ASCIA Guidelines for Hospital Management of Latex Allergic Patients

Preamble

These guidelines apply to patients with Type 1 and Type 4 reactions to latex.
The need for specific guidelines is because exposure to latex can lead to local and serious systemic reactions, including anaphylaxis. Latex is ubiquitous in hospitals, and as a result affected patients are presently at considerable risk.

Aim of Guidelines

The most important aim is to attempt to provide a latex safe environment.

A latex free product list must be drawn up and kept readily available within areas of emergency treatment. In institutions where powdered latex gloves are used the most difficult part of providing a latex safe environment is ensuring that the patient's air is not contaminated with powder from latex gloves, as this alone can trigger serious reactions in sensitive individuals.

Prophylaxis with steroids and H1 and H2 antagonists has not been found to prevent serious reactions, and should not be relied upon. (Anesth Analg 1993; 76:650-652.)

Where the diagnosis has already been made the aim of management is to reduce contact with latex equipment to a minimum, and so reduce the likelihood of a serious allergic reaction. Even so it is important to be vigilant and prepared to treat severe allergic reactions.

Not all patients will be identifiable, and in view of the increasing incidence of latex allergy if anaphylaxis occurs, especially in patients from high risk groups, latex equipment should be changed to nonlatex alternatives as part of treating the reaction.

The difficulty in preparing guidelines is that the sensitivity to latex varies from patient to patient. Some patients will tolerate latex skin contact, while others may have anaphylaxis to the residual latex powder in a ward. This means that while for some patients these guidelines are excessively cautious, they may not prevent serious reactions in all patients.

Management of known or suspected latex allergic patients

Identification of patients.

Use of a standardised questionnaire for all elective patients enquiring about reactions experienced with latex gloves, balloons or condoms. Questions should be aimed at detecting individuals at risk; identifying patients from high risk occupations, and in particular, those with atopy, and those with spina bifida. If clinically relevant, consider further investigation.

Definitely investigate patients with undiagnosed episodes of anaphylaxis, and those with severe fruit reactions.

Label the patient, the patient's notes, and the bed or trolley ideally in a way to differentiate the patient from patients with other allergies.

Prior to admission, except in the case of an emergency, admission to discharge planning must occur. This must involve medical, nursing, and domestic staff.

Preparation of a Latex Safe Environment

What equipment has latex in it

Latex is a component of a large number of medical devices.

At present there is no mandatory labelling and so considerable effort is required to keep an up-to-date record of latex free medical equipment.

Gloves
These are the most likely to cause serious reactions, especially if they contact mucous membranes. (BMJ 1994; 308:246-247.)

All latex gloves need to be removed from the immediate area of the patients.

Synthetic gloves must be used for all procedures. Neoprene gloves are available in sterile gloves and are latex free. Vinyl gloves are the only currently available synthetic examination gloves, but these are not as strong or as impermeable to viral particles as latex. Nitrile exam gloves will soon be available.

As a general guide the following need to be checked:

Surgical drains, urinary catheters, condom drainage, anti embolic stockings, bougie dilators, tourniquets, dental dams, embolectomy catheters.
Monitoring: BP leads, oximeters, ECG dots, pulmonary artery catheters.
IV lines, and infusion bags
Latex stoppers in ampoules
Plungers in some syringes
Catheter leg bag straps
Mattresses
Dressings, 'Elastic' bandages, Skin adhesives
Feeding nipples and tubes

Ward preparation

Nurse in charge of the ward ensures the guidelines are followed.
Steps 2, 3, 4, are not necessary if the institution does not use any powdered latex gloves.

1. Synthetic gloves must be used.

2. Prepare single room, where possible, at least 3 hours before patient admission.

3. All equipment and furniture to be damp dusted to remove latex powder.

4. For the duration of the patient's admission, the entire ward must use only powderless latex gloves to avoid contaminating the patient area with latex powder.

5. The prepared room must have signs attached at all entrances to ensure a latex safe area.

6. All procedures must be planned.

7. Be prepared to treat serious reactions.

Ward procedures

Synthetic gloves must be used.

The following procedures need planning:

i) blood taking: synthetic gloves, tourniquet over clothing
ii) inserting IV: see below
iii) giving IV, IM, SC drugs: see below
iv) bladder catheterisation: synthetic gloves and non latex catheter
v) internal examinations: synthetic gloves

Where possible perform procedures within prepared ward environment.

Ensure other departments are aware of the patient's latex allergy if the patient has to go to another area for investigations during admission.

Monitoring

i) Oximeter probe may contain latex, but can be used over a vinyl glove or a clear dressing.

ii) Arm for BP measurement must be covered to protect skin from BP leads.

iii) ECG dots may contain latex in the adhesive.

iv) Stethoscopes may contain latex in the tubing, ear pieces and bell.

v) Pulmonary artery catheters contain latex in the balloon and there has been a case report of anaphylaxis to such a device.(Anesthesiology 1995; 92:220-221) At present there are no non-latex alternatives and risks and benefits must be weighed up on an individual basis.

IV lines and Drugs

i) Synthetic gloves must be used.

ii) Use an IV line without latex ports, or if using a line with latex ports they must be removed and replaced with reflux valves, prior to running through IV fluid. There is a case report of anaphylaxis to an IV line where this was not done (J Allergy Clin Immunology 1993; 92:358-359).

iii) Infusions to be made up by injecting through giving set port of IV fluid bags rather than through the rubber bung, which is not in contact with the fluid and can be removed.

iv) Do not use colloids with latex bungs.

v) Latex free syringes should be used.

vi) No drugs to be drawn up through rubber bungs.

vii) No drugs to be given where there is a rubber stopper within the vial (Anesth Analg 1995; 80:1057-1-58).

viii) Only latex free IV dressings and skin tapes.

Resuscitation Equipment
In general resuscitation equipment purchased by hospitals should be latex free where this is possible. All resuscitation trolleys should routinely have powderless latex gloves, and nonlatex gloves should only be readily available when a latex allergic patient is in that area. When there is a patient with a latex allergy in an area the following must be available in that area:

Synthetic gloves.

Latex free circuit, masks, catheter mount, oral airways.