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Department of Anesthesia, Stanford University, Stanford, CA
To the Editor:
I have read with interest the review article on latex allergy by Hepner and Castells (1). It is important to realize that there is a big difference reported between the clinical manifestations of latex anaphylaxis occurring during anesthesia and those not anesthesia/surgery-related. Lieberman (2) compared 1,158 cases of latex anaphylaxis that were not associated with anesthesia with 583 cases during anesthesia. There were no reported cases of cardiovascular collapse in nonsurgical patients, while surgical patients had over a 50% incidence of cardiovascular collapse. Respiratory problems, on the other hand, seem more equally distributed between the anesthetized and nonanesthetized patients. In my opinion, you commonly get either one or the other. Cutaneous manifestations were seen more frequently (98%) in the nonanesthetized group, but that can easily be explained by the fact that the anesthetized patients are mostly draped. Finally, it is important to remember that adverse latex reactions during anesthesia usually occur between 30 to 60 min after induction.
References
Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
In Response:
We appreciate the interest of Dr. Brock-Utne in our review article (1), and he raises two very important topics. We completely agree that clinical manifestations of anaphylaxis during anesthesia markedly differ from those not anesthesia related. In a review article of anaphylactic reactions during surgical and medical procedures, Lieberman (2) compared an analysis of five series of anaphylaxis cases not associated with anesthesia (1,158 patients) with a French multicenter epidemiological review of perioperative cases of anaphylactoid and anaphylactic reactions (583 cases). Although cutaneous manifestations were more common in nonsurgical cases (98%), they also presented often in anaphylactic (75.6%) and anaphylactoid (86%) reactions during the perioperative period. Of note, a recent survey of anaphylaxis during anesthesia demonstrated that cardiovascular symptoms (73.6%; 53.7% with cardiovascular collapse), cutaneous symptoms (69.6%), and bronchospasm (44.2%) were the most common clinical features (3). However, because patients are under drapes and often unconscious or sedated, the early cutaneous signs of anaphylaxis are often unrecognized, leaving bronchospasm and cardiovascular collapse as the first recognized signs of anaphylaxis in the perioperative period. While bronchospasm was the sole presenting feature in 3.1% of cases, cardiovascular collapse presented alone in 8.4% of cases (3). It is important to note that although cardiovascular collapse is less likely to present in nonsurgical patients, it was not reported in the group in the Lieberman series (2). In addition, Lieberman (2) acknowledges that different series report signs and symptoms differently.
The other point raised by Dr. Brock-Utne refers to the timing of the presentation of adverse latex reactions, and we believe that this statement deserves some clarification. First, it depends on the type of reaction: irritant contact dermatitis may develop minutes to hours after exposure to latex-powdered gloves or chemicals, and type IV cell-mediated hypersensitivity reaction usually begins 48 to 72 h after exposure to antioxidants and rubber accelerators. The presentation of a type I IgE-mediated hypersensitivity reaction depends on the route of exposure. Latex proteins are absorbed slowly when the exposure is airborne, causing a delayed presentation 30 min after exposure. Parenteral or mucous membrane exposure may lead to an anaphylactic reaction shortly after exposure, as there is a higher rate of absorption of latex proteins. We agree with Dr. Brock-Utne that most cases of latex anaphylaxis during anesthesia present 30 to 60 min after induction, coinciding with a delayed airborne exposure or with mucous membrane exposure at the beginning of the surgical procedure.
References
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