Perioperative preparation for a sensitised patient
Preoperative medical assessment
Best practice would suggest that patient assessment is undertaken in the outpatient or pre-assessment unit prior to all elective surgery using a screening tool Patient Screening to identify at risk individuals. Ideally, the GP General Practice will have informed the surgeon of the patient’s sensitisation in the initial referral letter.
If pre-screening suggests that the patient may have an NRL sensitivity, diagnostic confirmation should be sought.
All forward planning and documentation should inform future carers of the patient’s sensitisation by effective recording in notes, on operating lists and the use of labels for Patient Notes. Patient confidentiality must be taken into account.
Usually undertaken by both anaesthetist and medical staff it is vital to the safe planning of perioperative care that an effective assessment of the allergic potential of each patient is undertaken. Allergy to related rubber products may give rise to deepening of questions but an allergy to cross-reactive allergens (in the main foodstuffs) may lead to a more informed decision about the patient’s allergic status.
- The sensitised patient should be (wherever possible) first on the operating list.
- The anaesthetist and relevant theatre staff should be notified in sufficient time in advance of surgery to make effective preparation (see Preoperative medical assessment).
Risk-assessment might suggest that anaesthesia and recovery should both take place in the operating room to minimise risk.
Working with the knowledge from the local database of NRL and NRL-free products, remove or cover any items containing NRL from the area where the patient will be treated. In the initial database formation, Sterile Services Departments will need to be involved to ensure that there is no NRL on or used for the preparation of instrument sets or accessories.
– Providing a barrier between the patient and the NRL will reduce or remove risk e.g. cover sphygmomanometer tubing with a drill sleeve or stockinette:
The remaining equipment in the operating room should be cleared of any possible NRL contamination by washing with a mild detergent solution: n.b. it is important that NRL gloves are NOT worn for this task.
Dependent on the number of air changes within the operating room, sufficient time should be allowed to reduce any aerosolised NRL proteins in the atmosphere. Most theatres work with a minimum of 20 air changes an hour and in lamina flow theatres, this can be as high as 500 air changes an hour. Application of basic physics and in the presence of effective maintained air flow systems it is suggested that in the lower air change rooms, the room should be safe to use within a minimum of 30 minutes after the removal of any natural rubber latex and preparatory cleaning and in lamina flow rooms, 15 minutes after the removal and preparatory clean. Risk-assessment of the severity of sensitisation will determine timings.
Drugs for the treatment of anaphylaxis should be readily available
Staff in the vicinity should be warned of the patient status either by word of mouth or by notices posted at all entrances.
Where the patient cannot be anaesthetised or recovered in the operating room, these rooms must be prepared and signed as for the operating room.
The Association of Anaesthetists for Great Britain and Ireland give guidance for “Anaphylactic reactions associated with Anaesthesia” including diagnosis of suspected latex-induced anaphylaxis.
Prior to transfer to the ward/ITU, communication must have taken place well in advance to inform of the patient status if sensitisation recognised within the perioperative area in order to allow time for ward preparation.
Theatre : ward handover should include all relevant information.
In the case of emergency situations, the patient can be questioned preoperatively if conscious and a risk-assessment made given the responses to the Patient screening tool. If the patient is unconscious, then best practice would suggest that NRL risks should be minimised and as far as is reasonably practicable, NRL products should be removed or covered.
In the emergency situation, it may not be possible to allow for suggested air changes to take place and the patient’s best interests with respect to their clinical condition must be assessed.
- National Association of Theatre Nurses “Understanding Latex Allergy in the Perioperative Setting” 2000 ISBN 0 9537287 2 2
- Association of Anaesthetists for Great Britain and Ireland “ Suspected Anaphylactic Reactions Associated with Anaesthesia” 1995
- Great Ormond Street Hospital “Anaesthetic guidelines for the management of children with NRL Allergy”