ANESTH ANALG 1991;72:83945
LETTERS TO THE EDITOR
Anaphylactic Shock Produced by Latex Key Words: ALLERGY,
ANAPHYLAXIS-latex.
To the Editor: Although natural rubber (latex obtained from Hevea brasiliensis) has been used for medical and dental treatments for many years, contact urticaria to rubber has been described only since 1979 (1).Evidence now indicates that exposure to the natural rubber of latex surgical gloves, breathing bags, or compressive bandages during anesthesia and operation can result in anaphylactic reactions (2-6). An 8-yr-old boy, weighing 25 kg, was admitted for a right herniorrhaphy. The patient and his parents were questioned and he was considered to have no history of allergic reactions. Three surgical procedures (two for congenital glaucoma and one for left hernia) under general anesthesia had been uneventful 6, 5, and 2 yr before. Anesthesia was induced with nitrous oxide and halothane. Caudal anesthesia was performed with a mixed solution of bupivacaine (32.5 mg) and lidocaine (130 mg). Twenty minutes after skin incision, as the last sutures were being placed, the pulse became nonpalpable. Cardiopulmonary resuscitation was initiated. Epinephrine (0.25 mg) was given intravenously. The trachea was intubated and the lungs ventilated with 100%oxygen. Airway pressures were unusually high. Chest compression could be discontinued after less than 1 min. As systolic blood pressure was only 35 mm Hg, epinephrine was given again (0.25 mg intravenously and 0.25 mg in the endotracheal tube). Hydrocortisone succinate (50 mg) and colloids (200 mL) were also administered. The child's cardiopulmonary state then appeared to stabilize. A transient generalized urticaria1 rash was observed. Venous blood was sampled for measurement of levels of plasma histamine, immunoglobulin E, and local anesthetics. As the child awakened, airway pressures increased and blood pressures decreased again. An epinephrine infusion (0.05 pgkg-'.min-') was given for the next 3 h. The patient recovered uneventfully and was discharged 2 days later. The signs observed in this case were characteristic of an anaphylactic reaction. As allergy to lidocaine and bupiv-
845
acaine is rare and the onset of signs was unusually delayed, the patient and his parents were questioned again. No history of allergic reactions to drugs or food could be found, but they reported several episodes of facial and periorbital swelling some minutes after he blew up rubber balloons. Plasma levels of lidocaine and bupivacaine assayed using a gas chromatography method (respectively 3.02 and 0.53 pg/mL) were below toxic levels. Skin prick tests were performed 6 wk later using lidocaine, bupivacaine, and a piece of washed rubber surgical glove. Only the latter proved to be positive. Plasma histamine measured by radioimmunoassay was 90.1 nmol/L (normal < 10.0 nmol/L). Latex-specificimmunoglobulin E measured by radioallergosorbent testing was increased (2.8 kU/L, normal < 0.4 kUIL). This case suggests that any preoperative assessment must systematically search for a history of rubber allergy to avoid the exposure to latex during anesthesia and operation. When in doubt, specific skin tests must be performed preoperatively . Emile Calenda, MD Jean P. Durand, MD Jean Petit, MD Fariz Bawab, MD Antoine Coquerel, PhD, Jacqueline Ensel, MD Claude Winckler, MD
MD
Dipartement d'Anesth~sie-R~nanimntion Chirurgicale H6pital Charles Nicolle UniversitC de Rouen 7, rue de Germont 76031 Rouen W d e x . France
References 1. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979;101:597-8. 2. Morales C, Basomba A, Carreira J, Sastre A. Anaphylaxis produced by rubber glove contact. Case reports and immunological identification of the antigen involved. Clin Exp Allergy 1989;19:425-9. 3. Axelsson JGK, Johanson SGO, Wrangsjo K. IgE-mediated anaphylactoid reactions to rubber. Allergy 1987;42:4650. 4. Axelsson JGK, Eriksson M, Wrangsjo K. Anaphylaxis and angioedema due to rubber allergy in children. Acta Paediatr Scand 1988;77:3144. 5. Slater JE. Rubber anaphylaxis. N Engl J Med 1989;320:112630. 6. Moneret-Vautrin DA, Laxenairc MC, Bavoux F. Allergic shock to latex and ethylene oxide during surgery for spina bifida. Anesthesiology 1990;73:5568.
LETTERS TO THE EDITOR
Anaphylactic Shock Produced by Latex Key Words: ALLERGY,
ANAPHYLAXIS-latex.
To the Editor: Although natural rubber (latex obtained from Hevea brasiliensis) has been used for medical and dental treatments for many years, contact urticaria to rubber has been described only since 1979 (1).Evidence now indicates that exposure to the natural rubber of latex surgical gloves, breathing bags, or compressive bandages during anesthesia and operation can result in anaphylactic reactions (2-6). An 8-yr-old boy, weighing 25 kg, was admitted for a right herniorrhaphy. The patient and his parents were questioned and he was considered to have no history of allergic reactions. Three surgical procedures (two for congenital glaucoma and one for left hernia) under general anesthesia had been uneventful 6, 5, and 2 yr before. Anesthesia was induced with nitrous oxide and halothane. Caudal anesthesia was performed with a mixed solution of bupivacaine (32.5 mg) and lidocaine (130 mg). Twenty minutes after skin incision, as the last sutures were being placed, the pulse became nonpalpable. Cardiopulmonary resuscitation was initiated. Epinephrine (0.25 mg) was given intravenously. The trachea was intubated and the lungs ventilated with 100%oxygen. Airway pressures were unusually high. Chest compression could be discontinued after less than 1 min. As systolic blood pressure was only 35 mm Hg, epinephrine was given again (0.25 mg intravenously and 0.25 mg in the endotracheal tube). Hydrocortisone succinate (50 mg) and colloids (200 mL) were also administered. The child's cardiopulmonary state then appeared to stabilize. A transient generalized urticaria1 rash was observed. Venous blood was sampled for measurement of levels of plasma histamine, immunoglobulin E, and local anesthetics. As the child awakened, airway pressures increased and blood pressures decreased again. An epinephrine infusion (0.05 pgkg-'.min-') was given for the next 3 h. The patient recovered uneventfully and was discharged 2 days later. The signs observed in this case were characteristic of an anaphylactic reaction. As allergy to lidocaine and bupiv-
845
acaine is rare and the onset of signs was unusually delayed, the patient and his parents were questioned again. No history of allergic reactions to drugs or food could be found, but they reported several episodes of facial and periorbital swelling some minutes after he blew up rubber balloons. Plasma levels of lidocaine and bupivacaine assayed using a gas chromatography method (respectively 3.02 and 0.53 pg/mL) were below toxic levels. Skin prick tests were performed 6 wk later using lidocaine, bupivacaine, and a piece of washed rubber surgical glove. Only the latter proved to be positive. Plasma histamine measured by radioimmunoassay was 90.1 nmol/L (normal < 10.0 nmol/L). Latex-specificimmunoglobulin E measured by radioallergosorbent testing was increased (2.8 kU/L, normal < 0.4 kUIL). This case suggests that any preoperative assessment must systematically search for a history of rubber allergy to avoid the exposure to latex during anesthesia and operation. When in doubt, specific skin tests must be performed preoperatively . Emile Calenda, MD Jean P. Durand, MD Jean Petit, MD Fariz Bawab, MD Antoine Coquerel, PhD, Jacqueline Ensel, MD Claude Winckler, MD
MD
Dipartement d'Anesth~sie-R~nanimntion Chirurgicale H6pital Charles Nicolle UniversitC de Rouen 7, rue de Germont 76031 Rouen W d e x . France
References 1. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979;101:597-8. 2. Morales C, Basomba A, Carreira J, Sastre A. Anaphylaxis produced by rubber glove contact. Case reports and immunological identification of the antigen involved. Clin Exp Allergy 1989;19:425-9. 3. Axelsson JGK, Johanson SGO, Wrangsjo K. IgE-mediated anaphylactoid reactions to rubber. Allergy 1987;42:4650. 4. Axelsson JGK, Eriksson M, Wrangsjo K. Anaphylaxis and angioedema due to rubber allergy in children. Acta Paediatr Scand 1988;77:3144. 5. Slater JE. Rubber anaphylaxis. N Engl J Med 1989;320:112630. 6. Moneret-Vautrin DA, Laxenairc MC, Bavoux F. Allergic shock to latex and ethylene oxide during surgery for spina bifida. Anesthesiology 1990;73:5568.
