Current Perspectives on the Perioperative Management of the Latex-Allergic Patient*
by Julie Smit, CRNA, MS and Margaret Faut-Callahan, CRNA, DNSc, FAAN
The incidence of latex allergy has created a need for anesthetists to identify potential risks, prepare a latex-safe environment, recognize an intraoperative anaphylactic reaction and manage the anaphylaxis in a latex-safe manner. Preanesthetic screening for potential risks can help prevent latex-related problems.
In a case report, a woman with no past medical history of allergies to medications, food or latex was found to be latex-sensitive during surgery. The woman's multiple surgical procedures could have been a clue to possible adverse events.
Anaphylaxis under anesthesia may be recognized by a combination of cutaneous, respiratory and cardiovascular symptoms, with the primary target being the cardiovascular system. If latex-related anaphylaxis does occur during an operation, the recommended steps for intraoperative and secondary treatment should be taken followed by close observation in an intensive care unit.
The recommended steps for managing intraoperative anaphylaxis are:
- Stop exposure to latex immediately. If you suspect intravenous line contamination, the solution set and bag must be changed.
- Administer 100% oxygen and maintain the airway.
- Discontinue all anesthetics.
- Provide fluid resuscitation with normal saline or lactated Ringer's. Up to 40% of the intravascular volume may be lost into the interstitial space.
- Epinephrine is the mainstay of initial pharmacological therapy due to its vasoconstrictor, positive inotropic and bronchodilatory properties. For hypotension, administer epinephrine 5 to 10mg IV in divided doses. In case of cardiovascular collapse, epinephrine 0.1 to 0.5mg IV can be titrated to produce hemodynamic stability. The dose of epinephrine for continuous IV infusion is 0.05 to 0.1mg/kg/min, or 4 to 8mg/min titrated to effect.
Steps for secondary treatment of anaphylaxis include:
- Diphenhydramine 0.5 to 1mg/kg IV. Antihistamines compete with histamine at receptor sites but do not inhibit anaphylactic reactions or histamine release. Parenteral H1 antagonists may cause hypotension in patients who are volume depleted secondary to antidopaminergic effects.
- Continue epinephrine for persistent hypotension or bronchospasm.
- Norepinephrine decreases cyclic adenosine monophosphate (cAMP), resulting in increased mediator release, so it should be used only for refractory hypotension. The appropriate dose ranges for norepinephrine are 0.05 to 0.1mg/kg/min or 4 to 8mg/min.
- Isoproterenol, 0.01 to 0.02mg/kg/min, is useful for refractory bronchospasm, pulmonary hypertension or right ventricular dysfunction. Because the profound b2 effects of this drug can produce systemic vasodilation, it should be used cautiously.
- Corticosteroids are also part of the secondary treatment of latex-related anaphylaxis. Indicated drugs in this category include hydrocortisone, 0.25 to 1g IV and methylprednisolone 1 to 2mg/kg every 6 hours. The onset of corticosteroids is 12 to 24 hours, which may attenuate the late-phase reactions that can occur 12 to 24 hours post-anaphylaxis.
- Albuterol can be used to treat bronchospasm. If given via the endotracheal tube, 4 to 12 metered dose inhaler puffs are needed; when nebulized, 0.25 to 1mL of albuterol in 2.5mL of normal saline should be given.
- When refractory hypotension with acidosis occurs, NaHCO3 -0.5 to 1mEq/kg IV can be administered based on arterial blood gas results.
- Glucagon 1mg IV may be effective for hypotension due to anaphylaxis that is refractory to epinephrine. Glucagon is a polypeptide hormone with potent chronotropic and inotropic activity. Repeated doses and a continous infusion might be necessary. Patients who receive glucagon should be monitored for hyperglycemia.
For patients known to be latex sensitive, a latex-safe environment should be prepared the evening before their arrival. The admitting area, preoperative holding area, operating room and postoperative room should be cleared of items containing latex and cleaned by personnel wearing nonlatex gloves.
Preoperative care can be safe for patients with latex allergy if latex avoidance techniques are used consistently and appropriately by all hospital staff members, and anesthetists understand their role in protecting the patient.
*Article published in CRNA: The Clinical Forum for Nurse Anesthetists, August 1999, Vol.10, No. 3..