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Urethral Lubrication

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  1. Urethral Lubrication Presenting the evidence Prescribing information is available from this meeting

  2. Catheterisation gels Why do we use them? Anaesthetic gel Antiseptic gel Discussion What do you use?

  3. The benefits of using a catheterisation gel Lubrication Facilitates insertion Anaesthetic Antiseptic

  4. Trauma “The occurrence of urethral constriction after transurethral intervention is not a matter of chance but a consequence of trauma.” Pain Infection 300,000 HCAI per year in UK 5000 will die CAUTI = 23% (National Audit Office 2005) Potential complications of catheterisation (Muctar. (1991). The importance of a Lubricant in Transurethral Interventions. Urologe (B), 31, 153-5)

  5. 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

  6. The anatomy of the male

  7. “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.” The benefit of lubrication in male catheterisation Muctar. (1991). The Importance of a Lubricant in Transurethral Interventions. Urologe (B), 31,153-5

  8. The benefit of lubrication in male catheterisation Distends and protects Trauma free catheterisation Readily eliminated from the bladder

  9. The anatomy of the female Micrographs of transverse through proximal (left), middle (centre), and distal (right) female human urethra

  10. “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” The benefit of lubrication in female catheterisation De Courcy-Ireland. (1993). An Issue of Sensitivity: Use of analgesic in catheterising women. Professional Nurse, 8, 738-42

  11. “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.” Protecting against trauma Muctar. (1991). The Importance of a Lubricant in Transurethral Interventions. Urologe (B), 31, 153-5

  12. 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)

  13. 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

  14. 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)

  15. 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)

  16. 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.

  17. 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.

  18. 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)

  19. 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.

  20. 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

  21. 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)

  22. 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)

  23. 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.

  24. 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)

  25. Catheter use & UTI rates Glynn et al. (1997). Hospital Acquired Infection Surveillance Policies and Practice PHLS

  26. 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)

  27. Are you surprised by these findings? What do you think?

  28. Thank you!

  29. 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.

  30. 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.

  31. FAQs Can antiseptic gel be used for catheterisation prior to a Caesarian section? Yes it can. Is antiseptic gel latex free?Yes, it is.

  32. Thank you for your attention Gill Nottidge 01274 322210 Gillian.nottidge@bradford.nhs.uk