Latex allergy - potentially a painful postoperative problem

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A healthy young woman presented for a subtotal hysterectomy on a routine gynaecology list with two relevant anaesthetic problems. During a previous anaesthetic, facial oedema had developed after the application of a facemask and a diagnosis of latex allergy had been made. No other information was known about this incident. Second, she was a Jehovah's Witness. Consequently, all reasonable precautions were implemented. The Trust policy on latex allergy was consulted, the patient placed first on the operating list to minimise the level of latex antigen in the atmosphere and latex-free equipment substituted where necessary. The risks of surgery were discussed with the patient and a latex-free (unprimed) blood salvaging autologous transfusion device was available in the operating theatre with the patient's consent. General anaesthesia was administered and the procedure performed without complication. The total blood loss was approximately 400 ml. As a result of being the first case on the morning list and the inherent organisation required to ensure safety due to the latex allergy and religious beliefs, it was not until near the end of the procedure that potential difficulties with postoperative analgesia became apparent. During the case, nitrous oxide and intravenous morphine had provided good haemodynamic stability. At this stage the possible options for postoperative analgesia were: 1 morphine patient-controlled analgesia (PCA); 2 epidural infusion of a local anaesthetic agent; 3 epidural diamorphine bolus; 4 intrathecal morphine; 5 intramuscular morphine + bilateral ilio-inguinal nerve blocks + nonsteroidal anti-inflammatory drugs. Morphine PCA was the preferred method but, although being of appropriate size, the available latex-free syringes were incompatible with all of the hospital delivery devices. The latter only accepted syringes with latex-containing bungs. Despite the low risk to the patient from this source [1], it was decided not to take this option. Unfortunately, the same problem arose when considering an epidural infusion of a local anaesthetic agent. Options 3 and 4 were rejected because of the uncertain additive respiratory depressant effects of morphine, which had been given intravenously during the procedure. Therefore, analgesia was achieved by performing bilateral ilio-inguinal blocks at the end of the procedure, followed by small (2.0 mg) intravenous increments of morphine given in the recovery room and thereafter, with intramuscular morphine and regular nonsteroidal analgesics. Intramuscular morphine was given according to the hospital algorithm for administration on an hourly as required basis [2]. A satisfactory level of analgesia was achieved with this approach. All hospitals should have in place protocols for the treatment of patients and staff who have allergy to latex. One possible difficulty is the provision of postoperative analgesia. As a result of this case epidural packs stocked within our hospital are now all latex free and the list of latex-free equipment has been adjusted accordingly. It is also possible to obtain latex-free syringes compatible with contemporary PCA syringe drivers. Indeed, as the incidence of latex allergy seems to be increasing, the pain team have set up a PCA system, which is only to be used by patients with latex allergy. However, should this equipment be unavailable, other forms of analgesia such as intrathecal opiates, peripheral nerve blocks or intermittent intramuscular opiates can be used. In addition, with a Jehovah's Witness who consents to the use of autologous blood transfusion, that apparatus must not contain, or be contaminated with, substances containing latex.