Over the past decade, considerable scientific and clinical information has been acquired and strategies have been implemented to reduce allergic reactions to latex in healthcare settings. Despite this effort, however, reports submitted in the PA-PSRS system indicate that latex exposure and allergic reactions continue. The following examples were reported to PA-PSRS:

• A condom catheter was placed on a patient with a documented latex allergy. The patient developed dermatitis.
• A surgeon used latex gloves while performing an invasive procedure on a patient with a documented latex allergy. During recovery, the patient became short of breath, and oxygen saturation decreased. The patient was treated until symptoms resolved.

Patients with latex allergy may experience reactions ranging from minor rashes to anaphylaxis.¹ The more exposures a latex-sensitive patient experiences, the more severe their reactions may become.²

Now that latex allergy protocols are implemented in the healthcare community, the new frontier may be to assure that such interventions are updated, effective, and fully implemented by the staff. Latex is extremely common in healthcare and consumer products. Approximately 40,000 products contain natural latex rubber proteins.³ Approximately 2,000 of these products are used in healthcare settings.⁴ Identifying which products contain latex and which are latex-free can be a tremendous challenge.

To prevent latex sensitization in high-risk groups or to prevent serious allergic reactions in those sensitized to latex, the most effective method is avoidance of contact with latex-containing materials.⁵ It is important that healthcare providers recognize that some products may contain latex and that appropriate alternatives may be available. In addition, updated information about latex-containing products can be integrated into patient education programs.

This article presents selected information from the clinical literature about latex-containing products that may be less well-known. The information is not comprehensive, but is designed to pique interest and spark further inquiry, as protocols and staff/patient education programs are reviewed and updated.

Since September 1998, the Food and Drug Administration (FDA) has required labeling of the presence of latex on all medical equipment that may come in contact with humans, as well as latex packaging materials that come in contact with the product.⁶ While the labeling requirement is helpful, there may be many products currently in use that were manufactured prior to the implementation of this labeling requirement. For example, providers may use latex-containing personal stethoscopes or reflex hammers that were acquired many years ago. In addition, the ruling does not include pharmaceuticals or items not regulated by the FDA. Also, individual components within a larger package may not be labeled.⁷

The following products may contain latex:

Hospital supplies: blood pressure cuffs; tubex syringes; ECG wires; pulse oximeters and cables; vascular compression stockings; ready-to-use enemas; Ace bandages; spacers for multi-dose inhalers; adhesive tapes; tourniquets; CPR mannequins; condom catheters; wheelchair cushions; oxygen masks/cannulas; incentive deep breathing exercisers; fitted hospital bed sheets; IV injection ports/tubing; disposable syringes with rubber plungers; ostomy pouches and straps; disposable incontinence pads; washable underpads; latex-stoppered multidose vials; nasogastric tubes (silastic-covered latex); certain dressings.

Personal protective equipment: goggles; masks; gloves; respirators.

Operating room: drapes with adhesive strips; bouffant caps and shoe protectors; surgical wound drains; instrument mats; mesh; electrode grounding pads; anesthesia machine reservoir bags; anesthesia masks; body positioning/holder devices; fiberoptic/video scopes; eye shields; laparoscopy insufflation hoses; needle counting systems; rubber breathing circuits and ventilation bellows; teeth protectors/bite blocks; bronchoscopy components (T-piece, saline injector, suction tubing).

Critical care/Emergency Departments: Ambu bags; endotracheal tubes; cervical spine collars; Swan-Ganz catheters.

Physical Therapy: exercise bands and balls; crutch pads (axillary and arm grips); cold/hot packs.

Medical Imaging: rubber aprons; positioning blocks; head straps.

Dietary: latex gloves (may contaminate food served to patients and employees).⁸

A review of the clinical literature identifies common elements in protocols related to the latex allergic patient:

• Coordination by a multidisciplinary committee/task force.
• Assessment/identification of those at risk.
• Communication among staff about the allergy.
• Strategies to eliminate/minimize latex exposure.
• Maintaining lists of latex-containing and latex-free products, using brand names.
• Latex-free carts/kits.
• Latex-safe procedures for specific patient care areas/departments.
• Ongoing education programs for healthcare providers and patients/families.
• Identification of symptoms and being prepared to provide interventions.
• Reviewing/monitoring data concerning latex reactions to assess program effectiveness and to take corrective actions.⁹

Several resources compile and communicate information about latex allergy to both healthcare providers and patients. Many are accessible on the Internet. Such information can be invaluable when up-dating protocols and educational programs.

Available Resources

• Mitchell N. Latex Allergy: accessing information of the Internet. J Emerg Nurs. 1007; 23:51-52.
• American College of Allergy, Asthma, and Immunology.
  www.acaai.org
• American Latex Allergy Association, ALERT. www.latexallergyresources.org
• National Institutes for Occupational Safety and Health. www.cdc.gov/NIOSH/latexalt.html
• Nurses World, Latex Free Information. www.nursesworld.com/latex.htm
• Pryor JP, Vonfricken K, Seibel R, Kauder DR, Schwab CW. Anaphylactic Shock from a Latex Allergy
   in a Patient with Spinal Trauma. Journal of Trauma Injury, Infection, and Critical Care 2001
  May; 50(5): 927-930.
• Latex Allergy News. CETRA Latex-Free Information Services. www.latexallergyhelp.com
• Spina Bifida Association of America. www.sbaa.org
• Latex Allergy Links. www.latexallergylinks.org
• Thurlow KL. Latex Allergies: Management and Clinical Responsibilities. Home Health-care Nurse
  2001 Jun; 19(6):369-371.
• Safety and Health Topics: Latex Allergy. U.S. Department of Labor, Occupational Safety & Health
  Administration. www.osha.gov/SLTC/latexallergy/index.html
• Holmes SA. Looking Out for Latex. Science and Children 1999 Feb; 21-25, 52-53.
• Binkley HM, Schroyer T, Catalfano J. Latex Allergies: A Review of Recognition, Evaluation,
  Management, Prevention, Education, and Alternative Product Use. Journal of Athletic
  Training 2003; 38(2):133-140.

Notes

1. Sussman GL, Beezhold DH, Liss G. Latex Allergy: Historical Perspective. Methods 2002 May; 27(1):3-9. Also Leby DA, Leynadier F. Latex Allergy: Review of Recent Advances. Current Allergy Reports 2001; 1:32-38. Also Sussman G, Gold M. Guidelines for the Management of Latex Allergies and Safe Latex Use in Healthcare Facilities. American College of Allergy, Asthma & Immunology 1996 Aug. alergymcg.edu/physicians/latex.html. Also Patriarca G, Nucera E, Buonomo A, Roncallo C, DePasquale T, Pollastrini E, Schiavino D. New Insights on Latex Allergy Diagnosis and Treatment. J Investig Allerg Clin Immunol 2002; 12(3):169-176.
2. Charous BL. The Puzzle of Latex Allergy: Some Answers, Still More Questions. Ann Allergy 1994; 73(4):277-281. Also ECRI. Ad-dressing Latex Allergy in Healthcare. ECRI. The Risk Management Reporter 1997 Oct. p.13. Also Lenehan GP. Latex Allergy: Sepa-rating Fact from Fiction. Nursing 2004 Feb; Suppl 12-18. Also U.S. Department of Labor. Occupational Safety and Health Administra-tion 4/12/99. Technical Information Bulletin: Potential for Allergy to Natural Rubber Latex Gloves and Other Natural Rubber Products. Also Muller BA. Minimizing Latex Exposure and Allergy. Postgraduate Medicine 2003 Apr; 113(4):91-97.
3. Gritter M. Latex Allergy. Lippincotts Primary Care Practice 1997 1(2):142-151. Also Johnson G. Avoiding Latex Allergy. Nursing Standard 13(31):12,21,49-56.
4. Dyck RJ. Historical Development of Latex Allergy. AORN Journal 2000 Jul; 72:27-29, 32-33, 35-40
5. Poley GE, Slater JE. Latex Allergy. J Allergy Clin Immunol 2000; 105:1054-1062.
6. Jezierski M. Creating a Latex-safe environment: Riddle Memorial Hospital’s Response to Protect Patients and Employees. J Emerg Nurs 1997; 23: 191-198. Also AORN Latex Guideline. AORN Journal 2004 Mar; 79(3): 653-672.
7. Elliott BA. Latex Allergy: The Perspective from the Surgical Suite. J Allergy Clin Immunol 2002 Aug; 110 (2Suppl);117-120
8. Latex in the Hospital Environment. Spina Bifida Association of America. 2003 Summer. www.sbaa.org. Also Tidwall J. About Latex Allergy. allergies.about.com/cs/latex/a/aa080999_p.htm. Also Binkley HM, Schroyer T, Catalfano J. Latex Allergies: A Review of Rec-ognition, Evaluation, Management, Prevention, Education, and Alternative Product Use. Journal of Athletic Training 2003; 38(2):138-140. Also Hees A, von Hintzenstern J, Peters KP, et al. Allergic and Irritant Reactions to Rubber Gloves in Medical Health Services: Spectrum, Diagnostic Approach, and Therapy. J Am Acad Dermatol Con;t 8) 1991; 26(3 pt 2): 831-839. Also Young MA, Myers M, McCullock LD, et al. Latex Allergy: A Guideline for Perioperative Nurses. AORN Journal 1992; 56(3):488-502. Also Latex Allergy News. CETRA Latex-Free Information Services. www.latexallergyhelp.com. Also Schumann L, Buhr V. Screening Patients for Latex Allergies. J Am Acad Nurse Pract 2000 Sep; 12(9)380-385.  Also Adkins D. Latex Products in the Hospital Environment. J of Emergency Nursing 1997; 23(2):135-138. Also Hamman CP, Rodgers PA, Sullivan K. Management of Dental Patients With Allergies to Natural Rubber Latex. Gen Dent 2002 Nov-Dec; 50(6):526-536. Also Brehler R,  Kutting B. Natural Rubber Latex Allergy. Archives of Internal Medicine 2001 Apr; 161(8):1057-1064. Also Kramper MA. Latex Allergy: A Nursing Update. ORL Head Neck Nurs 2000 Summer; 18(3):7-11. Also Engelken GJ. Heighten Your Response to Latex Allergy. JAAPA 1999 Aug; 12(8):53-65. Also Guidelines for Preventing Sensitivity and Allergic Reactions to Natural Rubber Latex in the Workplace. Society of Gastroenterology Nurses and Associates. Revised 2004. www.SGNA.org.
9. ECRI. Sample Policies and Procedures: Latex Sensitivity in Patients and Healthcare Workers. Healthcare Risk Control. Environ-mental Issues 18.2. 1998 Nov; 3:1-27. Also Stenst BL, Johnson RA. Latex Allergy. American Journal of Health Systems Pharmacy 1997 May; 54(9):1071-1075. Also Gehring LL, Ring P. Latex Allergy: Creating a Safe Environment. Dermatol Nurs 2000 Jun; 12(3):197-201. Also Jennings LM. Latex Allergy: Another Real Y2K Issue. Rehabilitation Nursing 1999 Jul-Aug; 24(4):140, 142.

Use Of Multidose Medication Vials And Latex Allergy

One latex avoidance strategy suggested in the literature relates to multidose vials. It was thought that the solution in such vials contained latex allergen from the stopper, or that the allergen could enter the needle used to puncture the vial stopper. It has been suggested that multidose vials with latex stoppers be replaced with glass ampules or latex-free vials.¹ Another proposed strategy was to remove latex stoppers from multidose vials to draw up medications, rather than puncturing the stopper with a needle in order to obtain the medication.²

A review of the literature, however, indicates that the risk of latex exposure from the use of multidose vials with latex stoppers is not clear.³  The level of latex allergen in such vials has been determined to be extremely low. In one study, the amount of latex protein found in medication vials was not detectable when the rubber stopper was punctured up to 40 times.⁴  Also, studies have indicated that there was no difference in measurable allergen of the solution when puncturing rubber stopper, compared to when latex stoppers were removed.⁵

The Johns Hopkins Hospital, which uses multidose vials widely, indicates the following in its Interdisciplinary Clinical Practice Manual: “When drawing up medication, it is not necessary to remove the stopper from the vial. Multidose vials should only be punctured once and then discarded, unless using the Clave multidose vial adaptor. Use IV tubing sets with synthetic ports to eliminate allergen exposure.”⁶ 

Isolated cases, however, continue to be reported of allergic reactions associated with use of multidose vials.⁷  Coring may occur with repetitive puncturing of a stopper on a multidose vial. This may result in microscopic rubber particles that may contaminate the medication or be injected into subcutaneous tissue.⁸

It is, therefore, incumbent upon each healthcare institution to decide whether and/or how to use multidose vials in the care of the latex-sensitive patient. In determining such a policy, institutions may wish to balance the potential for latex exposure by withdrawing a medication through a latex-stoppered vial with other considerations, including the patient’s degree of latex hypersensitivity and the potential for errors in dosage, dilution, contamination, and waste.⁹

Notes

1. Latex Sensitivity. ECRI Healthcare Risk Control 1996 Jan; Environmental Issues 18:1. Also AORN Latex Guideline. AORN Journal 2004 Mar; 79(3):653-672.
2. Davis BR. Perioperative Care of Patients with Latex Allergy. AORN Journal 2000; 72:47-54.
3. Senst BL, Johnson RA. Latex Allergy. Am J Health Syst Pharm 1997; 54:1071-5.
4. Yunginer et al. Latex Allergen Contents of Medical and Consumer Rubber Products. Journal of Allergy Clinical Immunology 1993; 91:241.
5. Thomsen DF, Burke TG. Lack of Latex Allergen Contamination of Solutions Withdrawn from Vials with Natural Rubber Stoppers. Am J Health Syst Pharm 2000; 57:44-7. Also Yunginger JW, Jones RT, Fransway AF, Kelso JM, Warner MA, Hunt LW. Extractable Latex Allergens and Proteins in Disposable Medical Gloves and Other Rubber Products. J Allergy Clin Immunology 1994; 93:836-42. 
6. Brown RH, Hamilton, RG, McAllister MA. How Health Care Organizations Can Establish and Conduct a Program for a Latex-Safe Environment. Joint Commis-sion Journal on Quality and Safety 2003; 29(3): 113-123.
7. Vassallo SA, Thurston TA, Kim SH, Todres ID. Allergic Reaction to Latex from Stopper of a Medication Vial. Anesth Analg 1995; 80:1057-8.
8. Primeau MN, Adkinson NJ, Hamilton RG. Natural Rubber Pharmaceurical Vial Closures Release Latex Allergens That Produce Skin Reactions. Journal of allergy and Clinical Immunology 2001 Jun; 107:958-962. Also Asakura T, Seino H, Noxaki S, Abe R. Occurrence of Coring in Insulin Vials and Possibility of  Rubber Piece Contamination by Self-Injection. Journal of the Pharmaceutical Society of Japan 2001 Jun; 121 (6): 459-463.
9. Senst BL, Johnson RA. Latex Allergy. Am J Health Syst Pharm 1997; 54: 1071-1075.