Urethral Lubrication
Presenting the evidence
Prescribing information is available from this meeting
Catheterisation gels
•
•
•
•
Why do we use them?
Anaesthetic gel
Antiseptic gel
Discussion
• What do you use?
The benefits of using a catheterisation
gel
• Lubrication
• Facilitates insertion
• Anaesthetic
• Antiseptic
Potential complications of
catheterisation
• Trauma
“The occurrence of urethral constriction after transurethral intervention is not a matter
of chance but a consequence of trauma.”
(Muctar. (1991). The importance of a Lubricant in Transurethral Interventions. Urologe (B), 31,
153-5)
• Pain
• Infection
300,000 HCAI per year in UK
5000 will die
CAUTI = 23%
(National Audit Office 2005)
Skills for Health K23
Knowledge and skills
• the types and use of lubrication and anaesthetic gels
Performance Criteria
• administer the appropriate lubrication or anaesthetic
gel following manufacturers instructions
The anatomy of the male
The benefit of lubrication in male
catheterisation
“The endoscopically visible folds in the urethra
are opened out by the lubricant and thus
preformed for the introduction of the
instrument which is then less likely to catch
in folds in the mucosa or in anatomically
narrow passages.”
Muctar. (1991). The Importance of a Lubricant in Transurethral Interventions. Urologe (B), 31, 153-5
The benefit of lubrication in male
catheterisation
Distends and protects
Trauma free
catheterisation
Readily eliminated
from the bladder
The anatomy of the female
Micrographs of transverse through proximal (left), middle (centre), and distal
(right) female human urethra
The benefit of lubrication in female
catheterisation
“If gel is used prior to catheterization the urethra is much
easier to locate because the gel opens the urethral folds
and orifice, speeding up the procedure and reducing the
risk of the vagina being catheterised instead”
De Courcy-Ireland. (1993). An Issue of Sensitivity: Use of analgesic in catheterising women. Professional
Nurse, 8, 738-42
Protecting against trauma
“The danger of damage to the urethra can only be
reduced if the highly vulnerable urothelium is
protected from traumatising contact with
instruments by an unbroken film of lubricant.”
Muctar. (1991). The Importance of a Lubricant in Transurethral Interventions. Urologe (B), 31, 153-5
Recommendations
Infection control
Prevention of healthcare-associated infection in primary and community
care
Clinical Guideline 2 (NICE 2003)
1.2.4 Catheter insertion
1.2.4.4 An appropriate lubricant from a single-use container should be
used during catheter insertion to minimise urethral trauma and infection
Urethral trauma will be minimised by using sterile, single-use lubricant or
anaesthetic gel (NICE 2012)
Maximising the effect of Lubrication
• Prime syringe prior to use
• Slow, steady instillation
– allow gel to coat and pre-form urethra
– aids urethral location in females by external meatal dilation
• Leave in urethra for 5 minutes
– to maximise 2% lidocaine effect
– to facilitate antimicrobial action
The argument for anaesthetic gel
• ‘Catheterisation is significantly more painful for
males than females.’ (Singer et al 1998 Tanabe et al 2004)
• ‘Patients pre-treated with lidocaine experienced
significantly less pain than those in the control
group.’ (Siderias 2004)
• ‘During catheterisation of females, discomfort was
significantly lower in a lignocaine group than a plain
gel group.’ (Chung et al 2007)
Against anaesthetic gel
• ‘No significant differences were found in pain scores
between the groups when catheterising women.’
(Tanabe et al 2004)
• ‘Plain gel causes less discomfort in the male urethra
than 2% lidocaine gel. It is the clinician’s
competence that makes the difference.’ (Ho et al 2003)
• ‘There is no difference in pain scores between
lidocaine and plain gel instillations.’ (Patel et al 2008)
Also…
• ‘Local anaesthetics should not be used on inflamed or
infected tissues.’ (Booth 2009)
• ‘Topical local anaesthetics can be absorbed through mucosal
surfaces’ (Booth 2009). Effects may include nervousness,
dizziness, hypotension and bradycardia.
• Advice given in the NICE (2003) guidelines is ambivalent on
whether a lubricant gel or an anaesthetic gel should be used
before catheterisation, leaving healthcare professionals in a
quandary as to which method constitutes best practice.
• Lidocaine, if absorbed systemically, may give rise
to a hypotensive state when used in conjunction
with anti-arrhythmic drugs.
• This risk is greatly reduced when lidocaine is
used topically.
• Since launch, over 25 million units of antiseptic
have been administered in the UK, with only 17
reports of adverse reactions, and in all cases, the
patients readily recovered.
Protecting against pain
• Contains 2% lidocaine
• Leave in urethra for 3 – 5 minutes for optimum
anaesthetic effect
• ‘Lidocaine gel is a useful topical application in
urethral pain, or to relieve the discomfort of
catheterisation.’ (BNF 2009)
The economic burden of infection
• Hospital patients with UTI infections incurred costs on average
1.8 times greater than non-infected patients. Average additional
cost for UTIs £1,327
• Patients who acquired UTIs remained in hospital 1.8 times
longer than uninfected (equivalent to 6 extra days)
• Patients with a HAI 7.1 times more likely to die in the hospital
Plowman et al. (1999). The socio-economic burden of hospital acquired infection. PHLS.
For antiseptic gel
“Infections of the urinary tract account for about
23% of hospital-acquired infection and are
commonly associated with catheterisation.”
National Audit Office 2005
“The infected urinary tract is the most common
source of Gram-negative septicaemia in
hospitalised patients.”
Ward V., Wilson J., Taylor L., Cookson B., Glynn A. (1997) Preventing hospital-acquired infection: Clinical
guidelines. PHLS
For antiseptic gel
• Chlorhexidine has a bactericidal effect on both gram
+ve and gram -ve bacteria, particularly E coli. (Kyle
2009)
• ‘The use of antiseptic, anaesthetic gel reduced the
rate of UTI by 50%.’ (Kambal et al 2004) (flawed study)
Against antiseptic gel
• Proteus mirabilis is resistant to Chlorhexidine.
(Baillie
1987 Stickler et al 1987)
• No significant difference in UTI rate between
chlorhexidine gel group and plain gel group. (Pawelczyk
2002) (small study)
• Chlorhexidine may cause life threatening
anaphylactic shock, even with urethral use. This may
be under-reported. (Booth 2009)
Against antiseptic gel
• MDA alert October 2012
• ‘The MHRA has received a number reports of anaphylactic reactions
following the use of products containing chlorhexidine. Two examples are
given below:
•
a patient had an anaphylactic reaction when a skin wipe that contained
chlorhexidine gluconate was used prior to cannulation. The patient had previously
had an anaphylactic reaction whilst under general anaesthetic but at the time the
cause of the reaction was unknown.
•
it was reported that a patient with a known chlorhexidine allergy, which was noted
on his file and on his wristband, suffered a cardiac arrest shortly after a
chlorhexidine impregnated central venous catheter was inserted whilst in the
operating theatre. He was successfully resuscitated.
Against antiseptic gel
• In the 1970’s the rate of UTI was proportionally lower
than today, yet only KY jelly or anaesthetic gels were
used for catheterisation, not antiseptic gel. (Booth 2009)
• The reduction in UTI’s related to the use of antiseptic
gels remains unproven. (Kyle 2009)
Catheter use & UTI rates
Speciality
% of patients
catheterised
Duration of
Infections per
catheterisation 1000 patient
(days)
(days)
Infections per
1000 device
(days)
Medicine
11.6
5.0
0.8
2.8
Surgery
34.4
3.5
1.6
3.9
Gynaecology
40.4
2.0
5.1
16.7
Orthopaedics
17.3
6.0
1.2
3.5
Overall rate
26.3
3.0
1.6
5.0
Glynn et al. (1997). Hospital Acquired Infection Surveillance Policies and Practice PHLS
Conclusion
‘The use of lubricating anaesthetic gels is a
controversial issue when considering urinary
catheterisation, urethral, suprapubic, indwelling and
intermittent, further complicated by the use of gels
containing antiseptic agents. There is a need for
further research into this aspect of care.’ (Pomfret 2001)
Are you surprised by these
findings?
What do you think?
Thank you!
FAQs
• How often can antiseptic gel be used?
In adults, the half-life of lidocaine in blood is 3 hours. To avoid accumulation,
the period between administrations should not be less than 3 hours.
• What is the maximum dose of antiseptic gel that may be safely given to
an adult in one administration?
Blood concentrations after administration of doses of up to 800mg
(approximately 40ml gel) into the urethra remain below toxic levels.
However, in practice, this amount should never be necessary.
FAQs
• At what age can antiseptic gel be administered?
There is no lower age limit. Guidelines for paediatric use are as
follows:
0-2 years
1-2ml
2-5 years
2-4ml
5-10 years
4-6ml
10+ years
4-6ml
• Will a patient experience discomfort during
administration?
Any discomfort such as a stinging sensation is likely to be caused
by the gel being administered too quickly. It is important that it is
administered slowly and evenly.
FAQs
• Can antiseptic gel be used for catheterisation prior to
a Caesarian section?
Yes it can.
• Is antiseptic gel latex free?
Yes, it is.
Thank you for your attention
Gill Nottidge
01274 322210
Gillian.nottidge@bradford.nhs.uk