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Latex Allergy and Implications For Urology Nursing.

Latex hypersensitivity is a major occupational health concern. Health care workers as well as patients who are not yet diagnosed are the most at-risk populations. Knowledge about everyday products that may increase one's exposure to latex allergy is an important prevention strategy and will assist in decreasing the overall incidence of latex allergy among patients and health care workers.

Objectives

This educational activity is designed for nurses and other health care professionals who care for and educate patients and health care workers regarding latex hypersensitivity. The multiple choice examination that follows is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to:

1. Describe the condition of latex hypersensitivity.

2. Implement strategies to reduce latex exposure to patients and health care workers.

It is well documented in the literature that latex hypersensitivity is a major occupational health concern. Health care workers (HCW) as well as patients who are not yet diagnosed are the most at-risk populations. Sensitization to latex antigens in HCW is due to the repeated exposure of wearing powdered latex gloves during surgical and diagnostic procedures. A medical emergency can result during a medical exam, procedure, or surgery for the patient or HCW who is not aware of his/her latex sensitivity. Nurses working directly with patients must have a thorough understanding of the etiology, pathophysiology, clinical presentation, treatment, and prevention for patients who are recognized as latex sensitive and those who are not yet diagnosed.

Nurses who specialize in urology may need to be more aware of specific risk factors associated with multiple urologic surgeries, reconstruction, or congenital urinary tract problems. Additionally, nurses and other health care workers (HCW) who specialize in the care of patients with urologic problems may have a greater exposure rate to latex allergy from the use of latex gloves for protection against bloodborne pathogens.

Etiology

Natural rubber latex has been used for over 100 years and is known for its biomechanical and biophysical properties of strength, elasticity, barrier qualities, and durability (Czuppon et al., 1993). Because of these desirable characteristics latex products have become ubiquitous in our environment today. Natural latex is a term that describes the milky fluid produced by the rubber tree Hevea brasiliensis. The term natural rubber latex (NRL) describes products that have been treated with various agents (heat, stabilizers, and other additives) to produce a cross-linked polymer called natural rubber. Products such as gloves, condoms, and latex party balloons are the items made from these water-based natural latex emulsions (Warshaw, 1998). The term dry rubber latex is the name used to refer to products that are made from dried, processed, or milled sheets of latex rubber. The terms latex and natural rubber have been used interchangeably throughout the literature, even though they are not synonymous.

It is the exposure to the natural rubber latex proteins that can cause hypersensitivity reactions among patients and HCW. Several major proteins have been isolated so far and are known to be responsible for the most frequent Type I and Type TV hypersensitivity reactions (see Table 1). Type I hypersensitivity reactions are caused by exposure to the proteins while Type IV occurs as a result of the chemicals added during the manufacturing process.

Latex proteins are separated into three groups: water-soluble, starch-bound, and latex-bound proteins. To quantify a latex exposure rate for latex-based health products, the accepted method is to measure the total protein content. An individual's immune system can recognize many different protein allergens. Because of this, patients and HCW should avoid environments that encourage over exposure to latex allergens by contamination in the environment (air) or transmission via the hands (powder).

Pathophysiology

There are a wide range of reactions exhibited by individuals sensitized by the latex allergens. The most common are the Type I and Type IV hypersensitivity reactions. Hypersensitivity refers to an immune response that can cause tissue damage or death of the host (Sutton & Gould, 1993). These two major types of hypersensitivity are characterized by the time of response of the symptoms: Type I or immediate hypersensitivity results in clinical manifestations within 30 minutes and Type TV or delayed hypersensitivity may take several days to develop (Doherty, 1993).

Immediate hypersensitivity can be divided into three types or syndromes: allergy, anaphylaxis, and anaphylactoid reaction. The mechanism of action for allergy and anaphylaxis is the same. These syndromes result in mast cell degranulation by cross-linking of immunoglobulin-E (IgE) molecules bound to the mast cell surface, resulting in secretion of histamine, prostaglandin's, and other inflammatory mediators. Allergy refers to a local response in a limited area where, in an anaphylactic reaction, there is a generalized and systemic response (Hansen, 1998).

Clinical manifestations of allergy are vasodilatation, edema, increased vascular permeability, inflammatory exudation, and smooth muscle spasm. Examples are seasonal allergic rhinitis, urticaria, conjunctivitis, asthma, and eczema. Clinical manifestations of anaphylaxis are manifested by constriction of the bronchioles and bronchi with contraction of smooth muscle causing bronchospasm, laryngeal edema, vomiting, and vascular collapse or shock. Some examples of anaphylaxis are responses seen following wasp and bee stings, injections of penicillin and other drugs, as well as fruits, foods, and certain food additives (for example, MSG) (Woods, Lambert, Platts-Mills, Drake, & Edlich, 1997).

The anaphylactoid syndrome is characterized by a mast cell degranulation by a non-IgE mechanism. Clinical manifestations are similar to anaphylaxis but are less intense and usually mild. Common agents that usually cause anaphylactoid reactions are contrast media used in diagnostic radiographic procedures, foods and drugs (Doherty, 1993; Hansen, 1998).

Type IV hypersensitivity -- cell-mediated or delayed-type hypersensitivity -- is a T-cell mediated response. This is seen when an irritant comes in contact with the skin. The contact dermatitis results from the irritant chemical or plant secretion such as poison ivy, poison oak, detergents, lotions, adhesive tape, Jewelry, clothing, and linens (Doherty, 1993). The clinical manifestations of erythema and inflammation appear usually within 3 to 4 days, can persist for weeks, and will recur if the person is exposed to products containing the same chemical (Woods et al., 1997).

High-Risk Groups for Latex Allergy

Several groups of individuals are at a high risk for developing a latex allergy (Steiner & Schwager, 1995; Woods et al., 1997; Zerin, McLaughlin, & Kerchner, 1996; Zoller, Thermann, Conrad, Fuchs, & Ringert, 1998). The groups are: (a) patients with myelomeningocele, (b) patients who have multiple invasive medical and surgical procedures during childhood (for example, spina bifida), (c) fruit allergy patients, (d) occupationally exposed workers, and (e) individuals with a family history of atopy. The occupationally exposed work group includes health care workers and latex industry workers. The Occupational Safety and Health Administration (OSHA) reported that there are more than 5 million American workers using latex gloves regularly who may be at risk for latex allergy (Voelker, 1992; Woods et al., 1997).

Patients in the high-risk groups should be identified by a detailed clinical history outlining all reactions to latex (medical, surgical, dental, household products, toys, clothing, gloves, etc). The history should include detailed information on any unexplained allergic or anaphylactic reactions experienced in the past, a past history of documented atopic condition (for example, asthma, eczema, and rhinitis), any drug, food, or fruit allergy (for example, bananas, avocados, kiwi).

Specifically, nurses working in urology clinics, surgical departments, or inpatient units must pay close attention to both patient and HCW exposure to allergy from natural rubber. Kelly, Kurup, Reijula, and Fink (1994) identified patients with genitourinary dysplasias undergoing multiple surgical procedures and requiring intermittent clean catheterization as a high-risk group. Other possible urology patient populations may include those undergoing multiple genitourinary reconstruction, penile prostheses, and patients using inflatable devices or other erection devices that have a natural rubber base.

HCW who specialize in urology nursing may experience an increased exposure rate to latex allergy due to the use of latex gloves for hand protection against bloodborne pathogens (Korniewicz & McLeskey, 1998). Some simple precautions that can assist HCW who work with urology patients include (a) using powder-free latex gloves, (b) good handwashing techniques to decrease the amount of powder residue on hands, and (c) using latex gloves that have low allergen content. Other precautions may include environmental checks related to air-venting systems in surgical suites, urology procedure rooms, or outpatient facilities.

Nephrology nurses must pay particular attention to dialysis patients. Stojanovic et al. (1998) identified a high incidence of systemic allergy to latex among dialysis patients. Therefore, dialysis patients should be screened for latex allergy. Potential sources of exposure include tape, gloves, catheters, latex ports used in IV tubing, rubber tourniquets, vial stoppers, and latex items being used in the environment near the patient.

Another group of patients who appear to have a high risk of developing a latex allergy are patients with myelomeningocele who undergo several imaging studies of the urinary tract as well as multiple surgical procedures. Items that may pose a risk to these patients are the same items identified above with the addition of pacifiers, nipples, and toys that may be in the waiting room (rubber balls, balloons, elastic bands, rubber dolls, etc.).

Nurses may also encounter latex in wheelchair wheels, black reusable Ambu-bags [R], stethoscopes, sphygmomanometer tubing, and fluoroscopy table foot boards (Zerin et al., 1996). It is important for nurses to be knowledgeable about items that may contain natural rubber latex so that they can provide education to latex-allergic patients. The goal is to take precautions to decrease exposure to prevent further sensitization and potential serious reactions for those at high risk.

Recommendations and Precautions

A comprehensive review on latex allergy has been completed by Warshaw 1998 and contains a very comprehensive list of educational resources for patients, nurses, and physicians. Providing a latex-safe environment for patients allergic to latex is challenging. However, being familiar with latex substitutes and safe equipment that can be used with patients identified or suspected of having latex allergies can prevent adverse outcomes. Table 2 lists substitute products and recommendations to help nurses protect their patients from adverse outcomes.

Urology nurses use a variety of common natural rubber latex and dry rubber latex products (see Table 3). Knowledge about everyday products that may increase one's exposure rate to latex allergy is an important prevention strategy. Knowledge about safe products and their use will assist in decreasing the overall incidence of latex allergy among patients and health care workers.

Nursing Interventions

It is recommended that a policy and procedure manual be developed for patients who are latex allergic. Other important policies may include developing a latex-free cart which should be available to those persons who are known to be latex sensitive. Additional precautions should be taken for patients undergoing surgery or urologic procedures. For example, designated latex-safe treatment rooms or operating room suites are recommended as well as scheduling known latex-sensitive patients as the "first case" of the day.

For Type I allergic reactions, antihistamines and sympathemimetic agents are the mainstay of therapy for symptoms such as urticaria and angioedema (Woods et al., 1997). Topical steroids are used for short-term treatment along with oral antihistamine; however, prolonged treatment with topical steroids is not recommended (Warshaw, 1998; Woods et al., 1997). Episodes of urticaria, angioedema, and rhinitis can progress to anaphylaxis even in patients treated with antihistamines and steroids; therefore, the nurse must be prepared for any emergency situation.

For mild symptoms, the administration of epinephrine 0.2 ml to 0.5 ml of 1:1,000 dosage subcutaneously, with repeated doses as necessary every 3 minutes is usually enough to control the symptoms. For severe anaphylactic reactions, an intravenous infusion of epinephrine should be given diluted to 1:50,000. For severe hypotension, vasopressors, fluids, and volume expanders should be administered. Oxygen via nasal cannula is sometimes helpful, but if severe hypoxia exists, endotracheal intubation is necessary (Woods et al., 1997).

Bernadette Patriarca, MSN, MA, RN, is a Toxicology Predoctoral Student and Clinical Instructor, University of Maryland, Baltimore, MD.

Denise M. Korniewicz, DNSc, RN, FAAN, is Professor of Nursing & Medicine, University of Maryland, Baltimore, MD.

Note: This article was supported by a training grant awarded from The National Institutes of Health, National Institute of Environmental Health Sciences (Grant No.5T 32 ES07263-

References

Akasawa, A., Hsieh, L.S., Martin, B.M., Liu, T., & Lin, Y. (1996). A novel acidic allergen, Hey b 5, in latex. Journal of Biological Chemistry, 271, 25389-25393.

Alenius, H., Kalkkinen, N., Lukka, M., Reunala, T., Turjanmaa, K., Makinen-Kiljunen, S., Yip, E., & Palosuo, T. (1995). Prohevein from the rubber tree (Hevea brasiliensis) is a major latex allergen. Journal of Clinical and Experimental Allergy, 24, 659-665.

Beezhold, D.H., Kostyal, D.A., & Sussman, G.L. (1997). IgE epitope analysis of the hevein preprotein; a major latex allergen. Journal of Clinical and Experimental Immunology, 108, 114-121.

Beezhold, D.H., Sussman, G.L. Kostyal, D.A., & Chang, N.S. (1994) Identification of a 46-kd latex protein allergen in health care workers. Journal of Clinical and Experimental Immunology, 98, 408-413.

Chen, Z., Posch, A., Lohaus, C., Raulf-Heimsoth, M., Meyer, H.E., & Baur, X. (1997). Isolation and identification of Hevein as a major IgE-binding polypeptide in Hevea latex. Journal of Allergy Clinical Immunology, 99, 402-409.

Czuppon, A.B., Chen, Z., Rennert, S., Engelke, T., Meyer, H.E., Heber, M., & Baur, X. (1993). The rubber elongation factor of rubber trees (Hevea brasiliensis) is the major allergen in latex. Journal of Allergy Clinical Immunology, 92, 690-697.

Doherty, P.C. (1993). Cell-mediated cytotoxicity. Cell, 75(4), 607-612.

Hansen, M. (1998) Pathophysiology foundations of disease and clinical intervention. Philadelphia: Saunders.

Kelly, K.J., Kurup, V.P., Reijula, K.E., & Fink, J.N. (1994). The diagnosis of natural rubber latex allergy. Journal of Allergy and Clinical Immunology, 93, 813-816.

Korniewicz, D., & McLeskey, S. (1998). Latex allergy and gloving standards. Seminars in Perioperative Nursing, 7(4), 216-221.

Kostyal, D.A., Hickey, V.L., Noti, J.D., Sussman, G.L., & Beezhold, D.H. (1998). Cloning and characterization of a latex allergen (Hev b 7): Homology to patatin, a plant PLA2. Journal of Clinical Experimental Immunology, 112, 355-362.

Nieto, A., Mazon, A., Estornell, F., Boquete, M., Carballada, F., Martinez, A., Asturias, J.A., Aguirre, M., Martinez, J., & Palacios, R. (1998). Profilin, a relevant allergen in latex allergy. Journal of Allergy and Clinical Immunology, 101, S207.

Slater, J.E., Vedvick, T., Arthur-Smith, A., Trybul, D.E., & Kekwick, R.G.O. (1996). Identification, cloning, and sequence of a major allergen (Hev b 5) from natural rubber latex (Hevea brasiliensis). Journal of Biological Chemistry, 271, 25394-25399.

Sowka, S., Wagner, S., Krebitz, M., Arija-Mad-Arif, S., Yusof, F., Kinaciyan, T., Brehler, R., Scheiner, O., & Breiteneder, H. (1998). CDNA cloning of the 43-kD latex allergen Hey b 7 with sequence similarity to patatins and its expression in the yeast Pichia pastoris. European Journal of Biochemistry, 255, 213-219.

Steiner, D.J., & Schwager, R.G. (1995). Epidemiology, diagnosis, precautions, and policies of intraoperative anaphylaxis to latex. Journal of the American College of Surgeons, 180, 754-761.

Stojanovic, A., Keena, D., Kroneman, O., Rocher, L., Weidbrauk, D., & Lauter, C.B. (1998). Latex specific IgE in hemodialysis patients. Abstract 663. Journal of Allergy and Clinical Immunology, 101(1), Part 2, 161.

Sunderasan, E., Hamzah, S., Hamid, S., Ward, M.A., Yeang, H.Y., & Cardosa, M.J. (1995). Latex B-serum beta-1-3 glucanase (Hev b II) and a component of the microhelix (Hev b IV) are major latex allergens. Journal of Natural Rubber Research, 10, 82-99.

Sutton, B.J., & Gould, H.J. (1993). The human IgE network. Nature, 366(6454), 421-428.

Vallier, P., Balland, S., Harf, R., Valenta, R., & Deviller, P. (1995). Identification of profilin as an IgE-binding component in latex from Hevea brasiliensis: Clinical implications. Journal of Clinical and Experimental Allergy, 25, 332-339.

Voelker, R. (1992, December 16). OSHA mandates universal precautions. AMA News.

Warshaw, E.M. (1998). Latex allergy. Journal of the American Academy of Dermatology, 39(1), 1-23.

Woods, J.A., Lambert, S., Platts-Mills, A.E., Drake, D.B., & Edlich, F.E. (1997). Natural rubber latex allergy: Spectrum, diagnostic approach, and therapy. The Journal of Emergency Medicine, 15(1), 71-85.

Yeang, H.Y., Cheong, K.F., Sudderasan, E., Hamnszah, S., Chew, N.P., Hamid, S., Hamilton, R.G., & Cardosa, M.J. (1996). The 14.6 kD rubber elongation factor (Hey b 1) and 24 kD (Hey b 3) rubber particle proteins are recognized by IgE from patients with spina bifida and latex allergy. Journal of Allergy and Clinical Immunology, 98, 628-639.

Yeang, H.Y., Ward, M.A., Zamri, A.S.M., Dennis, M.S., & Light, D.R. (1998). Amino acid sequence similarity of Hey b 3 to two previously reported 27 and 23 kDa latex proteins allergenic to spina bifida patients. Allergy, 53, 513-519.

Zerin, J.M., McLaughlin, K., & Kerchner, S. (1996). Latex allergy in patients with myelomeningocele presenting for imaging studies of the urinary tract. Pediatric Radiology, 26, 450-454.

Zoller, G., Thermann, F., Conrad, S., Fuchs, T., & Ringert, R-H. (1998). Comparison of questionnaire-based and serological screening for the natural latex allergy in children with neurogenic bladder dysfunction. European Urology, 34(1), 79-83.
Table 1
Registered Natural
Rubber-Latex Allergens *
                                   Predicted
Name        Trivial Name           Physiological Role
Hev b 1     Rubber elongation      Rubber biosynthesis
            factor
Hev b 2     Beta-1,3-glucanases    Defense-related
                                   protein
Hev b 3     Small rubber-particle  Latex coagulation?
            protein
Hev b 4     Microhelix component   Defense-related protein?
Hev b 5     Acidic latex protein   ?
Hev b 6.01  Prohevein, hevein      Defense-related
Hev b 6.02  hevein preprotein      protein (latex coagulation)
Hev b 6.03  Prohevein C-terminal
            domain
Hev b 7     Patatin-like protein   Defense-related protein,
                                   inhibitor of
                                   rubber biosynthesis?
Heb b 8     Latex profilin         Structural protein
Name        References
Hev b 1     Czuppon et al., 1993;
            Yeang et al., 1996
Hev b 2     Alenius et al.,1995;
            Sunderasan et al., 1995
Hev b 3     Yeang et al., 1996; 1998
Hev b 4     Sunderasan et al., 1995
Hev b 5     Akasawa et al., 1996; Slater et al., 1996
Hev b 6.01  Alenius et al., 1995;
Hev b 6.02  Chen et al., 1997;
Hev b 6.03  Beezhold et al., 1997
Hev b 7     Beezhold et al., 1994;
            Kostyal et al., 1998;
            Sowka et al., 1998
Heb b 8     Nieto et al., 1998;
            Vallier et al., 1995
(*)WHO.IUIS: World Health Organization-
International Union of Immunological Societies


Table 2. Substitute Products for Patient Protection

1. Use polyvinylchloride (vinyl) gloves which are nonlatex and least expensive substitute for latex gloves.

2. Remove all latex products out of the patient's room or environment.

3. Use blood pressure cuffs over patient's clothing and put a stock-inette over the stethoscope tubing.

4. Use Tegaderm[R] (3M), Micropore[R] (3M), or other nonlatex tape for dressings and to secure tubing in place.

5. Do not inject or withdraw through rubber ports of intravenous equipment, cover ports with nonlatex tape.

6. A checklist and alert sticker should be placed on the patient's chart alerting other staff members of the patient's latex allergy.

7. Always use single-dose ampules when giving parenteral medication and flushes.

8. Use a nonlatex tourniquet when drawing blood.

9. Instruct patients to avoid eating fruits, vegetables, and prepared foods that have been handled with latex gloves.

10. Instruct patients and caregivers to purchase a Medic-Alert bracelet.
Table 3.
Natural and Dry Rubber Latex
Products Commonly Used with
Urologic Patients
                                   Latex Products
General medical use                Gloves
                                   Hemodialyzers
                                   Enema retention cuffs
                                   Syringe stoppers
                                   Tourniquets
                                   Hot water bottles
                                   Wheelchair tires
                                   Blood pressure cuffs
                                   Electrode pads
                                   Intravenous tubings
                                   Catheters
                                   Stethoscope tubings
                                   Elastic support stockings
Obstetric/Gynecologic              Cervical caps
                                   Cervical dilators
                                   Diaphragms
                                   Condoms
Surgical/Urologic                  Endotracheal tubes
                                   Induction masks
                                   Adhesive tapes/belts
                                   Implants
                                   Urine bags and straps
                                   Urinals
                                   Penrose drains
                                   Bedpans
                                   Hemorrhoid pillows
                                   Catheters
                                   Incontinence undergarments
                                   Pessaries
                                   Urethral condoms
General products used in the home  Gloves
                                   Adhesive tape
                                   Rubber bands
                                   Shoes
                                   Underwear elastic
                                   Carpet backings
                                   Shower curtains
                                   Soft toilet seats
Products used for children         Rubber toys
                                   Balloons
                                   Baby bottle nipples
                                   Pacifiers
                                   Swim goggles
                                   Swim caps
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Author:Patriarca, Bernadette; Korniewicz, Denise M.
Publication:Urologic Nursing
Date:Sep 1, 1999
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