensi t ized
pati ents (2,10, 12,16,96,104, 105).
Heal th care workers wi t h l atex sensi ti vi ty are not at i ncreased ri sk when
i nci dental l y exposed t o dry, molded, or ext ruded rubber products in t he heal t h care
envi ronment; however, i f di rect contact wi t h such objects i s routi ne, exposure
shoul d be mi ni mi zed by covering t he obj ect or exposed body part (5).
Because of the many f actors t hat di ssemi nat e l at ex al l ergens and because lat ex
al l ergens are so preval ent i n some areas, i t may not be possi bl e to compl etel y
i sol ate workers f rom these al l ergens. In t hi s case, j ob reassi gnment may be
necessary. In the severel y al l ergic worker, i t may not be possi ble t o f i nd an area i n
t he heal t h care f aci l i t y that wi l l be saf e.
References
1. Hebl JR, Hal l BA, Sprung J. Prol onged cardi ovascular col l apse due to
unrecogni zed l at ex anaphyl axis. Anesth Analg 2004; 98: 11241126.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
2. Berry A. Natural rubber lat ex al l ergy: consi derat ions f or anesthesi ol ogi sts. Park
Ri dge, IL: Ameri can Soci ety of Anesthesi ol ogi sts, 1999.
3. Hol zman RS. Cl ini cal management of l atex-all ergi c chi l dren. Anesth Anal g
1997; 85:529533.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
4. Vassall o SA, Thurston TA, Ki m SH, et al . Al l ergi c reacti on to l at ex f rom stopper
of a medicati on vi al . Anest h Anal g 1995;80: 10571058.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
5. Ranta PM, Ownby DR. A revi ew of natural -rubber lat ex al l ergy in heal th care
workers. Cl i n I nf ect Dis 2004; 38: 252256.
[CrossRef ]
[Medli ne Li nk]
6. Zehr BD, Gromel ski S, Beezhol d D. Reduct ion of ant i geni c protein l evels i n l atex
gl oves af ter gamma i rradi at i on. Bi omed I nst Tech 1994; 8:481483.
7. Moneret-Vaut ri n DA, Laxenai re MC, Bavoux F. Al l ergic shock t o latex and
et hyl ene oxi de duri ng surgery f or spine bif ida. Anest hesi ol ogy 1990; 73:556558.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
8. Nati onal Inst i tut e f or Occupati onal Saf et y and Heal th. NIOSH al ert preventi ng
al l ergic react i ons to natural rubber l atex in the workpl ace (NIOSH Publi cat i on No.
97-135). Washi ngton, DC: Author.
9. Anonymous. Latex sensi t i vi ty among heal thcare workers. Technol Anesth
1994; 14(10):17.
10. Berry AJ. Latex al lergy: a problem f or pat i ents and personnel . APSF Newslett
1999; 14:33.
11. Swanson MC, Bubak ME, Hunt LW, et al . Quanti f i cati on of occupati onal l atex
aeroal l ergens i n a medical center. J Al l ergy Cl i n Immunol 1994;94:445451.
[CrossRef ]
[Medli ne Li nk]
12. Hei lman DK, Jones RT, Swanson MC, et al . A prospect ive, control led study
showi ng that rubber gl oves are the maj or cont ri but ors to latex aeroal lergen l evels i n
t he operat i ng room. J Al l ergy Cl i n Immunol 1996; 98:325330.
[CrossRef ]
[Medli ne Li nk]
13. Bernstei n M. An overvi ew of latex all ergy and i ts i mpl icati ons f or emergency
nurses. J Emerg Nurs 1996; 22:2936.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
14. Brock-Utne JG. Cli ni cal mani festati ons of latex anaphylaxi s duri ng anesthesia
di ff erent f rom t hose not anesthesi a/surgery-rel ated. Anesth Analg 2003;97: 1204.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
15. Harper DL, Castel ls MC. Cl inical manif estat ions of l atex anaphyl axi s duri ng
anesthesi a di ff er f rom those not anesthesi a/surgery-rel ated. Anest h Anal g
2003; 97:12041205.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
16. Thomas LC, Skerman JH. Latex al lergy: another compl i cati on f or
anesthesi ol ogy. Part 1. ASA Newsl ett 1999;63:1517.
17. Daki n M, Yent i s S. Latex al l ergy: a st rategy f or management. Anaesthesi a
1998; 53:774781.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
18. Hepner DL, Castel l s MC. Anaphyl axi s duri ng the peri operat i ve period. Anesth
Anal g 2003;97:13811395.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
19. Laxenai re MC, Mert es PM, Benabes B, et al . Anaphyl axi s during anaesthesi a:
resul ts of a two-year survey i n France. Br J Anaesth 2001; 87: 549558.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
20. Fisher M. Latex all ergy duri ng anaesthesi a: caut ionary tal es. Anaesth I ntens
Care 1997;25:302303.
[Medli ne Li nk]
21. Gerber AC, Jorg W, Zbinden S, et al . Severe intraoperat ive anaphyl axi s to
surgi cal gl oves: l atex al l ergy, an unf amil i ar condi ti on. Anesthesiology 1989;71:800
802.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
22. Harding L, Whi te JB. Another l at ex al lergy. Anaesthesi a 1994;49:926.
[CrossRef ]
[Medli ne Li nk]
23. Hodgson CA, Andersen BD. Latex al l ergy: an unf amil i ar cause of i nt ra-operat i ve
cardi ovascular col lapse. Anaesthesi a 1994;49:507508.
[CrossRef ]
[Medli ne Li nk]
24. Hepner DL. Sudden bronchospasm on intubat ion: latex anaphyl axi s? J Cl i n
Anesth 2000; 12:162166.
25. Leynadi er F, Pecquet C, Dry J. Anaphylaxis to lat ex duri ng surgery.
Anaesthesia 1989;44: 547550.
[CrossRef ]
[Medli ne Li nk]
26. McKi nst ry LJ, Fenton WJ, Barret t P. Anaesthesia and the pat i ent wi t h l atex
al l ergy. Can J Anaesth 1992;39:587589.
[Medli ne Li nk]
27. Nguyen DH, Burns MW, Shapi ro GG, et al . I ntraoperati ve cardi ovascular
coll apse secondary to l at ex al l ergy. J Urol 1991;146:571574.
[Medli ne Li nk]
28. Pol lard RJ, Layon AJ. Lat ex al l ergy i n the operat ing room: case report and bri ef
revi ew of the l i terat ure. J Cl i n Anest h 1996;8: 161167.
[CrossRef ]
[Medli ne Li nk]
29. Eckhout GVJ, Ayad S. Anaphyl axi s due t o ai rborne exposure to l atex in a
pri mi gravi da. Anesthesiology 2001;95:10341035.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
30. Ecki nger P, Ratner E, Brock-Utne J. Latex al l ergy: oh, what a surpri se! Another
reason why al l anesthesi a equi pment should be l atex-f ree. Anesth Anal g
2004; 99:629.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
31. Phi li p JH. Low f resh gas f low and high desf l urane vapori zer set ti ng control vi tal
si gn changes duri ng i nducti on. Anesthesi ology 1999;91:A1198.
32. Zucker-Pi nchoff B, Chandl er MJ. Latex anaphylaxi s masquerading as fentanyl
anaphylaxis: retract ion of a case report . Anesthesi ol ogy 1993;79:11521153.
[CrossRef ]
[Medli ne Li nk]
33. Zestos MM, Crei ghton R. Latex anaphylaxis duri ng t issue expander inserti on i n
a heal thy chi l d. Can J Anaest h 1997;44:12751277.
[Medli ne Li nk]
34. Spears FD, Li t tl ewood KE, Li u WH. Anaesthesi a for t he pati ent wi t h al l ergy to
l atex. Anaest h Intens Care 1995;23: 623625.
[Medli ne Li nk]
35. Brown RH, Schaubl e JF, Hami l ton RG. Prevalence of l atex al l ergy among
anesthesi ol ogi sts. Anesthesiology 1998;89:292299.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
36. Akl M. Latex al l ergy. Resi d Staf f Physi ci an 1996;42:2126.
37. Lebenbom-Mansour M, Oesterl e J, Ownby D, et al . The i nci dence of l atex
sensi ti vi ty i n ambul atory surgi cal pati ents: a correl ati on of hi stori cal factors wi th
posi t i ve serum i mmunogl obi n E l evels. Anesth Analg 1997; 85: 4449.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
38. Anonymous. Nebul i zers. Technol Anesth 2002;22: 10.
P. 440


39. Bubak ME, Reed CE, Fransway AF, et al . Subspeci al t y cl i ni cs: al lergi c
di seases. Mayo Cl i n Proc 1992;67: 10751079.
[Medli ne Li nk]
40. Konrad C, Fi eber T, Gerber H, et al . The preval ence of l atex sensi tivi ty among
anesthesi ol ogy staf f . Anesth Anal g 1997;84: 629633.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
41. Li ss GM, Sussman GL, Deal K, et al . Lat ex al lergy: epi demi ol ogi cal study of
1351 hospi tal workers. Occup Envi ron Med 1997; 54:335342.
[Full text Li nk]
[Medli ne Li nk]
42. Arel l ano R, Bradl ey J, Sussman G. Preval ence of latex sensi t i zati on among
hospi tal physicians occupat i onal l y exposed t o l at ex gl oves. Anesthesi ol ogy
1992; 77:905908.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
43. Tan BB, Lear JT, Watts J, et al . Peri operati ve col l apse: prevalence of l at ex
al l ergy i n pat i ents sensi tive to anaest het i c agents. Cont act Dermat i ti s 1997;36:47
50.
[CrossRef ]
[Medli ne Li nk]
44. Watts J. Latex al l ergy. Anaesthesi a 1997; 52:1019.
[Full text Li nk]
[Medli ne Li nk]
45. Hami d RKA. Latex al lergy. Di agnosi s, management and safe equipment(ASA
Ref resher Courses). At lanta: ASA, 1995.
46. Haeberl e HA, Lupic D, Mi doro-Hori uti T, et al . Rol e of cross-al l ergi es to l atex i n
cl i nical rout ine of anesthesi a. J Cl i n Anaesth 2003;15: 495504.
47. Kam PCA, Lee MSM, Thompson JF. Latex al l ergy: an emerging cl i ni cal and
occupati onal heal th probl em. Anaesthesi a 1997;52:570575.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
48. Paskawi cz J, Chatwani A. Latex all ergy: a concern f or anesthesi a personnel .
Am J Anaesthesi ol 2001;28: 435441.
49. Porri F, Pradal M, Lemiere C, et al . Associati on bet ween l atex sensi ti zat i on and
repeated l at ex exposure in chi l dren. Anest hesiol ogy 1997; 86:599602.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
50. Mert t es PM, Mout on C, Fremont S, et al . Latex hypersensi ti vi ty i n spi nal cord
i nj ured adul t pat i ents. Anaesth Intens Care 2001; 29:393399.
[Medli ne Li nk]
51. Bal lantyne JC, Brown E. Latex anaphyl axi s: anot her case, another cause.
Anesth Anal g 1995;81:13031304.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
52. Greenberg RS, Hami l ton RG, Brown RH. Di f ferent i al l atex al l ergy prevalence i n
anesthesi ol ogy subspeci al ti es. Anesthesi ology 1999;90:1238.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
53. Rinal di PA. Peri operat ive management of the pati ent wi t h l atex al l ergy (ASA
Ref resher Course #532). Orl ando: ASA, 1998.
54. Brown M-M, Hess R. Managi ng l at ex al lergy i n the cardi ac surgical pat i ent . Cri t
Care Nurs Q 1998;21:815.
[Medli ne Li nk]
55. Beezhol d DH, Sussman GL. Determining t he al lergeni c potenti al of l atex gloves.
Surgi cal Services Mgt 1997; 3:3541.
56. Thomas LC, Skerman JH. Latex al lergy: another compl icati on f or
anesthesi ol ogy. Part 2. ASA Newsl ett 1999;63:1720.
57. Hepner DL, Castel l s MC. Lat ex al l ergy: an update. Anesth Anal g 2003; 96:1219
1229.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
58. Pal czynski C, Wal usi ak J, Ruta U, et al . Occupati onal al l ergy to latex. Li fe
t hreateni ng reacti ons i n heal t h care workers: report of three cases. Int J Occup Med
Envi ron Heal th 1997;10: 297301.
[Medli ne Li nk]
59. Bai ley DA, Rei l l y ME, Atki ns PM, et al . I mpl ementi ng a system for care of
pati ents wi t h l atex al l ergy. Inf ection Cont rol and St eri l i zati on Tech 1998;4: 2736.
60. Senst BL, Johnson RA. Latex al l ergy. Am J Heal th-Syst Pharm 1997;54:1071
1075.
[Full text Li nk]
[Medli ne Li nk]
61. Bi rmingham PK, Dsi da RM, Grayhack JJ, et al . Do l atex precauti ons i n chi l dren
wi th myelodysplasia reduce int raoperat ive al l ergi c reacti ons. J Ped Orthopaedics
1996; 16:799802.
62. Moser D. How our hospi tal tackl ed l atex sensi t i vit y. Outpati ent Surgery
Magazi ne 2001;11:6272.
63. Lee J. What' s new i n l at ex-and powder-f ree gloves. Outpati ent Surgery
Magazi ne 2003;4:5660.
64. Set lock MA, Cot ter TP, Rosner D. Latex al l ergy: fai l ure of prophyl axis t o
prevent severe reacti on. Anesth Anal g 1993;76:650652.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
65. Pat terson LJ, Mi lne B. Lat ex anaphyl axi s causi ng heart bl ock: role of rani t idine.
Can J Anaesth 1999;46:776778.
[Medli ne Li nk]
66. Landwehr LP, Boguni ewi cz M. Current perspecti ves on l atex al l ergy. J
Pedi at rics 1996;128:305312.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
67. Swartz J, Leonard M. Preventi on of l atex al l ergy. Anesth Anal g 1993;77: 1080.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
68. Anonymous. FDA fol l ows other governments requi ri ng l atex product l abel i ng.
Bi omed Saf e Stand 1997;18:150151.
69. Royer K. Choosi ng latex-f ree suppl i es. Outpati ent Surgery Magazi ne 2004;
5(10)(suppl ): 2224.
70. Wasek S. What' s new i n surgical gl oves. Out pat i ent Surgery Magazi ne
2006; 7(2): 7276.
71. Shoup AJ. Gui del i nes for the management of latex al l ergies and saf e use of
l atex in peri operat ive practi ce sett ings. AORN J 1997; 66:726730.
[CrossRef ]
[Medli ne Li nk]
72. Anonymous. FDA proposes new l abel ing regulat i on for l atex-containing
products. Technol Anesth 1996;17:13.
73. Redmond MC. Latex al lergy: recogni t ion and perioperati ve management. J Post
Anesth Nurs 1996; 11: 612.
[Medli ne Li nk]
74. Armst rong TSH, Barr JM. Lat ex al l ergystrat egi es f or management .
Anaesthesia 1998;53: 1236.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
75. Kubasi ewi cz MK. Latex al lergy and nonl at ex syri nges. Anesth Analg
1996; 83:1352.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
76. Most el lo LA. The cl inical si gni f icance and management of latex al l ergy (ASA
Annual Ref resher Courses). New Orl eans: ASA, 1996.
77. Nyabadza M. Preventi ng l atex sensi t i sati on and f orei gn body micro-embol i .
Anaesthesia 2001;56: 705.
[Full text Li nk]
[Medli ne Li nk]
78. Anonymous. Ameri can Associati on of Nurse Anesthet ists l atex al lergy protocol .
J Am Assoc Nurse Anesth 1993;61:223224.
79. Thomsen DJ, Burke TG. Lack of l at ex al l ergen contami nat i on of solut i ons
wi thdrawn f rom vi al s wi th natural rubber stoppers. Am J Heal th Syst Pharm
2000; 57:4447.
[Full text Li nk]
[Medli ne Li nk]
80. Barbara J, Chabane MH, Leynadier F, et al . Retenti on of ai rborne latex
part icl es by a bacteri al and vi ral f i l ter used i n anaesthesi a. Anaesthesia
2001; 56:231234.
[Ful l text Li nk]
[CrossRef ]
[Medli ne Li nk]
81. Barbara J, Santai s MC, Levy DA, et al . Preventi on of lat ex sensi ti zati on i n
gui nea pigs by a bacterial and vi ral f i l ter used i n anaesthesi a. Br J Anaesth
2005; 95:349354.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
82. Watts J. Latex al l ergy. Anaesthesi a 1997; 52:1019.
[Full text Li nk]
[Medli ne Li nk]
83. Hol zman RS. Latex al l ergy: an emerging OR probl em. Anesth Anal g
1993; 76:635641.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
84. Blanshard HJ, Mi l ne MR. Lat ex-f ree reservoi r bags: exchangi ng one potenti al
hazard f or anot her. Anaesthesi a 2004;59:177179.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
85. Wakakuwa JS, Shulman MS. Lat ex al l ergy and cardiac surgery. Anest h Anal g
2003; 97:1545.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
86. Bernstei n ML. Latex-saf e emergency cart products l ist. J Emerg Nurs
1998; 24:5861.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
86A. Bai ley PD, Basti en JL. Int raoperat ive l at ex hypersensi t ivi t y: do not overl ook
Penrose drai ns. J Cl i n Anesth 2005; 17:485487.
[CrossRef ]
[Medli ne Li nk]
87. Opsomer O, Van Boven M, Pendevi ll e P, et al . An unusual presentati on of lat ex
al l ergy. Can J Anaesth 1993;40:1000.
[Medli ne Li nk]
88. Pat ri arca G, Nucera E, Buonomo A, et al . Lat ex al l ergy desensi t i zat ion by
exposure protocol ; f ive case reports. Anesth Analg 2002; 94:754758.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
89. Pat ri arca G, Nucera E, Pol l ast ri ni E, et al . Subli ngual desensi ti zati on: a new
approach to l atex al lergy probl em. Anest h Anal g 2002;95:956960.
[Full text Li nk]
[CrossRef ]
[Medli ne Li nk]
90. Heese A, Hint zenst ern JV, Pet ers K-P, et al . Al lergi c and i rri t ant reacti ons t o
rubber gl oves i n medi cal heal th services. J Am Acad Dermat ol 1991;25: 831839.
[Medli ne Li nk]
91. Hunt LW, Fransway AF, Reed CE, et al . An epi demi c of occupati onal al lergy to
l atex invol vi ng heal th care workers. JOEM 1995;37:12041209.
92. Sussman GL, Li ss GM, Deal K, et al . Incidence of latex sensi ti zati on among
l atex gl ove users. J Al l ergy Cl i n Immumol 1998;101:171178.
93. Zucker-Pi nchoff B. Latex al l ergy: a personal perspect ive. ASA Newsl et t
1999; 63:1213.
94. Hack M. The preval ence of l atex al l ergy i n operati ng theat re st af f . Anaesth
I ntens Care 2001;29:4347.
[Medli ne Li nk]
95. Kaczmarek RG, Si lverman BG, Gross TP, et al . Preval ence of l atex-specif i c IgE
anti bodi es i n hospi tal personnel . All ergy Ast hma Immunol 1996;76:5156.
96. Vandenpl as O, Del wi che J-P, Si bi l l e Y. Occupati onal asthma due t o l atex i n a
hospi tal admi ni st rat ive empl oyee. Thorax 1996;51:452453.
[Full text Li nk]
[Medli ne Li nk]
97. Phi ll i ps VL, Goodri ch MA, Sul l i van TJ. Heal th care worker disabi l i t y due to l at ex
al l ergy and asthma: a cost anal ysi s. Am J Publ i c Heal th 1999; 89:10241027.
[Medli ne Li nk]
98. Anonymous. Lat ex al lergi es: what you should know. Same Day Surg
1999; 23:7376.
99. Randel GI. Lat ex al lergy: who i s next? ASA Newsl et t 1997;61(5): 1417.
100. Baur X, Ammon J, Chen Z, et al . Heal th ri sk i n hospi tal s through ai rborne
al l ergens f or pat ients pre-sensi ti zed to l atex. Lancet 1993; 342:11481149.
[CrossRef ]
[Medli ne Li nk]
101. Lee J. Seven ways to t el l i f your staff i s a ri sk f or l atex all ergy. Outpati ent
Surgery Magazine 2003;4:6672.
102. Zucker-Pi nchof f B. Latex-al l ergy organi zat ion recommends many new nonl atex
gl oves as saf et y tools. APSF Newsl et t 1999; 14:49.
103. Ol sen RJ, Lynch P, Coyl e MB, et al . Exami nat ion gl oves as barri ers to hand
contaminati on i n cl i ni cal practi ce. JAMA 1993;270:350353.
[CrossRef ]
[Medli ne Li nk]
104. Levy DA, Al louache S, Chabane MH, et al . Powder-f ree prot ei n-poor natural
rubber lat ex gl oves and l atex sensi t i zat ion. JAMA 1999;281:988.
[CrossRef ]
[Medli ne Li nk]
105. Hunt LW, Boone-Orke JL, Fransway AF, et al . A medi cal -cent er-wi de
mul ti di sci pl i nary approach t o the problem of natural rubber l atex al lergy. JOEM
1996; 38: 765770.
P. 441


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. What factors contri bute to the i ncreasing incidence of l atex al lergy?
A. I ncreased length of surgi cal procedures
B. Changes i n the manuf acturing process
C. Younger people enteri ng the heal th care i ndustry
D. I ncreased use of l atex products because of universal precauti ons
Vi ew Answer2. Which are likel y routes of sensi tization to latex?
A. Skin contact
B. I nhalat i on
C. I ngesti on
D. Parenteral i nj ect i on
Vi ew Answer3. Which i tem(s) l isted bel ow is unl ikely to cause l atex
al lergy?
A. Wheelchai r t i res
B. Washed venti l ator bel lows
C. Syri nge pl ungers
D. Products steri l i zed wi t h ethyl ene oxi de
Vi ew Answer4. Powdered gloves pose a greater threat than those wi thout
powder because
A. Latex prot ei ns bi nd t o the powder
B. The powder cont ai ns al l ergens
C. Powder may spray i nt o the operati ng room when they are donned or removed
D. Fi l ters i n the venti l ati on system may become cl ogged
Vi ew Answer5. What are the symptoms of i rri tant contact dermati ti s?
A. Skin cracki ng
B. I tchi ng
C. Scal i ng
D. Dryness
Vi ew Answer6. What are the characteristi cs of Type IV hypersensitivity?
A. Delayed hypersensi t ivi t y
B. Al ways stays wi thi n the area of the anti gen
C. May be associated wi t h dizziness
D. Ski n rash i s seen wi thi n 5 hours
Vi ew Answer7. Characteristi cs of Type I hypersensi ti vi ty include
A. React ions may lead to mortali ty or morbidi t y
B. Symptoms can occur days later
C. React ions range f rom mi l d to severe
D. They are mediated by I gF ant i bodi es
Vi ew Answer8. Pri mary cl inical features of Type I hypersensi ti vi ty
i ncl ude
A. Bronchospasm
B. Cutaneous symptoms
C. Cardi ovascular sympt oms
D. Neurol ogic symptoms
Vi ew Answer9. What are the important points to look for when taki ng a
hi story in an attempt to determine the presence of latex al lergy?
A. Hand dermati t is i n conj uncti on wi th weari ng l atex gloves
B. Sensi ti vi t y to ragweed
C. Food al lergy to watermel ons, pi neappl es, strawberri es, and t omat oes
D. Predi sposi ti on to mul t iple al l ergic condi ti ons
Vi ew Answer10. Which condi ti ons are associated with a high i nci dence of
l atex allergy?
A. Geni touri nary t ract abnormal i t ies
B. Congeni tal ort hopedic defects
C. Esophageal stri ctures
D. Spinal cord injury
Vi ew Answer11. Important features of the SPT i ncl ude
A. Hi gh i nci dence of anaphyl axis
B. Reasonabl y good sensi ti vi ty and speci fi ci ty
C. Avai l abil i ty of a good test sol uti on
D. Pati ents wi t h anaphyl axis duri ng surgery are al most invari ably ski n-pri ck posi t i ve
Vi ew Answer12. Preventive measures for l atex al lergy include
A. Determining the products t hat cont ai n latex
B. Usi ng oi l -based hand creams or l ot ions
C. Using powderl ess gl oves
D. Total l y el i mi nati ng l at ex exposure
Vi ew Answer13. Consi derations for drug prophyl axis i nclude
A. H
2
blockers may increase t he ri sk f or pati ents wi t h heart bl ock
B. I t may mask the si gns of anaphyl axi s
C. I t may del ay i mpl ement at ion of treat ment, i f anaphyl axis occurs
D. I t wi l l prevent anaphyl axi s
Vi ew Answer14. Regarding labeling for latex content,
A. I f the label does not i ndicate that i t contai ns l atex, i t i s l atexf ree
B. Products not regul ated by the FDA must be l abeled i f t hey contain l atex
C. Drug manuf acturers must l abel products regardi ng l atex
D. The FDA requi res that al l medical products that may di rect l y or i ndi rectl y contact
t he body be l abel ed i f they contain l atex
Vi ew Answer15. Surgical precauti ons that need to be taken i f a patient is
known to be latex sensiti ve include
A. No one shoul d enter t he operat i ng room weari ng l atex gl oves
B. The case shoul d be posted f or t he fi rst case of the day
C. Cl ot hes that have not been exposed to l atex should be worn
D. Latex alert si gns should be posted i nside and outsi de the room
Vi ew Answer16. Which steps can be taken to li mit the l ikeli hood of l atex
al lergy resul ti ng from i ntravenous or parenteral i njec-ti ons?
A. Usi ng medicati ons suppli ed i n ampul es
B. Usi ng glass syringes
C. Prepari ng drugs j ust before use
D. Using rubber syri nge pl ungers
Vi ew AnswerP. 442


17. Methods to treat i rritant contact dermatitis i ncl ude
A. Reduce exposure to t he i rri t ant
B. Use of a pl ast ic gl ove l i ner
C. Topi cal cort i costeroi ds
D. Protect ive hand cream
Vi ew Answer18. Steps that heal th care workers can take to protect
themsel ves against l atex exposure include
A. Washi ng hands af ter l atex gl oves are removed
B. Usi ng non-lat ex gl oves where inf ecti ous materi al wi l l not be encountered
C. Covering breaks i n the ski n wi th a pl astic barri er
D. Using oi l -based creams or l ot i ons
Vi ew Answer