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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. 

Environment Services/Domestic/Kitchen Staff

The environmental services staff must be made aware of the existence of such a patient so that they do not use latex gloves when cleaning.

Kitchen staff should only prepare food with synthetic gloves.

Ensure food allergies are noted when preparing food.

 

Content updated March 2010

Latex Allergy Information for New Employees

The following steps are based on a common sense approach to minimising latex sensitisation of all healthcare workers.

1. Use non-latex gloves for activities that are not likely to involve contact with infectious materials (food preparation and housekeeping etc.).

2. Appropriate barrier protection is necessary when handling infectious material. If you choose latex gloves, use powder free with reduced protein content: such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy (although symptoms may still occur in some workers). 

3. Use appropriate work practices to reduce the chance of latex reactions. When wearing latex gloves, do not use oil-based hand creams or lotions unless they have been shown to reduce latex problems. After removing latex gloves, wash hands and dry thoroughly. 

4. Take advantage of all latex allergy education and training provided by your employer, and learn to recognise the symptoms of latex allergy. 

5. If you develop symptoms avoid direct contact with latex products and see a physician experienced in latex allergy. Carefully follow your physician's instructions for dealing with allergic reactions to latex. 

6. If you have latex allergy: avoid contact with latex products; avoid areas where you might inhale powder from latex gloves worn by others; tell your employer that you have a latex allergy; and wear a medic-alert bracelet. It must be stressed that it is best to treat early to prevent the sensitisation to latex becoming too severe. 

(Adapted from recommendations of the National Institute for Occupational Safety and Health, 1997)

 

Content updated March 2010

Guidelines to Promote Safe Practice in the Dental Environment for Latex Allergic Patients

Introduction

Include questions regarding the possibility of latex allergy in your history

Ensure patient notes and ID bands are suitably identified with latex allergic status  

1. General Dentistry

a) Dentists/Dental Chairside
Assistants
Non latex gloves (eg neoprene, nitrile, vinyl).
Latex powder free environment
b) Rubber dam Do not use Rubber Dam
Can use:
Silicone Dam (Roeko products from various dental supply houses)
c) Local Anaesthetic Use local anaesthetics from plastic ampoules and latex free syringes.
Pre-loaded cartridges - check with manufacturers.
d) Syringes Many single use syringes are latex free. Check with manufacturer. E.g Terumo are latex free.
e) Mouth props Use a plastic, disposable mouth prop eg; "Denta-Pops Great Aspirations" from Horseley Dental Company.
f) Eye Protection Check the bridge piece of glasses for latex containing components.
g) Impression materials No contra indications - rubber based impression materials are synthetic rubber
h) Other dental products Polishing disks have a latex backing; probably low risk, use with caution.
Rubber "prophy" polishing cup - use polishing brush.
i) Toothbrushes Avoid toothbrushes with a rubber interdental pic and rubber handles.

2. Specialist Dentistry

a) Endodontics

GP points

GP points are derived from trees in the same botanical family as natural rubber, and there in lies the potential for cross allergenicity. This problem has been highlighted by a report which emphasises the problems with over filling root canals with GP points. If one can guarantee there is no over filling with GP then it can be used, however the potential for over filling and resulting allergic response must be remembered. REF:J Allergy Clin Immunol 1994;93;943-4
rubber stoppers on
endodontic files
measure with a tweezer grip or make an informed assessment of risk.
b) Orthodontics Check head gear components for latex containing items. Elastic/surgical ligatures and power chain may be a problem - check with manufacturer. As alternative, use wire ligatures.
Check for rubber grips on ortho wire cutters, band removers and band placers.

3. Latex Safe General Anaesthesia for General and Restorative Dentistry

a) Scheduling Schedule latex allergic patients first in the morning to lessen their exposure to air borne latex particles.
b) Anaesthesia personnel The anaesthetist and anaesthetic nurse must be advised well in advance of the scheduling of latex allergic patients.
c) Theatre staff All theatre staff to wear non latex gloves.
d) Gloves eg. Ansell Dermaprene
Baxter Duraprene
J & J Allergard
e) Masks Non Latex masks are to be used in all situations.
(King System, Promedica, Rusch, Smith).
f) IV Equipment
Latex Bungs
Braun Reflux Valves
3 Way Taps
IV Line Braun line with reflux valves
Smith
OR replace latex bungs prior to running IV fluid through line
Fluid Bags All IV fluids to come from non latex bags
Remove or tape latex port
Colloids - Haemaccel Albumex 5
Drugs may have latex
stoppers

Remove all stoppers
Emergency Drugs IMS Minijet drugs
Syringes Terumo
g) Gas tubing Examples of latex free circuits are
Fisher & Paykel, Promedica, Bain Circuit.
h) Reservoir bag Use non-latex alternative.
(King, Promedica, Rusch).
i) Mouth props Plastic "Denta-Pops Great Aspirations" from Horseley Dental Company.
j) Monitoring
Oximeter Probes
Datex, Ohmeda are latex free
Or place vinyl glove over finger or toe
BP Cuff Leads Cover the limb prior to placing BP Cuff
Critikon Soft Cuffs
ECG Dots Medtel
3M
Kendall
k) Post op Similar precautions to the operating room as listed above.

4. IV Sedation

The same precautions apply as for general anaesthesia.

5. Emergency/Resuscitation

Equipment

 

Content updated March 2010

Similar precautions to the O.R.

 

 

Notes

1. Susceptible children or children with susceptible parents, are not to be given balloons at the end of the session.

2. For OMFS please also refer to Operating Suite Guidelines page 11

3. All recommended products are available in Australia - check with your local supply company.

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