Leslie C. Thomas, M.D.
Jonathan H. Skerman, M.D.

"Latex Allergy: Another Complication for Anesthesiology" was presented in part as a Scientific and Educational Exhibit at the Annual Meeting of the American Society of Anesthesiologists, Orlando, Florida, October 17-21, 1998. As follows is part 1 of a two-part summary of the presentation. Part 2 will be published in an upcoming issue of the NEWSLETTER.

Allergic reactions to latex were first described by Nutter in 1979 as contact urticaria resulting from exposure to natural latex products.¹ Since then, reports of hypersensitivity to latex have increased steadily. The prevailing opinion concerning the increased prevalence of latex allergy is that it has occurred as a result of the introduction of universal precautions for prevention of acquired immunodeficiency syndrome (AIDS) and hepatitis B. There have been approximately 1,000 cases of allergic or anaphylactic reactions to latex-containing medical products reported to the U.S. Food and Drug Administration since 1988.²

The number of cases reported will increase sharply as knowledge of the subject and latex allergy reporting increase.² With more patients at risk or with a history of latex allergy, as well as the general risks inherent to health care workers, it is incumbent upon anesthesiologists to become familiar with this burgeoning problem. Here we present pertinent information necessary to the management and understanding of these patients from the viewpoint of the practicing anesthesiologist.

What Is Latex?

Latex is the milky sap from the rubber tree, Hevea brasiliensis. It contains hundreds of proteins, rubber, amino acids and carbohydrates suspended in water. After the latex is obtained from the tree by tapping, a preservative is added, and the resulting mixture is centrifuged, yielding a concentrated product. The concentrated latex is then heated by a process called vulcanization, which makes it heat-stable and elastic. Chemicals, accelerators, antioxidants, stabilizers, extenders and other ingredients are then added to obtain the finished product, which contains 2 percent to 3 percent latex proteins.³ Natural rubber is derived from latex and should be distinguished from synthetic rubber, which is produced from petrochemicals. Synthetic rubber does not contain allergy-inciting plant proteins but is virtually identical to natural rubber in its physical properties.

Latex is found in many products commonly used in the hospital, the community and the home. There are alternative non-latex products for all of these items. Usually, these alternatives are made of plastic, vinyl or silicone.

Allergic Reactions to Latex: A Broad Range of Symptoms

Generally, most people react with either a Type I or Type IV allergic reaction such as contact dermatitis.

Type I: Immediate hypersensitivity or anaphylactic: most common under anesthesia

• mediated by IgE antibodies
• requires previous exposure; with repeat exposure to antigen, becomes bound to IgE
• IgE binds to mast cells, causing degranulation angioedema, bronchospasm, anaphylactic shock, rhinoconjunctivitis, local or generalized urticaria ⁴

Type IV: Delayed hypersensitivity mediated by T cells

• clinically seen as contact dermatitis
• patient is sensitized and upon re-exposure to antigen, results in T cell proliferation
• nonspecific pruritus to red, weepy skin
• caused by accelerators and chemicals used in glove manufacture and not by latex itself
• occurs six to 48 hours after contact⁴
• reduces barrier properties of skin, which allows absorption of larger amounts of chemicals or proteins, thus increasing risk of latex sensitization⁵

Irritant contact dermatitis (nonimmune): gradual onset

• caused by hand washing, glove chemicals, antiseptics
• characterized by redness, cracks, fissures
• exacerbated by sweating or rubbing under glove with residual soaps and detergents in prolonged contact with the gloved surface⁵

Anaphylactic reactions can happen at any time to a person who previously had only irritant or contact dermatitis; it is thought that dermatitis breaks the protective barrier of skin, which facilitates increased latex protein absorption.

Prevalence in Health Care Workers

The prevalence of latex allergy in health care workers varies between 7 percent and 17 percent. Since 1992, there has been a disproportionate increase in Type I allergies to latex, while the incidence of Type IV allergies has decreased.⁶ These reactions are initiated by:

1. Exposure of skin to latex gloves (causing hematogenous spread).
2. Contact of mucous membranes such as with urinary catheters, or serosal surfaces with latex gloves during dental or gynecological examinations,⁷ intraoperatively or during barium enema examinations.⁵
3. Inhalation of latex proteins, which adhere to glove powder and become aerosolized during glove usage and removal. The protein content in powdered latex gloves is much higher than that in powder-free latex gloves;⁶ therefore, powderless gloves decrease airborne exposure to latex and may lead to fewer adverse reactions.

Gloves: Powdered Versus Nonpowdered

Latex gloves are the most common source of exposure to potent allergens. In addition to being present in the gloves themselves, many latex rubber proteins are carried by the glove powder. Curtailing exposure to latex proteins should help to decrease the exposure to health care workers and patients. The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy and Immunology (ACAI) have issued a joint statement concerning the use of powdered/nonpowdered gloves:

"Latex gloves should be used only as mandated by accepted Universal Precautions standards. The routine use of latex gloves by food handlers, housekeeping, transport and medical personnel in low risk situations should be discouraged."⁸

The protein and allergen content varies widely among different brands of latex gloves. Washing during glove manufacture can remove the majority of extractable latex proteins at very little added expense.⁹ Moving from powdered latex gloves to nonpowdered helps to minimize adverse reactions to latex at very little added expense. It has also been shown that latex allergy-related symptoms are significantly associated with latex aeroallergen concentrations in work areas. Latex levels of 0.6ng/m³ or greater are associated with the development of latex specific IgE antibodies as well as conjunctivitis, asthma and rhinitis. The use of powder-free latex gloves helps to control the spread of these aeroallergens in the working environment.

National Institute for Occupational Safety and Health Advisory: Use nonlatex gloves for activities not likely to involve contact with infectious materials and use only powder free latex gloves with reduced protein content when necessary.¹⁰

Who Is at Risk?

The prevalence of latex allergy in the general population is <0.5 percent. In atopic individuals, this increases to 3.0 percent.^11,12 In a study of atopic and non-atopic children, Liebke et al. reported that 21 percent of the atopic children showed specific IgE antibodies to latex. This is important because these children had less extensive contact with latex than those in well-known risk groups (e.g., spina bifida children).¹³ In a study of anesthesia staff at one hospital, 15.8 percent had positive skin tests, with the most important risk factor being atopy,¹⁴ which demonstrates the increased risk of anesthesiologists becoming sensitized. No time correlation was evident, although in dental students, the prevalence was found to increase from 2 percent in the second semester to 10 percent in the 10th semester.¹⁵ Brown et al. showed the prevalence of latex sensitization among anesthesiologists to be 12.5 percent, of whom 10.1 percent had no symptoms. The risk factors for sensitization were atopy, history of allergy to selected fruits and a history of skin symptoms with latex glove use. This study also showed no time correlation.¹⁶

Most of these allergic individuals have been repeatedly exposed to products containing latex. For example, in spina bifida children, two risk factors included more than six surgeries and/or atopy.¹¹ Bode et al. also showed that frequent surgery and atopy represented an increased risk of hypersensitivity to latex. In addition, 71 percent of the spina bifida patients in their study had latex sensitivity.¹⁷

Individuals with the following food or plant allergies often have cross-reactive allergies to latex: banana, avocado, chestnut, apricot, kiwi, papaya, passion fruit, pineapple, peach, nectarine, plum, cherry, melon, fig, grape, potato, tomato, celery, hazelnut, wheat or ficus plant. Patients with these allergies should be questioned about reactivity to latex and even consider skin and serologic testing. Not all patients with these food allergies will need to avoid contact with latex, as it is not yet known whether the occurrence of both types of allergy in an individual results from a shared common antigen or a cross-reacting antigen.^5,18

Many anesthesiologists recommend asking specific questions in the medical history directed at identifying those patients at risk, i.e., previous surgeries, atopy, food allergies, previous exposure or reaction to latex, asthma or spinal cord problems. In a study of 1,000 ambulatory surgical patients, historical factors were correlated with positive serum IgE levels. Although 6.7 percent had IgE antibodies to latex, the specificity and positive predictive value of history was low, as 9 percent of latex sensitive individuals had negative histories. However, certain aspects of the history did have a greater correlation with the presence of IgE antibodies: asthma history more than doubled the risk of having antilatex antibodies, and food allergy also increased the risk.¹⁹

References:

1. Nutter AF. Contact urticaria to rubber. Br J Dermatol. 1979; 101:597-598.
2. Special Bulletin. Latex Allergy. Am Coll Allergy Asthma Immunol. 1996.
3. Obrand DI, El Azeim HA, Concepcion B, Ahn SS. Hypersensitivity of the vascular endothelium to latex balloon catheter. Ann Vasc Surg. 1997; 11:536-539.
4. ReddyS. Latex allergy. Am Fam Phys. 1998; 57:93-102.
5. SussmanG, Gold M. Guidelines for the management of latex allergies and safe latex use in health care facilities. Am Coll Allergy Asthma Immunol. 1996.
6. Heese A, Peters KP, Koch HU. Type I allergies to latex and the aeroallergenic problem. Eur J Surg. 1997; suppl 579:19-22.
7. Santos R, Hernández-Ayup S, Galache P, Morales FG, Batiza VA, Montoya D II. Severe latex allergy after a vaginal examination during labor: A case report. Am J Obstet Gynecol. 1997; 177:1543-1544.
8. AAAAI and ACAI Joint Statement concerning the use of powdered and nonpowdered natural rubber latex gloves. Ann Allergy Asthma Immunol. 1997; 79:487.
9. Brehler R, Kolling R, Webb M, Wastell C. Glove powder - a risk factor for the development of latex allergy? Eur J Surg. 1997; suppl 579:23-25.
10. NIOSH Alert No 97-135: Preventing allergic reactions to natural rubber latex in the workplace. 1997.
11. TurjanmaaK, Alenius H, Makinen-Kiljunen S, Reunala T, Palosuo T. Natural rubber latex allergy. Allergy Eur J All Clin Immunol. 1996; 51:593-602.
12. Tan BB, Lear JT, Watts J, Jones P, English JSC. Perioperative collapse: Prevalence of latex allergy in patients sensitive to anaesthetic agents. Contact Dermatitis. 1997; 36:47-50.
13. Liebke C, Niggemann B, Wahn U. Sensitivity and allergy to latex in atopic and non-atopic children. Pediatr Allergy Immunol. 1996; 7:103-107.
14. Konrad C, Fieber T, Gerber H, Schuepfer G, Muellner G. The prevalence of latex sensitivity among anesthesiology staff. Anesth Analg. 1997; 84:629-633.
15. Heese A, Peters KP, Stahl J, et al. Incidence and increase in type I allergies to rubber gloves in dental medicine students. Hautarzt. 1995; 46:15-21.
16. Brown RH, Schauble JF, Hamilton RG. Prevalence of latex allergy among anesthesiologists. Anesthesiology. 1998; 89:292-299.
17. Bode CP, Füllers U, Röseler S, Wawer A, Bachert C, Wahn V. Risk factors for latex hypersensitivity in childhood. Pediatr Allergy Immunol. 1996; 7:157-163.
18. Freeman GL. Co-occurrence of latex and fruit allergies. Allergy Asthma Proc. 1997; 18:85-88.
19. Lebenbom-Mansour MH, Oesterle JR, Ownby DR, Jennett MK, Post SK, Zaglaniczy K. The incidence of latex sensitivity in ambulatory surgical patients: A correlation of historical factors with positive serum immunoglobin E levels. Anesth Analg. 1997; 85:44-49.

Leslie C. Thomas, M.D., is Assistant Professor, Department of Anesthesiology, Louisiana State University Medical College, Shreveport, Louisiana.

Jonathan H. Skerman, M.D., is Professor of Anesthesiology and Professor of Obstetrics and Gynecology, Louisiana State University Medical College, Shreveport, Louisiana.

return to top

FEATURES

• Exploring Issues of Informed Consent
  
  
• Competence and Informed Consent: When Is a Patient Not Able to Make Decisions About Medical Therapy?
  
  
• Perioperative DNR Orders: New Options, Greater Flexibility
  
  
• Pediatric Assent: Can Children Understand, Assess and Communicate Their Wishes?
  
  

ARTICLES

• Dallas - A City Deep in the Heart
  
  
• Plans Under Way for 1999 ASA Annual Meeting in Dallas
  
  
• Latex Allergy: Another Complication for Anesthesiology, Part 1
  
  
• Becoming an Information-Driven Organization
  
  
• Office-Based Anesthesia Update: Guidelines, Education and Support Are Invaluable

DEPARTMENTS

• Ventilations
  
• Administrative Update
  
• What's New In ...
• Practice Management
  
• Residents' Review
  
• ASA News
  
• In Memoriam
• FAER Report
  

The views expressed herein are those of the authors and do not necessarily represent or reflect the views, policies or actions of the American Society of Anesthesiologists.

NL Archives

Information for Authors