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August 1999
Volume 63 |
Number 8
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| Latex Allergy:
A Personal Perspective |
Barbara Zucker-Pinchoff, M.D.
Picture this: a routine, scheduled cesarean delivery, made more
interesting by the fact that the patient is a colleague. The epidural
is placed uneventfully. The surgery begins. The patient starts
to complain of itchy eyes and a stuffy nose and says, "I must
be allergic to something in the air conditioning." You notice
that her face is becoming flushed. Her hands are swelling and
her blood pressure begins to fall. By this time, fortunately,
a healthy baby has been delivered. But the patient's blood pressure
continues to fall in spite of IV fluids and multiple boluses of
ephedrine. Anaphylactic shock is flashing through your mind, but
how is it possible? You double check the chart and there it is:
NKDA (no known drug allergies), and no I.V. drugs have been given.
This scenario should strike fear in your heart because,
as an anesthesiologist, you are at risk. This could be your patient,
or the patient could be you. Unfortunately, I was the patient
in this case. Once anaphylactic shock was diagnosed, treatment
was prompt and successful, including several hours on an epinephrine
infusion in the recovery room.
As you can see from the title of this article, I proved
to be allergic to latex. As anesthesiologists, the emerging latex
allergy epidemic must be of great concern to us. We are a high-risk
group, both to treat it and to experience it. Latex allergy not
infrequently presents as an O.R. disaster. Patients may not know
they have latex allergy until they have an overwhelming exposure
(such as four latex-gloved hands in the abdomen, as in the case
above), or their caregivers, ourselves included, may not have
taken an adequate history to uncover sensitivity to latex.
We are also at high risk to develop latex allergy. This
is because of our frequent changes of exam gloves (how many pairs
do you don and doff each day? 10? 20? 30?). These gloves are usually
latex and, because they are often selected on the basis of cost,
they are frequently high in proteins and highly powdered. These
two properties (high protein, high powder) make them extremely
allergenic. The allergens are transmitted to you both through
the skin (dissolved in sweat), through any breaks in the skin
and via inhalation of the powder, which is rich in adsorbed latex
proteins. The anesthesia area of the O.R. has one of the highest
concentrations of latex aeroallergens in the hospital.1
You notice that her face is becoming flushed. Her hands are
swelling and her blood pressure continues to fall in spite of
IV fluids and multiple boluses of ephedrine. Anaphylactic shock
is flashing through your mind, but how is it possible? This scenario
should strike fear in your heart because this could be your patient,
Everyone seems to think, "Not me. This sort of thing only
happens to other people." I was no exception. I never thought
of myself as an "allergic" person. The only allergy I had experienced
was seasonal hay fever, sometimes severe, but nothing else. My
self-image was that of a strong, healthy person. It was hard for
me to accept that I had a serious medical problem. Latex allergy
can be a catastrophic medical problem.
Every person with latex allergy that I have spoken to,
and there have been many, goes through a number of stages similar
to those described by Kubler-Ross, relating to death and dying.2
These include shock, denial, anger and finally acceptance. Denial
is something that we physicians are very good at when it comes
to our own health. Many will tell you, "Oh, it's just the powder."
"It's not so bad, I just have to take antihistamines ... and inhalers
... and sometimes steroids." "It'll be OK if I just change gloves,
right?" "No, I haven't had diagnostic tests. I don't have time."
"What's the big deal?"
The big deal is that those with type I, IgE mediated,
immediate hypersensitivity to latex proteins are at risk - at
risk to develop occupational asthma and at risk to develop full
blown anaphylaxis upon any exposure to latex. Simply changing
gloves is not enough, in part because the powder on other people's
gloves spreads latex proteins onto every surface they touch and
into the air we all breathe. Ongoing exposure increases the risk.
According to Brown et. al.,3 12.5
percent of anesthesiologists studied had antibodies to latex,
and 2.4 percent had clinical latex allergy. The 10.1 percent with
antibodies but without symptoms are thought to be "presymptomatic."
In other words, they are walking time bombs, who, with continued
exposure, may become symptomatic at any time. Once one is symptomatic,
one's career may be at stake.
Those who continue to work after being diagnosed do so
only by taking increasing doses of antihistamines. They stop wearing
latex gloves. They may develop occupational asthma, which may
or may not be recognized as such (often due to inhaled antigens).
They may require inhaled bronchodilators, then inhaled steroids
to control symptoms. When symptoms flare, with episodes of hives,
angioedema, and near-constant rhinitis and conjunctivitis, occasional
courses of systemic steroids will be needed. In my case, even
though I was taking antihistamines and inhaled steroids after
the first anaphylactic shock incident, I experienced another anaphylactic
episode in a delivery room when five people popped powdered latex
gloves out of a box. That was when I finally realized that it
was no longer safe, for me or my patients, for me to continue
working.
So what can be done? First and foremost, educate yourself
and your colleagues. The ASA Task Force on Latex Allergy has produced
a booklet on latex allergy, which was sent to you last month. Read
it and share it. Secondly, encourage your institution to become
"latex-safe." Some institutions, such as Johns Hopkins, are becoming
latex-free, adopting a no-latex-gloves policy. Others are becoming
latex-safe, or latex-aware, by adopting a policy of using nonlatex
gloves in many settings (exam gloves, food handling, maintenance
work) and purchasing only nonpowdered, low-protein latex gloves
where latex is used. These steps will markedly reduce latex allergen
exposure for patients, employees, yourself and your colleagues.
References:
- Swanson MC, Bubak ME, Hunt LW, et al.
Quantification of occupational latex aeroallergens in a medical
center. J Allergy Clin Immunol. 1994; 94:445-451.
- Kubler-Ross E. On Death and Dying.
New York: The Macmillan Company; 1969:264.
- Brown RH, Schauble JF, Hamilton RG. Prevalence
of latex allergy among anesthesiologists. Anesthesiology.
1998; 89:292-299. or the patient could
be you.
Barbara Zucker-Pinchoff, M.D., is Assistant
Clinical Professor of Anesthesiology, The Mount Sinai Medical
Center, and Director, Physicians Against Latex Sensitization,
New York, New York.
"Natural
Rubber Latex Allergy: Considerations for Anesthesiologists" has
been developed by the Task Force on Latex Sensitivity of the ASA
Committee on Occupational Health of Operating Room Personnel.
The purpose of this booklet is to identify the risk factors among
anesthesiologists and their patients for such allergic reactions
and to recommend strategies for avoidance as well as treatment
should allergic reactions develop.
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