Latex Hypersensitivity Reactions Despite Prophylaxis Pamela L. Kwittken, M.D., Jack Becker, M.D., Benjamin Oyefara, M.D., Roger Danziger, M.D., Nicholas A. Pawlowski, M.D., and Sharon Sweinberg, M.D.
ABSTRACT La/ex rubber hypersensitivity represents a significant problemfacing the medical. surgical. radiologic. and dental professions. As a tertiary care center, the Childrens Hospital of Philadelphia has a large population of patients with spina biflda and complex genitourinary anomalies; a number of these children have latex rubber allergy, which may first present as intraoperative anaphylaxis. Although there is no substitutefor complete antigen avoidance, all medical products containing latex rubber may not have suitable alternatives. Therefore. we have formulated a protocol to prevent perioperative reactions through the use of prophylactic medications and the limitation of latex exposure. This regimen includes steroids, antihistamines. and bronchodilators when indicated. In four children, prophylaxis failed peri operatively because of parenteral infusion of latex rubber proteins. (AllergyProc 13, 3:123-127,1992)
hildren with spina bifida and bladder exstrophy C have been reported to have an increased risk of allergic reactions, including anaphylaxis, to natural latex rubber. )-9 Because of the potential severity of these reactions and the current lack of a proved method to identify those at risk, we formulated a preoperative medication regimen based on current recommendations for radiocontrast media (RCM) prophylaxis. 10.1 I
From the Allergy Section. Children's Hospital of Philadelphia, Philadelphia. PA 19104 Portions of this material were presented at the 60th Annual Meeting of the American Academy of Pediatrics. Section on Allergy and Immunology, October 26, 1991; New Orleans. Louisiana
Success using such a prophylactic regimen has been noted by several investigators.4•5 In the four patients described, surgery was tolerated without any allergic complications due to latex; however, all patients experienced moderate to severe anaphylaxis caused by inadvertent intravenous administration of latex proteins perioperatively, despite premedication. METHODS T aboratory confirmation of latex rubber allergy by .L radioallergosorbent test (RAST) for latex-specific IgE was performed by Dr. Jay Slater at Children's National Medical Center, Washington, DC by a method previously described.6 Anesthetic skin testing was performed to thiopental (25 mg/mL), pancuronium (I mg/ mL), vecuronium (10 mg/5 mL), and succinylcholine (20 mg/mL) as follows:10,12 full-strength prick testing was performed to each agent suspected in the allergic reaction. If prick testing was negative, intradermal testing was used with three to four serial IO-fold dilutions (1: 10,000 to 1:10). No intradermal solution greater than 1:10 was used because nonspecific irritation was found in adult control volunteers. Antibiotic skin testing was similarly performed with standard 10,000 units/mL of penicillin G and benzylpenicilloyl polylysine (Pre-Pen, Swartz Pharma, Kremers-Urban Co., Milwaukee, WI), as well as cefazolin when indicated.lo When fullstrength prick to cefazolin (100 mg/mL) was negative, intradermal skin testing was performed using four serial 10-fold dilutions (starting with I: 1000); the maximum concentration achieved was 1 mg/mL, after which nonspecific irritation occurred. Positive (histamine) and negative (normal saline) controls were also placed; a positive test was considered 3 mm larger than the diameter of the normal saline wheal.
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
123
Preoperative Protocol
e have used separate regimens for patients with a W known history of latex rubber allergy and for those in a high-risk group who may manifest the allergy. The latter group includes patients with spina bifida, complex genitourinary anomalies, multiple operations, and intraoperative anaphylaxis of unknown etiology. For patients with a history of sensitivity to latex rubber, 24 hours of preoperative medications are recommended; these include diphenhydramine, methylprednisolone, and cimetidine (Table I). Latex allergic children who have not had a life-threatening reaction may receive oral medication at home if the parents are judged to be reliable by hospital staff. When a 24-hour period is not available for preoperative medications, hydrocortisone can be substituted for methylprednisolone because of its more rapid onset of action. 13 Medications are continued on the day of surgery and 24 hours thereafter unless indwelling latex devices exist or allergic complications arise. Should these extenuating circumstances occur, the drugs are then tapered more slowly. In uncomplicated cases, the medication is tapered over 2 days, with the use of oral preparations whenever feasible. Recent surveys show that 18 to 28 % of spina bifida patients have a history of latex rubber allergy,3 and as high as 47% may be positive for latex-specific IgE by RAST.4 Therefore, patients who lack a clinical history of latex rubber allergy but belong to one of the highrisk groups noted above were given oral premedication before surgery. This regimen includes prednisone and oral diphenhydramine 12 hours before surgery. An Hz blocker is optional but highly recommended if an antihistamine other than diphenhydramine must be used (Table 2). The intravenous equivalents of these medications are administered on the day of surgery and given orally 24 hours after surgery. Children with a history of reactive airway disease have peak flow measurements monitored daily. Inasmuch as anesthesia alone can cause or exacerbate bronchospasm, the patient's daily asthma medications are continued; minimal preparation includes use of inhaled
albuterol and cromolyn (via nebulizer or metered dose inhaler) every 6 hours. For all patients, reasonable precautions are taken to avoid latex exposure. AlI known latex materials (such as gloves and drains) are removed from the environment. Intravenous infusion sets are used in which the buretrol does not contain latex; one type of set used in our institution is the Ivion ™ brand (Ivion Corporation, Englewood, CO). Latex injection ports are not used to introduce medication; instead, the buretrol's injection port is removed and replaced with a con nector or plastic stopcock. Aseptic techniques are instituted for these make-shift ports; the entire intravenous set is changed every 48 hours to minimize iatrogenic infection. Emergency medications and equipment are available at the bedside. Case I
atient A is an Il-year-old white girl with spina Pbifida, ventriculoperitoneal shunt (VPS), and blad-
der exstrophy. She was born prematurely at 32 weeks' gestation. The patient had no history of atopy or drug allergy. During her eleventh surgical procedure, the anesthesiologist's latex glove came into contact with her buccal mucosa while placing the mask (non latex) on her face to begin halothane induction. She immediately experienced anaphylaxis with hypotension, diffuse flushing, oropharyngeal edema, and difficulty in ventilation. Her latex specific IgE by RAST was positive at 15.6% binding (positive is considered greater than 1.0%),6,7confirming her latex sensitivity. Two months later, the patient was scheduled for cystoscopy under anesthesia and vaginoplasty. She was premedicated with intravenous diphenhydramine, methylprednisolone, and cimetidine 24 hours before surgery. After 18 hours of premedication, she experienced two episodes of urticaria and wheezing with hypoxia (pulse oximetry 92% on room air) when diphenhydramine and methylprednisolone were injected through a latex port on the intravenous soluset. The patient required oxygen, epinephrine, supplemental diphenhydramine, cimetidine, and methylprednisolone.
TABLE I Premedication Protocols: Patients with Known Latex Anergy
124
Medication
Dosage
Alternative
Diphenhydramine Methylprednisolone Cimetidine
1 mg/kg/dose q6h IV/PO I mg/kg/dose q6h IV/PO 5 mg/kg/dose q6h IV/PO
Terfenadine 30-60 mg q 12h PO Prednisone 0.5 mg/kg/dose q 12h Ranitidine 1-2 mg/kg/day IV divided q8h; 3-4 mg/kg/day PO divided q 12h
May-June 1992, Vol. 13, No.3
Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
TABLE II Premedication Protocols: High Risk Patients Medication
Dosage
Alternative
Diphenhydramine Prednisone
I mg/kg/dose q6h PO 0.5 mg/kg/dose ql2h PO
Terfenadine* 30-60 mg ql2h PO
* Cimetidine or ranitidine are optional but highly recommended when an
HI blocker other than diphenhydramine
is
used.
Twenty-four hours later, cystoscopy was performed under general anesthesia uneventfully. One month later, the patient was readmitted for vaginoplasty. She received the same preoperative prophylaxis, as well as careful avoidance of latex injection ports, and had no allergic complications during surgery. Case 2 atient B is a 15-year-old white boy with bladder exstrophy, asthma, and allergic rhinitis. He was diagnosed with latex rubber allergy at age 13 years after experiencing multiple episodes of intraoperative anaphylaxis with negative skin tests to anesthetic agents (these included thiopental, vecuronium, pancuronium, and succinylcholine). He also had a history of urticaria, bronchospasm, and eyelid swelling on contact with balloons and latex gloves. His latex-specific IgE by RAST was positive at 5.2%. The patient was premedicated with intravenous diphenhydramine, ranitidine, methylprednisolone, as well as nebulized albuterol 24 hours before insertion of an artificial urinary sphincter (his forty-seventh operative procedure). His baseline peak flow measurement was 300 L/m. Although the surgery was uneventful, the patient experienced recurrent episodes of wheezing and facial erythema during the 12-hour postoperative period on the ward. These episodes were temporally related to intravenous infusions of stock solution (5% dextrose and 0.5% normal saline). His peak flow measurement had decreased by 30%. It was then noted that his soluset inadvertently had been replaced for one that contained latex in the buretrol. After the entire intravenous set, including the intravenous catheter, was changed, he required an additional 24 hours of medication for the symptoms to resolve and his peak flow measurement to normalize.
P
Case 3 atient C is a 17-year-old white girl with spina bifida, VPS, and kyphoscoliosis. She had a history of eyelid swelling and erythema when near latex gloves or balloons from the age of 5 but had undergone six operations without any allergic complications. A baseline
P
peak flow measurement of 250 L/m was obtained due to her restrictive lung disease. She was premedicated with intravenous diphenhydramine, methylprednisolone, and cimetidine 24 hours before vesicostomy placement. During surgery, she experienced two episodes of hypotension and bronchospasm shortly after receiving pancuronium; the symptoms resolved with fluid boluses and epinephrine. Twelve hours postoperatively, she experienced acute bronchospasm with hypoxia (room air pulse oximetry 85%), periorbital edema, and facial flushing. She required supplemental oxygen, epinephrine, nebulized albuterol, as well as additional diphenhydramine, cimetidine, and methylprednisolone for 48 hours before the symptoms resolved completely. Her peak flow measurement remained decreased at 200 L/m during this time and did not return to baseline until 3 days later. Retrospective inquiries revealed that the patient's nonlatex soluset inadvertently had been replaced for one whose buretrol contained latex; in addition, her roommate's doctors had donned and removed their latex gloves in the room shortly after the episode began, which may have contributed to the reaction. Latex-specific IgE by RAST was positive at 2.3%. The patient returned to allergy clinic 3 weeks later and was skin-test positive to pancuronium at a I: 10 intradermal dilution, explaining her intraoperative events. Case 4 atient 0 is a 5-year-old white girl with spina bifida and VPS. She was admitted for elective shunt revision because of headaches and a decline in IQ. The patient had no history of latex rubber allergy and had undergone 12 previous operations without incident. She received oral prednisone and diphenhydramine 12 hours before this procedure as well as intravenous diphenhydramine, cimetidine, and methylprednisolone immediately before anesthesia induction because of her high-risk status. Surgery was uneventful, but 4 hours later, a third dose of cefazolin was administered through the latex port of her intravenous set. Within 5 minutes, the
P
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
125
patient experienced flushing and dyspnea. These symptoms resolved with epinephrine and an extra dose of diphenhydramine. Because drug allergy could not be excluded, the house officer decided to premedicate her with diphenhydramine before administering an alternate beta-Iactam antibiotic. Three hours later, diphenhydramine was injected through the latex port; within 5 minutes, she became hypotensive, cyanotic, and dyspneic, with audible wheezing. She required vigorous fluid resuscitation, epinephrine, oxygen, inhaled beta agonists, as well as additional steroids and antihistamines. Latex-specific IgE by RAST was positive at 4.2%. The patient returned to allergy clinic I month later; her skin tests to penicillin and cefazolin were negative.
DISCUSSION ,4.11 four patients experienced
serious adverse reactions to latex rubber exposure through inadvertent use of latex-containing buretrols or injection ports (Table 3). Although three patients were previously identified as having latex rubber allergy, one was not. All four patients, however, had a minimum of 12 hours of prophylactic medications before intravenous exposure to latex rubber proteins. Reactions due to these intra-
1-l..
venous devices have been reported in conjunction with ethylene oxide as an agent used in the sterilization of intravenous tubingl4 and not with infusion of natural latex proteins. Ethylene oxide did not appear to be a factor in our patients' reactions inasmuch as they occurred in radiation-sterilized devices, but one cannot rule out the previous sensitization to natural latex rubber via haptenation with this substance. Three patients tolerated their surgeries without allergic manifestations; one did not secondary to pancuronium allergy that was documented by skin-test. Although it has been controversial whether to use an H2 receptor blocker in radiocontrast media (RCM) prophylaxis, we have had success using these agents. I I With the theoretical possibility of histamine receptor
TABLE III Case Summary Patient
Age (yr)
Known Latex Allergy?
A B C
II 15 17
Yes Yes Yes
15.6% 5.2%
D
5
No
4.2%
* Radioal/ergosorbent
RAST*
2.3%
test performed by Dr. Jay Slater, Childrens National Medical Center, Washington, DC. Positive is greater than 1.0% binding.6•7
126
imbalance promoting bronchospasm, we do not recommend use of an H2 blocker alone. IS Diphenhydramine crosses the blood brain barrier and may not be tolerated in certain patients with seizure disorders or sleep apnea (e.g., due to the Arnold-Chiari malformation).13 In these selected cases, we recommend terfenadine. It should be noted that there is no data regarding the use of this antihistamine in anaphylaxis or RCM prophylaxis, although its efficacy in urticaria is established.lo Therefore, we strongly recommend additional use of an H2 blocking agent in conjunction with terfenadine. Cimetidine has been well researched in RCM prophylaxis, however, it too has certain disadvantages. While interfering with the cytochrome P450 system, it alters the metabolism of theophylline, anticonvulsants, and oral contraceptives. IS The alternative is ranitidine, which seems to be equally effective. Its advantages include t.i.d. dosing instead of q.i.d. for parenteral use and fewer reports of arrhythmias, which have been associated with the rapid administration of cimetidine.13.16 Precautionary measures include removing all latex gloves from the patient's room to prevent aerosolization ofIatex particles carried by the glove powder. 17-19Steri Ie neoprene and nonsterile vinyl gloves are substituted. If latex gloves must be used for infection control, we recommended donning and removing them outside the patient's room and using a nonlatex glove over them for patient contact.
CONCLUSIONS
,4. dverse reactions to natural latex 1-l.. eliminated or diminished during
rubber may be surgery with premedication and avoidance of latex-containing devices. Prophylactic premedication may not prevent allergic reactions caused by an intravenous "bolus" of latex rubber particles. Meticulous care should be taken to avoid the use of latex-containing intravenous infusion sets and inadvertent injection through latex ports. Latex glove use should be avoided near allergic patients because of the hazard of aerosolized particles. In the event of an apparent alIergic reaction to latex rubber, other causes (i.e., antibiotics, anesthetic agents) must be investigated because these allergies may coexist. Currently, there is no standard in vitro or in vivo diagnostic technique that safely predicts latex rubber allergy.20-22 Therefore, we recommend that all patients with spina bifida, genitourinary anomalies, multiple operations, or unexplained intraoperative anaphylaxis receive prophylactic premedication and maximal avoidance of latex-containing devices. In addition, to prevent sensitization, children with spina bifida and genitourinary anomalies should avoid latex rubber devices during all medically related (i.e., bladder catheterization, enemas, intravenous infusion sets) and recrea-
May-June 1992, Vol. 13, No.3
Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
tional activities (e.g., balloons, snorkel masks, Koosh™ balls, and other rubber toys). House staff, nursing staff, and family members must be instructed in the recognition and avoidance of natural latex rubber items. All patients with latex rubber allergy should receive a Medic-AlerfM bracelet (MedicAlert Foundation, Turlock, CA) identifying their condition; they need to carry oral antihistamines, as well as self-injectable epinephrine for those patients who have had life-threatening reactions.
REFERENCES I.
Gelb L, ed. Allergic reactions to latex-containing medical de-
vices. FDA Medical Bulletin 156: 1-2, 1991. 2. Gold M, Swartz J, Gilmour RF, et al. Intraoperative anaphylaxis: an association with latex sensitivity. J Allergy Clin Immunol 87:662-665, 1991. 3. Meeropol E, Kelleher R, Leger R, et at Allergic reactions to rubber in patients with myelodysplasia. N Engl J Med 323: 1072, 1990. 4. Merguerian PA, Klein RB, Rozyncki AA, et at Intraoperative anaphylactic reaction due to latex hypersensitivity. Urology 36:301-304, 1991. 5. Nguyen DH, Burns MW, Mitchell ME, et at Intraoperative cardiovascular collapse secondary to latex allergy. J Urol 146:571-574,1991. 6. Slater JE. Rubber anaphylaxis. N Engl J Med 320: I 126-1130, 1989.
7. 8.
Slater JE, Mostello A, Honsinger RW, et at Type I hypersensitivity to rubber. Ann Allergy 65:411-414,1991. Sussman GL, Tarlo S, Dolovich J. The spectrum of IgE-me-
9. 10.
II. 12.
13. 14.
diated responses to latex allergy. JAMA 265:2844-2847,1991. Swartz J, Braude BM, Gold M, et al. Intraoperative anaphylaxis to latex. Can J Anaesth 37:589-592. 1990. Lawlor GJ, Fischer n. Manual of Allergy and Immunology, 2nd ed. Boston, MA: Little, Brown and Co., 1988, pp. 214-224, 242-271. Lasser EC. Pseudoallergic drug reactions. In: Immunology and Allergy Clinics of North America 11:645-655, 1991. Moscicki RA, Sockin SM, Bloch KJ. Anaphylaxis during induction of general anesthesia: subsequent evaluation and management. J Allergy Clin Immunol 86:325-332,1990. AMA Drug Evaluations, 5th ed. Chicago, IL: American Medical Association, 1983, pp. 892-893, 1478. Moneret-Vautrin DA, Laxenaire MC, Bavous F. Allergic shock to latex and ethylene oxide during surgery for spina bifida. Anaesthesia 73:556-558, 1990.
15. Florence FB, Katz J. Anesthesia for the child with asthma. Am J Asthma Allergy Ped 4:133-140, 1991. 16. Physicians' Desk Reference, 46th ed. Oradell, Nl: Medical Economics Data, 1992, pp. 1063-1067, 2228-2231. 17. Bauer X, Jager D. Airborne antigens from latex gloves. Lancet 335:912, 1990. 18. Turjanmaa K, Reunala T, Pauloso T, et at Allergens in latex surgical gloves and glove powder. Lancet 336: 1558, 1990. 19. Van der Meeren HLM, van Erp PEJ. Life-threatening urticaria from glove powder. Contact Dermatitis 14:190-191, 1986. 20. Slater lE, Mostello LA. Routine testing for latex allergy in patients with spina bifida is not recommended. Anesthesiology 74:391-392, 1991. 21. Spaner D, Dolovich J, Buttoo K, et al. Hypersensitivity to natural latex. 1 Allergy Clin ImmunoI83:1135-1137, 1989. 22. Turjanmaa K, Reunala T, Rasanene L. Comparison of diagnostic methods in latex and surgical glove contact urticaria. Contact Dermatitis 14:241-247,1988. 0
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
127
ABSTRACT La/ex rubber hypersensitivity represents a significant problemfacing the medical. surgical. radiologic. and dental professions. As a tertiary care center, the Childrens Hospital of Philadelphia has a large population of patients with spina biflda and complex genitourinary anomalies; a number of these children have latex rubber allergy, which may first present as intraoperative anaphylaxis. Although there is no substitutefor complete antigen avoidance, all medical products containing latex rubber may not have suitable alternatives. Therefore. we have formulated a protocol to prevent perioperative reactions through the use of prophylactic medications and the limitation of latex exposure. This regimen includes steroids, antihistamines. and bronchodilators when indicated. In four children, prophylaxis failed peri operatively because of parenteral infusion of latex rubber proteins. (AllergyProc 13, 3:123-127,1992)
hildren with spina bifida and bladder exstrophy C have been reported to have an increased risk of allergic reactions, including anaphylaxis, to natural latex rubber. )-9 Because of the potential severity of these reactions and the current lack of a proved method to identify those at risk, we formulated a preoperative medication regimen based on current recommendations for radiocontrast media (RCM) prophylaxis. 10.1 I
From the Allergy Section. Children's Hospital of Philadelphia, Philadelphia. PA 19104 Portions of this material were presented at the 60th Annual Meeting of the American Academy of Pediatrics. Section on Allergy and Immunology, October 26, 1991; New Orleans. Louisiana
Success using such a prophylactic regimen has been noted by several investigators.4•5 In the four patients described, surgery was tolerated without any allergic complications due to latex; however, all patients experienced moderate to severe anaphylaxis caused by inadvertent intravenous administration of latex proteins perioperatively, despite premedication. METHODS T aboratory confirmation of latex rubber allergy by .L radioallergosorbent test (RAST) for latex-specific IgE was performed by Dr. Jay Slater at Children's National Medical Center, Washington, DC by a method previously described.6 Anesthetic skin testing was performed to thiopental (25 mg/mL), pancuronium (I mg/ mL), vecuronium (10 mg/5 mL), and succinylcholine (20 mg/mL) as follows:10,12 full-strength prick testing was performed to each agent suspected in the allergic reaction. If prick testing was negative, intradermal testing was used with three to four serial IO-fold dilutions (1: 10,000 to 1:10). No intradermal solution greater than 1:10 was used because nonspecific irritation was found in adult control volunteers. Antibiotic skin testing was similarly performed with standard 10,000 units/mL of penicillin G and benzylpenicilloyl polylysine (Pre-Pen, Swartz Pharma, Kremers-Urban Co., Milwaukee, WI), as well as cefazolin when indicated.lo When fullstrength prick to cefazolin (100 mg/mL) was negative, intradermal skin testing was performed using four serial 10-fold dilutions (starting with I: 1000); the maximum concentration achieved was 1 mg/mL, after which nonspecific irritation occurred. Positive (histamine) and negative (normal saline) controls were also placed; a positive test was considered 3 mm larger than the diameter of the normal saline wheal.
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
123
Preoperative Protocol
e have used separate regimens for patients with a W known history of latex rubber allergy and for those in a high-risk group who may manifest the allergy. The latter group includes patients with spina bifida, complex genitourinary anomalies, multiple operations, and intraoperative anaphylaxis of unknown etiology. For patients with a history of sensitivity to latex rubber, 24 hours of preoperative medications are recommended; these include diphenhydramine, methylprednisolone, and cimetidine (Table I). Latex allergic children who have not had a life-threatening reaction may receive oral medication at home if the parents are judged to be reliable by hospital staff. When a 24-hour period is not available for preoperative medications, hydrocortisone can be substituted for methylprednisolone because of its more rapid onset of action. 13 Medications are continued on the day of surgery and 24 hours thereafter unless indwelling latex devices exist or allergic complications arise. Should these extenuating circumstances occur, the drugs are then tapered more slowly. In uncomplicated cases, the medication is tapered over 2 days, with the use of oral preparations whenever feasible. Recent surveys show that 18 to 28 % of spina bifida patients have a history of latex rubber allergy,3 and as high as 47% may be positive for latex-specific IgE by RAST.4 Therefore, patients who lack a clinical history of latex rubber allergy but belong to one of the highrisk groups noted above were given oral premedication before surgery. This regimen includes prednisone and oral diphenhydramine 12 hours before surgery. An Hz blocker is optional but highly recommended if an antihistamine other than diphenhydramine must be used (Table 2). The intravenous equivalents of these medications are administered on the day of surgery and given orally 24 hours after surgery. Children with a history of reactive airway disease have peak flow measurements monitored daily. Inasmuch as anesthesia alone can cause or exacerbate bronchospasm, the patient's daily asthma medications are continued; minimal preparation includes use of inhaled
albuterol and cromolyn (via nebulizer or metered dose inhaler) every 6 hours. For all patients, reasonable precautions are taken to avoid latex exposure. AlI known latex materials (such as gloves and drains) are removed from the environment. Intravenous infusion sets are used in which the buretrol does not contain latex; one type of set used in our institution is the Ivion ™ brand (Ivion Corporation, Englewood, CO). Latex injection ports are not used to introduce medication; instead, the buretrol's injection port is removed and replaced with a con nector or plastic stopcock. Aseptic techniques are instituted for these make-shift ports; the entire intravenous set is changed every 48 hours to minimize iatrogenic infection. Emergency medications and equipment are available at the bedside. Case I
atient A is an Il-year-old white girl with spina Pbifida, ventriculoperitoneal shunt (VPS), and blad-
der exstrophy. She was born prematurely at 32 weeks' gestation. The patient had no history of atopy or drug allergy. During her eleventh surgical procedure, the anesthesiologist's latex glove came into contact with her buccal mucosa while placing the mask (non latex) on her face to begin halothane induction. She immediately experienced anaphylaxis with hypotension, diffuse flushing, oropharyngeal edema, and difficulty in ventilation. Her latex specific IgE by RAST was positive at 15.6% binding (positive is considered greater than 1.0%),6,7confirming her latex sensitivity. Two months later, the patient was scheduled for cystoscopy under anesthesia and vaginoplasty. She was premedicated with intravenous diphenhydramine, methylprednisolone, and cimetidine 24 hours before surgery. After 18 hours of premedication, she experienced two episodes of urticaria and wheezing with hypoxia (pulse oximetry 92% on room air) when diphenhydramine and methylprednisolone were injected through a latex port on the intravenous soluset. The patient required oxygen, epinephrine, supplemental diphenhydramine, cimetidine, and methylprednisolone.
TABLE I Premedication Protocols: Patients with Known Latex Anergy
124
Medication
Dosage
Alternative
Diphenhydramine Methylprednisolone Cimetidine
1 mg/kg/dose q6h IV/PO I mg/kg/dose q6h IV/PO 5 mg/kg/dose q6h IV/PO
Terfenadine 30-60 mg q 12h PO Prednisone 0.5 mg/kg/dose q 12h Ranitidine 1-2 mg/kg/day IV divided q8h; 3-4 mg/kg/day PO divided q 12h
May-June 1992, Vol. 13, No.3
Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
TABLE II Premedication Protocols: High Risk Patients Medication
Dosage
Alternative
Diphenhydramine Prednisone
I mg/kg/dose q6h PO 0.5 mg/kg/dose ql2h PO
Terfenadine* 30-60 mg ql2h PO
* Cimetidine or ranitidine are optional but highly recommended when an
HI blocker other than diphenhydramine
is
used.
Twenty-four hours later, cystoscopy was performed under general anesthesia uneventfully. One month later, the patient was readmitted for vaginoplasty. She received the same preoperative prophylaxis, as well as careful avoidance of latex injection ports, and had no allergic complications during surgery. Case 2 atient B is a 15-year-old white boy with bladder exstrophy, asthma, and allergic rhinitis. He was diagnosed with latex rubber allergy at age 13 years after experiencing multiple episodes of intraoperative anaphylaxis with negative skin tests to anesthetic agents (these included thiopental, vecuronium, pancuronium, and succinylcholine). He also had a history of urticaria, bronchospasm, and eyelid swelling on contact with balloons and latex gloves. His latex-specific IgE by RAST was positive at 5.2%. The patient was premedicated with intravenous diphenhydramine, ranitidine, methylprednisolone, as well as nebulized albuterol 24 hours before insertion of an artificial urinary sphincter (his forty-seventh operative procedure). His baseline peak flow measurement was 300 L/m. Although the surgery was uneventful, the patient experienced recurrent episodes of wheezing and facial erythema during the 12-hour postoperative period on the ward. These episodes were temporally related to intravenous infusions of stock solution (5% dextrose and 0.5% normal saline). His peak flow measurement had decreased by 30%. It was then noted that his soluset inadvertently had been replaced for one that contained latex in the buretrol. After the entire intravenous set, including the intravenous catheter, was changed, he required an additional 24 hours of medication for the symptoms to resolve and his peak flow measurement to normalize.
P
Case 3 atient C is a 17-year-old white girl with spina bifida, VPS, and kyphoscoliosis. She had a history of eyelid swelling and erythema when near latex gloves or balloons from the age of 5 but had undergone six operations without any allergic complications. A baseline
P
peak flow measurement of 250 L/m was obtained due to her restrictive lung disease. She was premedicated with intravenous diphenhydramine, methylprednisolone, and cimetidine 24 hours before vesicostomy placement. During surgery, she experienced two episodes of hypotension and bronchospasm shortly after receiving pancuronium; the symptoms resolved with fluid boluses and epinephrine. Twelve hours postoperatively, she experienced acute bronchospasm with hypoxia (room air pulse oximetry 85%), periorbital edema, and facial flushing. She required supplemental oxygen, epinephrine, nebulized albuterol, as well as additional diphenhydramine, cimetidine, and methylprednisolone for 48 hours before the symptoms resolved completely. Her peak flow measurement remained decreased at 200 L/m during this time and did not return to baseline until 3 days later. Retrospective inquiries revealed that the patient's nonlatex soluset inadvertently had been replaced for one whose buretrol contained latex; in addition, her roommate's doctors had donned and removed their latex gloves in the room shortly after the episode began, which may have contributed to the reaction. Latex-specific IgE by RAST was positive at 2.3%. The patient returned to allergy clinic 3 weeks later and was skin-test positive to pancuronium at a I: 10 intradermal dilution, explaining her intraoperative events. Case 4 atient 0 is a 5-year-old white girl with spina bifida and VPS. She was admitted for elective shunt revision because of headaches and a decline in IQ. The patient had no history of latex rubber allergy and had undergone 12 previous operations without incident. She received oral prednisone and diphenhydramine 12 hours before this procedure as well as intravenous diphenhydramine, cimetidine, and methylprednisolone immediately before anesthesia induction because of her high-risk status. Surgery was uneventful, but 4 hours later, a third dose of cefazolin was administered through the latex port of her intravenous set. Within 5 minutes, the
P
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
125
patient experienced flushing and dyspnea. These symptoms resolved with epinephrine and an extra dose of diphenhydramine. Because drug allergy could not be excluded, the house officer decided to premedicate her with diphenhydramine before administering an alternate beta-Iactam antibiotic. Three hours later, diphenhydramine was injected through the latex port; within 5 minutes, she became hypotensive, cyanotic, and dyspneic, with audible wheezing. She required vigorous fluid resuscitation, epinephrine, oxygen, inhaled beta agonists, as well as additional steroids and antihistamines. Latex-specific IgE by RAST was positive at 4.2%. The patient returned to allergy clinic I month later; her skin tests to penicillin and cefazolin were negative.
DISCUSSION ,4.11 four patients experienced
serious adverse reactions to latex rubber exposure through inadvertent use of latex-containing buretrols or injection ports (Table 3). Although three patients were previously identified as having latex rubber allergy, one was not. All four patients, however, had a minimum of 12 hours of prophylactic medications before intravenous exposure to latex rubber proteins. Reactions due to these intra-
1-l..
venous devices have been reported in conjunction with ethylene oxide as an agent used in the sterilization of intravenous tubingl4 and not with infusion of natural latex proteins. Ethylene oxide did not appear to be a factor in our patients' reactions inasmuch as they occurred in radiation-sterilized devices, but one cannot rule out the previous sensitization to natural latex rubber via haptenation with this substance. Three patients tolerated their surgeries without allergic manifestations; one did not secondary to pancuronium allergy that was documented by skin-test. Although it has been controversial whether to use an H2 receptor blocker in radiocontrast media (RCM) prophylaxis, we have had success using these agents. I I With the theoretical possibility of histamine receptor
TABLE III Case Summary Patient
Age (yr)
Known Latex Allergy?
A B C
II 15 17
Yes Yes Yes
15.6% 5.2%
D
5
No
4.2%
* Radioal/ergosorbent
RAST*
2.3%
test performed by Dr. Jay Slater, Childrens National Medical Center, Washington, DC. Positive is greater than 1.0% binding.6•7
126
imbalance promoting bronchospasm, we do not recommend use of an H2 blocker alone. IS Diphenhydramine crosses the blood brain barrier and may not be tolerated in certain patients with seizure disorders or sleep apnea (e.g., due to the Arnold-Chiari malformation).13 In these selected cases, we recommend terfenadine. It should be noted that there is no data regarding the use of this antihistamine in anaphylaxis or RCM prophylaxis, although its efficacy in urticaria is established.lo Therefore, we strongly recommend additional use of an H2 blocking agent in conjunction with terfenadine. Cimetidine has been well researched in RCM prophylaxis, however, it too has certain disadvantages. While interfering with the cytochrome P450 system, it alters the metabolism of theophylline, anticonvulsants, and oral contraceptives. IS The alternative is ranitidine, which seems to be equally effective. Its advantages include t.i.d. dosing instead of q.i.d. for parenteral use and fewer reports of arrhythmias, which have been associated with the rapid administration of cimetidine.13.16 Precautionary measures include removing all latex gloves from the patient's room to prevent aerosolization ofIatex particles carried by the glove powder. 17-19Steri Ie neoprene and nonsterile vinyl gloves are substituted. If latex gloves must be used for infection control, we recommended donning and removing them outside the patient's room and using a nonlatex glove over them for patient contact.
CONCLUSIONS
,4. dverse reactions to natural latex 1-l.. eliminated or diminished during
rubber may be surgery with premedication and avoidance of latex-containing devices. Prophylactic premedication may not prevent allergic reactions caused by an intravenous "bolus" of latex rubber particles. Meticulous care should be taken to avoid the use of latex-containing intravenous infusion sets and inadvertent injection through latex ports. Latex glove use should be avoided near allergic patients because of the hazard of aerosolized particles. In the event of an apparent alIergic reaction to latex rubber, other causes (i.e., antibiotics, anesthetic agents) must be investigated because these allergies may coexist. Currently, there is no standard in vitro or in vivo diagnostic technique that safely predicts latex rubber allergy.20-22 Therefore, we recommend that all patients with spina bifida, genitourinary anomalies, multiple operations, or unexplained intraoperative anaphylaxis receive prophylactic premedication and maximal avoidance of latex-containing devices. In addition, to prevent sensitization, children with spina bifida and genitourinary anomalies should avoid latex rubber devices during all medically related (i.e., bladder catheterization, enemas, intravenous infusion sets) and recrea-
May-June 1992, Vol. 13, No.3
Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
tional activities (e.g., balloons, snorkel masks, Koosh™ balls, and other rubber toys). House staff, nursing staff, and family members must be instructed in the recognition and avoidance of natural latex rubber items. All patients with latex rubber allergy should receive a Medic-AlerfM bracelet (MedicAlert Foundation, Turlock, CA) identifying their condition; they need to carry oral antihistamines, as well as self-injectable epinephrine for those patients who have had life-threatening reactions.
REFERENCES I.
Gelb L, ed. Allergic reactions to latex-containing medical de-
vices. FDA Medical Bulletin 156: 1-2, 1991. 2. Gold M, Swartz J, Gilmour RF, et al. Intraoperative anaphylaxis: an association with latex sensitivity. J Allergy Clin Immunol 87:662-665, 1991. 3. Meeropol E, Kelleher R, Leger R, et at Allergic reactions to rubber in patients with myelodysplasia. N Engl J Med 323: 1072, 1990. 4. Merguerian PA, Klein RB, Rozyncki AA, et at Intraoperative anaphylactic reaction due to latex hypersensitivity. Urology 36:301-304, 1991. 5. Nguyen DH, Burns MW, Mitchell ME, et at Intraoperative cardiovascular collapse secondary to latex allergy. J Urol 146:571-574,1991. 6. Slater JE. Rubber anaphylaxis. N Engl J Med 320: I 126-1130, 1989.
7. 8.
Slater JE, Mostello A, Honsinger RW, et at Type I hypersensitivity to rubber. Ann Allergy 65:411-414,1991. Sussman GL, Tarlo S, Dolovich J. The spectrum of IgE-me-
9. 10.
II. 12.
13. 14.
diated responses to latex allergy. JAMA 265:2844-2847,1991. Swartz J, Braude BM, Gold M, et al. Intraoperative anaphylaxis to latex. Can J Anaesth 37:589-592. 1990. Lawlor GJ, Fischer n. Manual of Allergy and Immunology, 2nd ed. Boston, MA: Little, Brown and Co., 1988, pp. 214-224, 242-271. Lasser EC. Pseudoallergic drug reactions. In: Immunology and Allergy Clinics of North America 11:645-655, 1991. Moscicki RA, Sockin SM, Bloch KJ. Anaphylaxis during induction of general anesthesia: subsequent evaluation and management. J Allergy Clin Immunol 86:325-332,1990. AMA Drug Evaluations, 5th ed. Chicago, IL: American Medical Association, 1983, pp. 892-893, 1478. Moneret-Vautrin DA, Laxenaire MC, Bavous F. Allergic shock to latex and ethylene oxide during surgery for spina bifida. Anaesthesia 73:556-558, 1990.
15. Florence FB, Katz J. Anesthesia for the child with asthma. Am J Asthma Allergy Ped 4:133-140, 1991. 16. Physicians' Desk Reference, 46th ed. Oradell, Nl: Medical Economics Data, 1992, pp. 1063-1067, 2228-2231. 17. Bauer X, Jager D. Airborne antigens from latex gloves. Lancet 335:912, 1990. 18. Turjanmaa K, Reunala T, Pauloso T, et at Allergens in latex surgical gloves and glove powder. Lancet 336: 1558, 1990. 19. Van der Meeren HLM, van Erp PEJ. Life-threatening urticaria from glove powder. Contact Dermatitis 14:190-191, 1986. 20. Slater lE, Mostello LA. Routine testing for latex allergy in patients with spina bifida is not recommended. Anesthesiology 74:391-392, 1991. 21. Spaner D, Dolovich J, Buttoo K, et al. Hypersensitivity to natural latex. 1 Allergy Clin ImmunoI83:1135-1137, 1989. 22. Turjanmaa K, Reunala T, Rasanene L. Comparison of diagnostic methods in latex and surgical glove contact urticaria. Contact Dermatitis 14:241-247,1988. 0
Allergy Proc. Delivered by Ingenta to: UCL LIBRARY IP: 46.148.31.37 On: Wed, 15 Jun 2016 02:48:38 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
127
