HEPMP Ljubljana HEPMP Ljubljana DRAFT March 12-16, 2018 Lecture Book & Meeting Report Editors: Blaž M. Geršak, Maja Šoštarič March 12-16, 2018 HEPMP Ljubljana Table of Contents Table of Contents DRAFTpage Lecture series 1 - Welcome Address 1.1 Introduction to University of Ljubljana joined lectures 1.2 6 Introduction to Faculty of Medicine Ljubljana 1.3 Introduction to Clinical Department of Anesthesiology 20 1.4 Introduction to Faculty of Medicine Department of Anesthesiology 75 1.5 Introduction to International office and Erasmus program 90 Lecture series 2 - Education 2.1 What graduate students learn about pain medicine 108 2.2 What residents learn about pain medicine 128 2.3 Pain medicine education for family medicine practitioners 175 Table of Contents: Lecture series 1-2 HEPMP Ljubljana Table of Contents Lecture series 3 - Office of Outpatient Pain Management 3.1 Establishment of Office of Outpatient Pain Management 198 DRAFT 3.2 Multidisciplinary approach to chronic pain management 214 3.3 The role of Slovenian Society of Pain Medicine 2.4 joined lectures 249 Pain medicine education for healthcare providers Lecture series 4 - Obstetric Analgesia 4.1 Establishment of a modern obstetric anesthesia service 271 4.2 Multidisciplinary obstetric anaesthesia research projects 305 4.3 10-year experience with remifentanil labor analgesia 320 Lecture series 5 - Acute Pain Management 5.1 Establishment of acute pain management service 350 5.2 Role of the Anesthesiology department in acute pain management service 383 5.3 Implementation of protocols for acute pain management 392 5.4 Education of healthcare providers on acute postoperative pain management 418 Table of Contents: Lecture series 3-5 HEPMP Ljubljana Table of Contents Lecture 6.1 - Pain Management at the Institute of Oncology DRAFT - Office of Outpatient Pain Management 432 Meeting Report - Training of Existing Teaching Staff from Partner Countries at Programme Countries 450 Lecture series 7 - Research and Publication on Pain Medicine, containing lectures 7.1 Organizing research on pain medicine and 7.2 Publications on pain medicine in Slovenia, is not included in this Lecture Book due to its hypothetical nature. Table of Contents: Lecture 6.1 & Meeting Report HEPMP Ljubljana Welcome Address DRAFT Lecture series 1 Welcome Address 1.1 Introduction to University of Ljubljana 1.2 joined lectures Introduction to Faculty of Medicine Ljubljana 1.3 Introduction to Clinical Department of Anesthesiology 1.4 Introduction to Faculty of Medicine Department of Anesthesiology 1.5 Introduction to International office and Erasmus program Lectures 1.1 - 1.5 page 5 - 106 HEPMP Ljubljana - Day 1 Welcome Address Lectures 1.1 and 1.2 DRAFT Introduction to the University of Ljubljana Introduction to Faculty of Medicine Ljubljana prof. Igor Švab, MD, PhD Dean, Faculty of Medicine Ljubljana Lectures 1.1 and 1.2 page 6 - 19 Introduction to University & Faculty of Medicine Ljubljana Welcome Address DRAFT University of Ljubljana Connecting to prosper prof. Igor Švab, MD, PhD slide /13 1 Introduction to University & Faculty of Medicine Ljubljana Welcome Address The Structure of Higher Education in Slovenia DRAFT prof. Igor Švab, MD, PhD slide /13 2 Introduction to University & Faculty of Medicine Ljubljana Welcome Address UNIVERSITY OF LJUBLJANA DRAFT Established in 1919 - 23 faculties - 3 academies - A traditional, comprehensive and research oriented university - App. 41 000 students prof. Igor Švab, MD, PhD slide /13 3 Introduction to University & Faculty of Medicine Ljubljana Welcome Address • Comprehensive, DRAFT research oriented university • 40.109 students • 5.730 employees • an annual budget of 304,7 mio € • Ranked among top 3% of world universities prof. Igor Švab, MD, PhD slide /13 4 Introduction to University & Faculty of Medicine Ljubljana Welcome Address • Established in 1919 with 5 member faculties (including Medicine) DRAFT • At present the University of Ljubljana consists of: ▪ 23 faculties and ▪ 3 arts academies STUDY FIELDS: Natural Science, Technology and Engineering, Social Sciences, Humanities, Medicine, Art University of Ljubljana prof. Igor Švab, MD, PhD slide /13 5 Introduction to University & Faculty of Medicine Ljubljana Welcome Address DRAFT • Research • Quality • Education • Internationalisation • Knowledge transfer Three pillars of core business & two strategic orientations prof. Igor Švab, MD, PhD slide /13 6 Introduction to University & Faculty of Medicine Ljubljana Welcome Address • 4027 registered researchers DRAFT • 412 young researchers + 7 post-docs • 174 long-term research programmes • 480 research projects • Every teacher is expected to be involved in research Research focus prof. Igor Švab, MD, PhD slide /13 7 Introduction to University & Faculty of Medicine Ljubljana Welcome Address EU Projects 2006-2016 DRAFT 419 421 437 428 400 402 366 329 303 276 234 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 prof. Igor Švab, MD, PhD slide /13 8 Introduction to University & Faculty of Medicine Ljubljana Welcome Address Publications 2612 DRAFT ▪ Number of publications registered in WoS - stagnant 2538 2449 2440 2420 2345 2011 2012 2013 2014 2015 2016 ▪ Citations of publications doubled in 5 years 337090 296245 259303 225020 193988 165580 c10(2011) c10(2012) c10(2013) c10(2014) c10(2015) c10(2016) prof. Igor Švab, MD, PhD slide /13 9 Introduction to University & Faculty of Medicine Ljubljana Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT • 26 departments • 13 institutes • 3 health services institutes • 3 centers prof. Igor Švab, MD, PhD slide /13 10 Introduction to University & Faculty of Medicine Ljubljana Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT In Numbers EMPLOYEES IN TOTAL: 872 - administrative and technical staff: 389 (46,50%) - teaching staff: 347 (38,30%) - full/part time researcher: 107 - young researchers/investigators: 35 Research programmes and projects: national: 61 EU + other international: 30 prof. Igor Švab, MD, PhD slide /13 11 Introduction to University & Faculty of Medicine Ljubljana Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT STUDY PROGRAMMES Uniform second-level master‘s programmes - Medicine (MD) 6 years / 12 semesters, 150 students - Dental medicine (DMD), 6 years / 12 semesters, 50 students Doctoral study programme - BIOMEDICINE (PhD) 4 years, 100 students prof. Igor Švab, MD, PhD slide /13 12 Introduction to University & Faculty of Medicine Ljubljana Welcome Address Elective subjects Basic Medical DRAFT Modules Clinical Modules Preclinical/Clinical ( year 1-3) Basic structure Elective subjects of study programme Medicine Clinical Modules with intergrated & clinical practice Dental Medicine Clinical ( year 4-6) Comprehensive Clinical Science Examination (CCSE) - elective prof. Igor Švab, MD, PhD slide /13 13 HEPMP Ljubljana - Day 1 Welcome Address Lecture 1.3 DRAFT Introduction to the Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana prof. Vesna Novak Jankovič, MD, PhD Head, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 1.3 page 20 - 74 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 1 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 2 Introduction to Clinical Department of Anesthesiology Welcome Address Ljubljana EMONA - Roman castrum DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 3 Introduction to Clinical Department of Anesthesiology Welcome Address 1974 DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 4 Introduction to Clinical Department of Anesthesiology Welcome Address William Morton 1846 - the first use of ether as an anaesthetic DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 5 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT Slovenia ⦿ 4 months later ⦿ Dr. Leopold Nathan prof. Vesna Novak Jankovič, MD, PhD slide /54 6 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 7 Introduction to Clinical Department of Anesthesiology Welcome Address Prof.EDO ŠLAJMER MD PhD 31. October 1901 first spinal anaesthesia DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 8 Introduction to Clinical Department of Anesthesiology Welcome Address First endotracheal intubation DRAFT UNRRA- first endotracheal tubes Prof. Miro Košak 1947 prof. Vesna Novak Jankovič, MD, PhD slide /54 9 Introduction to Clinical Department of Anesthesiology Welcome Address Prim.Drago Hočevar MD DRAFT ⦿ 1949 Clinical department of anaesthesiology and intensive therapy ⦿ Copenhagen - school of anaesthesiology prof. Vesna Novak Jankovič, MD, PhD slide /54 10 Introduction to Clinical Department of Anesthesiology Welcome Address Prof. Darinka Soban MD PhD EPIDURAL ANAESTHESIA 1960ś DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 11 Introduction to Clinical Department of Anesthesiology Welcome Address Correspondence K.Linnaeus-J.A.Scopoli DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 12 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 13 Introduction to Clinical Department of Anesthesiology Welcome Address 1960 DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 14 Introduction to Clinical Department of Anesthesiology Welcome Address Matjaž - 1st slovenian anaesthesia machine DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 15 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 16 Introduction to Clinical Department of Anesthesiology Welcome Address Prof. Stojan Jeretin MD,PhD CARS - central anaesthetic reanimation service DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 17 Introduction to Clinical Department of Anesthesiology Welcome Address Prof. Lučka Toš Md PhD DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 18 Introduction to Clinical Department of Anesthesiology Welcome Address Prof. Vesna Paver Eržen MD PhD CEEA courses DRAFT Medical simulation centre prof. Vesna Novak Jankovič, MD, PhD slide /54 19 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 20 Introduction to Clinical Department of Anesthesiology Welcome Address PREDSTAVITEV KOAIT DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 21 Introduction to Clinical Department of Anesthesiology Welcome Address ORGANIZACIJSKA SHEMA KOAIT DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 22 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 23 Introduction to Clinical Department of Anesthesiology Welcome Address 2. ODDELEK ZA INTENZIVNO TERAPIJO DRAFT Enote intenzivne terapije: • CIT: 20 postelj 567 pacientov • KVIT: 12 postelj 1.020 pacientov • Opekline: 4 postelje 10 pacientov • Enote intenzivne nege na Ginekološki kliniki: • KO za ginekologijo 16 postelj – 1.304 pacientov • KO za reprodukcijo 9 postelj – 729 pacientov • KO za perinatologijo 8 postelj prof. Vesna Novak Jankovič, MD, PhD slide /54 24 Introduction to Clinical Department of Anesthesiology Welcome Address 3. ODDELEK ZA TERAPIJO BOLEČINE DRAFT ⦿ prvi pregled 1.836 ⦿ ponovni pregled 846 ⦿ terapevtski posegi: 10.174 ⦿ SKUPAJ: 12.856 obravnav prof. Vesna Novak Jankovič, MD, PhD slide /54 25 Introduction to Clinical Department of Anesthesiology Welcome Address Pain service 1998 prim. Marija Godec, prof. Rawal DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 26 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT 4. Department for respiratory therapy ⦿Preoperative evaluation ⦿No pts – 10.135 ⦿No procedures – 162.264 ⦿NIV – 10.237 ur ⦿IPV – 5.052 ur prof. Vesna Novak Jankovič, MD, PhD slide /54 27 Introduction to Clinical Department of Anesthesiology Welcome Address 5. Department for development and research DRAFT • Research: • research projects (ARRS 1x, European projects – 2x, other 9x) • UMC LJ projects(21) • Education: • European centre for training of anaesthesiologists • students of MF UL and Faculty of health science UL (1015 students MF, 218 študentov FHS) • residents of anaesthesiology(136) • other residents (6) • specialistic exams (8) • Education of nurses, technicians prof. Vesna Novak Jankovič, MD, PhD slide /54 28 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT 436 employees ⦿ Anaesthesiologists 100 ⦿ Residents 52 ⦿ CRNA 243 prof. Vesna Novak Jankovič, MD, PhD slide /54 29 Introduction to Clinical Department of Anesthesiology Welcome Address Academic titles (20%) DRAFT ⦿ 2 prof (Vesna Novak-Jankovič, Tatjana Stopar-Pintarič), ⦿ 4 assoc prof (Maja Šoštarič, Neli Vintar, Tomislav Mirkovič, Primož Gradišek), ⦿ 9 PhD (Alenka Spindler Vesel, Minca Voje, Janez Benedik, Katja Režonja, Darja Šervicl Kuchler, Iztok Potočnik, Marija Damjanovska, Marko Žličar), ⦿ 2 MSc (Rade Stanič, Nina Kosmač), ⦿ 4 primariji (Snežana Žarkovič, Tatjana Babnik, Gorazd Požlep, Rade Stanič). prof. Vesna Novak Jankovič, MD, PhD slide /54 30 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT 2016 ⦿ 100 000 procedures ⦿ 30 000 general anaesthesias ⦿ 4500 regional anaesthesias ⦿ Surgical ICU 600 pts ⦿ CV ICU 1000 pts prof. Vesna Novak Jankovič, MD, PhD slide /54 31 Introduction to Clinical Department of Anesthesiology Welcome Address UMC Ljubljana DRAFT ⦿ Premature babies, newborns ⦿ Congenital heart diseases ⦿ Congenital diseases, ⦿ Major neurosurgical, thoracic, abdominal surgery ⦿ Transplantations (heart, liver, kidney) ⦿ TAVI ⦿ CAS, coiling prof. Vesna Novak Jankovič, MD, PhD slide /54 32 Introduction to Clinical Department of Anesthesiology Welcome Address Working places Mon Tue Wen Thu Fri Surgical division 29 32 30 31 28 DRAFT Gynecological and obstetric division 8 8 8 8 8 Ortopedic clinic 4 4 4 4 4 ORL 3 3 2 3 2 Internal division 2 1 1 1 Paediatric clinic 2 2 1 1 2 Clinic for ophtalmology 2 1 2 1 2 Clinic for stomatology 1 1 1 Department for radiology 2 2 2 3 1 Preoperative evaluation 3 5 5 5 3 Others 11 12 10 10 11 CIT 9 9 9 9 9 After shifts 11 11 11 11 11 82 92 86 88 82 prof. Vesna Novak Jankovič, MD, PhD slide /54 33 Introduction to Clinical Department of Anesthesiology Welcome Address Duties DRAFT ⦿ Helicopter transportations interhospital (70-80) ⦿ CPR, polytraumas (450) ⦿ Intrahospital CPR (350) prof. Vesna Novak Jankovič, MD, PhD slide /54 34 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT New methods ⦿ Radiofrequency rhizotomy 2010 chronic back pain ⦿ US central and peripheral nerve blocks ⦿ ECMO (Extra Corporeal Membrane Oxygenation) ⦿ HEARTMATE LVD ⦿ BIS operating theatre ICU ⦿ NIRS cerebral oximetry prof. Vesna Novak Jankovič, MD, PhD slide /54 35 Introduction to Clinical Department of Anesthesiology Welcome Address New methods DRAFT ⦿ Prevention (VAP – ventilatory associated pneumonia) endotracheal tube with subglottic aspiration, ⦿ HFV – high frequency ventilation (ARDS, ALI-acute lung injury), ⦿ HFJV-high frequency jet ventilation for laryngeal surgery ⦿ CritiCool cooling system for head injury ⦿ Early goal directed therapy LIDCO Rapid , VIGILEO, VIGILANCE ⦿ Awake neurosurgery ⦿ Awake VATS ⦿ TAP blokov (transversus abdominis plane blocks), ⦿ Microdialysis head injury prof. Vesna Novak Jankovič, MD, PhD slide /54 36 Introduction to Clinical Department of Anesthesiology Welcome Address New methods DRAFT ⦿ PROSAFE international data base ICU patients ⦿ Point of Care (POC) (ROTEM, MULTIPLATE) for the control of haemostasis ⦿ Dexmedetomidine perioperative use, ⦿ NIV of surgical pts prof. Vesna Novak Jankovič, MD, PhD slide /54 37 Introduction to Clinical Department of Anesthesiology Welcome Address Improvements DRAFT ⦿ Optimisation of organisation ⦿ Schedule pro Bokosoft – electronic programme for the schedule of our doctors and nurses ⦿ Electronic anaesthetic template ⦿ Electronic administration (HIPOKRAT, BIRPIS data base) prof. Vesna Novak Jankovič, MD, PhD slide /54 38 Introduction to Clinical Department of Anesthesiology Welcome Address Guidelines and recommendations DRAFT ⦿ v letu 2010 smo v klinično prakso uvedli nove slovenske smernice za antikoagulantno in antitrombotično zdravljenje ob področni anesteziji. Dosegljive so tudi na spletni strani www.szaim.org (objava v Zdrav Vestn 2009;78:619-25); ⦿ v letu 2014 smo uvedli evropske smernice za perioperativno nadomeščanje tekočin pri otrocih; na našo pobudo je Lekarna UKCL začela izdelovati glukozo 1 % z elektroliti; po našem priporočilu je navedeno smernico v svojo prakso uvedel tudi KO za otroško kirurgijo in intenzivno terapijo; ⦿ z Alergološko in imunološko sekcijo, Sekcijo za pediatrično pulmologijo, alergologijo in klinično imunologijo, Združenjem zdravnikov družinske medicine in Slovenskim združenjem za urgentno medicino smo sodelovali pri izdelavi smernic za obravnavo bolnika z alergično reakcijo "Dogovor o obravnavi anafilaksije". ⦿ izdelali smo "Priporočila za nadomeščanje tekočin pri odraslih" (objava v Zdravniškem vestniku 2015) ⦿ izdelali smo "Priporočila za težko intubacijo" (objava v Zdravniškem vestniku 2014) ⦿ izdelali smo smernice za predoperativno teščost odraslega bolnika in otroka prof. Vesna Novak Jankovič, MD, PhD slide /54 39 Introduction to Clinical Department of Anesthesiology Welcome Address Booklets DRAFT 1. Etična priporočila za odločanje o zdravljenju in paliativni oskrbi bolnika ob koncu življenja v intenzivni medicini 2. Dogovor o obravnavi anafilaksije 3. Priporočene smernice za obravnavo poškodovancev z blago in zmerno poškodbo glave prof. Vesna Novak Jankovič, MD, PhD slide /54 40 Introduction to Clinical Department of Anesthesiology Welcome Address Standard DRAFT certificate ⦿DNV accreditation -> international standard ⦿Certifikati ISO 9001:2008 & EN 15224: 2012 prof. Vesna Novak Jankovič, MD, PhD slide /54 41 Introduction to Clinical Department of Anesthesiology Welcome Address Guidelines, protocols DRAFT 2009 – 1st edition SOP-i 2015 – 2nd edition SOP-ov prof. Vesna Novak Jankovič, MD, PhD slide /54 42 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT Mobile application smartphones 2016 prof. Vesna Novak Jankovič, MD, PhD slide /54 43 Introduction to Clinical Department of Anesthesiology Welcome Address From 1997 in UKCL ESA EDAIC Part I DRAFT May 2011 "OLA" - On-line exam of Anaesthesiology". prof. Vesna Novak Jankovič, MD, PhD slide /54 44 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 45 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 46 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT Kristina Radinovic MD phD (UMC Belgrade) ESA fellow 2017(Jul,Aug,Sep) prof. Vesna Novak Jankovič, MD, PhD slide /54 47 Introduction to Clinical Department of Anesthesiology Welcome Address Poleg že navedenega: • sodelujemo pri številnih terciarnih projektih v sklopu UKCL (do sedaj 36), DRAFT • sodelujemo s Saint George Hospital v Londonu pri hemodinamski optimizaciji kirurških bolnikov, • smo uvedli uvajalne izobraževalne tečaje za novozaposlene specializante anesteziologije in za diplomirane medicinske sestre, • v Medicinskem simulacijskem centru izvajamo številne tečaje in učne delavnice za zaposlene v UKCL: tečaji oživljanja, tečaji področne anestezije, tečaji uvajanja centralnih venskih katetrov, tečaji uvajanja intravenskih kanil, tečaji aspiracije intubiranih pacientov, tečaji za lajšanje akutne pooperativne bolečine, tečaji multimodalnega monitoringa (BIS, INVOS, LIDCO) za tuje udeležence, učne delavnice hipoksija in izvajanje NIV za respiratorne terapevte. prof. Vesna Novak Jankovič, MD, PhD slide /54 48 Introduction to Clinical Department of Anesthesiology Welcome Address Clinical Department of Anaesthesiology and Surgical Intensive Therapy – UMC Ljubljana DRAFT Year 2014 – 3829 reg. anaesthesias prof. Vesna Novak Jankovič, MD, PhD slide /54 49 Introduction to Clinical Department of Anesthesiology Welcome Address 2010 European multicentric study DRAFT (EuSOS– European Surgical Outcomes Study) chief investigator prof. Rupert Pearse London ,UK 2012 Lancet (IF39.08) PEARSE, Rupert M, MORENO, Rui P, BAUER, Peter, PELOSI, Paolo, METNITZ, Philipp, SPIES, Claudia, VALLET, Benoit, VINCENT, Jean Louis, HOEFT, Andreas, RHODES, Andrew, et al. Mortality after surgery in Europe: a 7 day cohort study. The Lancet, ISSN 0140-6736. [Print ed.], Sep. 2012, vol. 380, [no.] 9847, str. 1059-1065. [COBISS.SI-ID 4437567] LAS VEGAS APRICOT NECTARINE ETPOS CREACTIVE POPULAR prof. Vesna Novak Jankovič, MD, PhD slide /54 50 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT Cooperation with international organisations: ⦿ World Federation of societies of anaesthesiologists (WFSA) ⦿ European Society of Anaesthesiology (ESA) ⦿ European Board of Anaesthesiology (EBA) – UEMS ⦿ EACTA (European Association of cardiothoracic anaesthesiologists) ⦿ Committee for European Education in Anaesthesiology (CEEA); ⦿ European Society of Regional Anaesthesia (ESRA) ⦿ NASC (National Anaesthesiologists Societies Committee) ⦿ ESPA (European Society of Paediatric Anaesthesiology) ⦿ ERC (European Resuscitation Council) prof. Vesna Novak Jankovič, MD, PhD slide /54 51 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT Cooperation with experts: ⦿ Rupert Pearse - Royal Hospital White Chapel London, UK ⦿ Krešimir Matkovič - VRVis Zentrum fur Virtual Reality and Visualizierung Forschungs, Wien, Austria ⦿ Kamen Vlasakov - Harvard University, Boston, USA ⦿ Iliaz Hodžovič - University of Cardiff, Cardiff, UK ⦿ Maurizio Cecconi - St. George Hospital, London, UK ⦿ Admir Hadžič - Columbia University, New York,USA ⦿ Robert Fitzgerald - Karl Landsteiner Society Wien, Austria ⦿ Jochen Hinkelbein-University medical centre Köln. Germany prof. Vesna Novak Jankovič, MD, PhD slide /54 52 Introduction to Clinical Department of Anesthesiology Welcome Address Publications DRAFT Journals: ⦿ 2008 – 94 articles (od tega z IF 7) ⦿ 2009 – 200 articles (od tega z IF 7) ⦿ 2010 – 75 (od tega z IF 13) ⦿ 2011 – 99 prispevkov (od tega z IF 20) ⦿ 2012 – 90 prispevkov (od tega z IF 17) ⦿ 2013 - 80 prispevkov (od tega z IF 7) ⦿ 2014 - 132 prispevkov (od tega z IF 11) (smo avtorji poglavja Anesteziologija (od strani 63-160) v univerzitetnem učbeniku Kirurgija, glavni urednik prof. Vladimir Smrkolj); ⦿ 2015 – 222 prispevkov (od tega z IF 17) ⦿ 2016 – 75 prispevkov (od tega z IF 19) ⦿ 2017 – 155 prispevkov (od tega z IF 29) prof. Vesna Novak Jankovič, MD, PhD slide /54 53 Introduction to Clinical Department of Anesthesiology Welcome Address DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /54 54 HEPMP Ljubljana - Day 1 Welcome Address Lecture 1.4 DRAFT Introduction to the Department of Anesthesiology and Reanimatology, Faculty of Medicine Ljubljana assoc. prof. Maja Šoštarič, MD, PhD Head, Department of Anesthesiology and Reanimatology, Faculty of Medicine Ljubljana President, Slovenian Society of Anesthesiology and Intensive Care Lecture 1.4 page 75 - 89 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Anaesthesiology in Slovenia DRAFT • 1846 Massachusetts Boston - first anaesthesia • 1847 Ljubljana – first anesthesia • 1932 Oxford – first Department of anaesthesiology • 1945-1946 VMA Beograd Department for plastic surgery – head anaesthesiologist from GB • 1949 - establishment of anaesthesiology unit assoc. prof. Maja Šoštarič, MD, PhD slide /14 1 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Education of anaesthesiology in Slovenia DRAFT • First courses of anaesthesiology in WHO centres in Copenhagen • After the return they started education of anaesthesiology in Slovenia • 1953 - 1970 organised courses for anaesthesiologist lasted from 6-12 months on this courses also pathophysiologists, pulmonologists, cardiologists, pharmacologists participated • The courses were organised in the hospital Golnik which was the leading institute for thoracic surgery and anaesthesiology • At the end of the courses there was an exam which lasted for 3 days and this was the beginning of education of anaesthesiology in Slovenia • At the same time the courses for anaesthesia nurses began, they lasted for 2 months • In 1961 there was 35 anaesthesiologists in Slovenia assoc. prof. Maja Šoštarič, MD, PhD slide /14 2 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Department of anaesthesiology and reanimatology Medical Faculty Ljubljana DRAFT • 1987 the class for anaesthesiology was established in the Department of surgery at MF • In the undergraduate study 15 hours of anaesthesiology lessons and 4 hours of reanimatology were included • Already at that time the practical work in operating theatres and workshops on reanimatology were organised. • To evaluate the knowledge and skills of the students an exam of anaesthesiology was introduced in curriculum for the first time • 1994 the first independent Department of anaesthesiology and reanimatology was established at MF UL • The department actively collaborate in the establishment of European school of anaesthesiology assoc. prof. Maja Šoštarič, MD, PhD slide /14 3 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Teaching • The undergraduate education is the main part of our work • We teach reanimation and anaesthesiology • Obligatory subjects • Optional subject assoc. prof. Maja Šoštarič, MD, PhD slide /14 4 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Obligatory subject DRAFT • Emergency medicine 1 and 2 • in 1st 2nd 6th year • Together with all who are involved in emergency medicine • BLS, IMLS, ALS • Most of the lectures and practical work is performed in Simulation Centre assoc. prof. Maja Šoštarič, MD, PhD slide /14 5 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Anaesthesia • In in 4th year • Lectures • Practical work in SC • Individual practical work in operation theatre assoc. prof. Maja Šoštarič, MD, PhD slide /14 6 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Optional subject anaesthesia • They gain deepened knowledge of anaesthesia • 5th year class assoc. prof. Maja Šoštarič, MD, PhD slide /14 7 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Pain DRAFT • 6th year • Together with Institute for pathophysiology and Institute for pharmacology • Lectures • Practical work assoc. prof. Maja Šoštarič, MD, PhD slide /14 8 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address Topics • Outline of pain pathophysiology DRAFT • Analgesics • Chronic pain management • Management of obstetric pain • Acute pain service • Alternative pain management • Managemnet of cancer pain • Presentation of seminar assoc. prof. Maja Šoštarič, MD, PhD slide /14 9 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Seminars • Acute postoperative pain management • Chronic back pain • Pain during delivery assoc. prof. Maja Šoštarič, MD, PhD slide /14 10 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Practical work • Acute pain service • Multidisciplinary work in pain clinic assoc. prof. Maja Šoštarič, MD, PhD slide /14 11 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Airway management • From basic airway management to difficult airway • Lectures • Practical work in simulation centre assoc. prof. Maja Šoštarič, MD, PhD slide /14 12 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT US in anaesthesiology • Basic knowledge • US for i.v. catheters • Regional anaesthesia and US • Respiratory system and US • US for perioperative haemodynamic evaluation assoc. prof. Maja Šoštarič, MD, PhD slide /14 13 Introduction to Faculty of Medicine Department of Anesthesiology Welcome Address DRAFT Scientific research work • A close connecting of undergraduate and postgraduate teaching and clinical work is necessary for scientific research work in the field of anaesthesiology and perioperative intensive care medicine • The performed scientific research work was possible due only to work on the clinic and cooperation with CD in UMC or other department in peripheral hospitals. assoc. prof. Maja Šoštarič, MD, PhD slide /14 14 HEPMP Ljubljana - Day 1 Welcome Address Lecture 1.5 DRAFT Introduction to the International office at Faculty of Medicine Ljubljana and the Erasmus program prof. Tomaž Marš, MD, PhD Vice Dean, Faculty of Medicine Ljubljana Head, Erasmus program at Faculty of Medicine Ljubljana Lecture 1.5 page 90 - 106 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT INTERNATIONALISATION and MOBILITY PROGRAMMES - networking - international programme - outgoing students - incoming students ERASMUS+ International Credit Mobility Prof. Dr. Tomaž Marš, Erasmus+ Coordinator prof. Tomaž Marš, MD, PhD slide /16 1 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT Institutional Mobility • Utrecht Network - MAUI - Mid-American Universities International Network Member - AEN - Australian-European Network Members • UNICA- Institutional Network of the Universities from Capitals of Europe • Rector‘s conference: Alpe – Jadran • EUA - European University Association • CEEPUS - Central European exchange programme for University Studies • CEI - Central European Initiative University Network • SAR– Scholars at Risk • Western Balkans platform • CELSA • The GUILD prof. Tomaž Marš, MD, PhD slide /16 2 Introduction to International office and Erasmus program Welcome Address DRAFT Erasmus Code: SI LJUBLJA01 94 UNIVERSITIES in 24 COUNTRIES prof. Tomaž Marš, MD, PhD slide /16 3 Introduction to International office and Erasmus program Welcome Address DRAFT Partner Universities in the World: 94 partner universities in Argentina, Brazil, USA, Republic of South Africa, European Union and Japan, Lebanon, Kazakhstan, Georgia, Mexico, EEC, Turkey Dominican Republic, Serbia, Macedonia, Nepal, ... prof. Tomaž Marš, MD, PhD slide /16 4 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT Full membership in ’ECTS-MA’’ Constitutive member of and participates in MEDINE II ‘’NPHC’’ http://www.med-ects.org/index.htm http://www.nphc.info/ MEDINE I and II, TRUNAK, HEPMP, ALLIANCE4 LIFE, …. prof. Tomaž Marš, MD, PhD slide /16 5 Introduction to International office and Erasmus program Welcome Address DRAFT Mobility programmes: Erasmus + STT / STA mobility grants Bilateral Inter-institutional Agreements /UL and UL MF Institutional grants for researchers (UL and UL MF) INTERNATIONAL RELATIONS OFFICE Central Office of International Relations prof. Tomaž Marš, MD, PhD slide /16 6 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA DRAFT FACULTY OF MEDICINE Mobility & (Re)Integration Strong holds: - Open environment for students and researchers - Academic excellence, Infrastructure and equipment - Access to Clinical Institutions, Clinical Practice - Social Benefits prof. Tomaž Marš, MD, PhD slide /16 7 Introduction to International office and Erasmus program Welcome Address OUTGOING STUDENTS DRAFT BRAZIL ACADEMIC Erasmus Erasmus+ Tropical Lions BASILEUS (Surgery IFMSA HOUSTON Kleve TOGETHER YEAR exchange placement Medicine Club CR) 2006/2007 7 0 0 0 60 22 6 0 95 2007/2008 4 0 0 17 68 18 8 0 115 2008/2009 22 1 0 17 81 23 6 0 150 2009/2010 36 5 0 15 58 19 10 0 143 2010/2011 29 16 0 14 66 20 9 0 154 2011/2012 24 7 2 12 52 45 6 7 0 155 2012/2013 37 7 0 7 92 30 35 6 2 216 2013/2014 36 16 2 8 88 30 86 10 2 278 2014/2015 64 22 1 1 89 30 60 9 1 277 2015/2016 64 20 0 19 80 30 30 6 0 249 prof. Tomaž Marš, MD, PhD slide /16 8 Introduction to International office and Erasmus program Welcome Address INCOMING STUDENTS DRAFT Academic Erasmus Erasmus Bilateral BASILEUS CEEPUS IFMSA TOTAL year exchange placement agreement 2006/2007 2 0 0 54 56 2007/2008 1 0 2 60 63 2008/2009 7 0 1 68 76 2009/2010 9 0 0 55 64 2010/2011 21 2 1 55 79 2011/2012 30 6 2 63 8 3 112 2012/2013 54 0 3 87 8 3 155 2013/2014 58 11 1 81 3 0 154 179 2014/2015 81 0 3 74 21 0 2015/2016 90 0 7 57 21 2 177 prof. Tomaž Marš, MD, PhD slide /16 9 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA DRAFT FACULTY OF MEDICINE OUTGOING STUDENTS - Rules and regulations - Calls Announcements - Selection process - Workshop for Learning Agreements preparation - Documents and procedure (prior, in between, after) mobility prof. Tomaž Marš, MD, PhD slide /16 10 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA DRAFT FACULTY OF MEDICINE OUTGOING STUDENTS Criteria for candidate selection: - year of study - average grade of study - interview with teaching commission - student tutor - language knowledge prof. Tomaž Marš, MD, PhD slide /16 11 Introduction to International office and Erasmus program Welcome Address UNIVERSITY OF LJUBLJANA FACULTY OF MEDICINE DRAFT INCOMING STUDENTS -Informations -Rules and regulations -Application procedure -Learning Agreements and Study preparation -Welcome day -Documents and procedure (prior, inbetween, after) mobility http://www.mf.uni-lj.si/vsebina/menu1/2410 prof. Tomaž Marš, MD, PhD slide /16 12 Introduction to International office and Erasmus program Welcome Address DRAFT prof. Tomaž Marš, MD, PhD slide /16 13 Introduction to International office and Erasmus program Welcome Address SCHEDULE FOR LECTURES/SEMINARS/CR OF 3RD, 4TH AND 5TH YEAR SUBJECTS* LECTURES, SEMINARS, CLINICAL ROTATIONS 2016/2017 national Individual week date IV. year subjects V. year subjects holidays subjects Fundamentals of DRAFT Investigative 26.9.-30.9. Methods (Radiology) 1. 3.10.-7.10. MAXILOFACIAL SURGERY with 2. 10.10.-14.10. FUNDAMENTALS OF DENTAL MEDICINE 3. 17.10.-21.10. NERVOUS SYSTEM 4. 24.10.-28.10. OPHTHALMOLOGY 5. 31.10.-4.11. 31.10.&1.11. 6. 7.11.-11.11. Pathology EXAMINATION 7. 14.11.-18.11. Pathophysiology 8. 21.11.-25.11. Pharmacology ORL MENTAL HEALTH 9. 28.11.-2.12. Anaesthesiology 10. 5.12.-9.12. Methods and 11. 12.12.-16.12. Tools in Public EXAMINATION EXAMINATION Health (WHOLE 12. 19.12.-23.12. EXAMINATION URINARY TRACT YEAR COURSES) 13. 26.12.-30.12. 25.12.&26.12., 1.1. Christmas & NY holidays Christmas & NY holidays SUBJECT SCHEDULE 3RD, 14. 2.1.-6.1. URINARY TRACT 15. 9.1.-13.1. 16. 16.1.-20.1. 4TH AND 5TH YEAR MUSKELOSKELETAL SYSTEM GYNEACOLOGY&OBSTETRICS 17. 23.1.-27.1. 18. 30.1.-3.2. 19. 6.2.-10.2. 8.2. EXAMINATION EXAMINATION EMC 20. 13.2.-17.2. E 21. 20.2.-24.2. N GASTROINTESTINAL TRACT 1 SES SES, 2 ICI 22. 27.2.-3.3. SKIN AND VENEREAL ICS ISEA ICS ISEA D ED 23. 6.3.-10.3. DISEASES TR d TR an OR d M E D IA LIC an IA 24. 13.3.-17.3. N SIC ED U O ED B A 25. 20.3.-24.3. EXAMINATION P M EN P ETA R 26. 27.3.-31.3. IM Pathology M FO 27. 3.4.-7.4. MON Pathophysiology EXAMINATION INFECTIOUS DISEASES 28. 10.4.-14.4. Pharmacology CANCER AND BLOOD 29. 17.4.-21.4. Anaesthesiology DISEASES 30. 24.4.-28.4. 27.4. Methods and 31. 1.5.-5.5. 1. & 2.5. Tools in Public 32. 8.5.-12.5. Health (WHOLE 33. 15.5.-19.5. YEAR COURSES) INFECTIOUS DISEASES CI R CU L A T O R Y S Y S T E M 34. 22.5.-26.5. CANCER AND BLOOD 35. 29.5.-2.6. DISEASES 36. 5.6.-9.6. RESPIRATORY SYSTEM 37. 12.6.-16.6. EXAMINATION 38. 19.6.-23.6. EXAMINATION * This is a draft schedule and we reserve the right to eventual changes. prof. Tomaž Marš, MD, PhD slide /16 14 Introduction to International office and Erasmus program Welcome Address Proposal for programme for CLINICAL ROTATIONS**** IN SURGERY, INTERNAL MEDICINE, PEDIATRICS AND PRIMARY HEALTH CARE (FAMILY MEDICINE) 6th YEAR CLINICAL ROTATIONS 6th YEAR (2016/2017) INTERNAL PRIMARY HEALTH GYNECOLOGY & week date SURGERY *** PEDIATRICS MEDICINE * CARE ** OBSTETRICS August 1.8.-5.8. 8.8.-12.8. 16.8.-19.8. 22.8.-26.8. PAEDIATRICS CR DRAFT September 29.8.-2.9. 5.9.-9.9. GYNECOLOGY 12.9.-16.9. AND OBSTETRICS CR 19.-23.9. 26.-30.9. 1. 3.10.-7.10. 2. 10.10.-14.10. 3. 17.10.-21.10. 4. 24.10.-28.10. 1st group clinical practices 5. 31.10.-4.11. 6. 7.11.-11.11. 7. 14.11.-18.11. CR (different subfields) 8. 21.11.-25.11. 9. 28.11.-2.12. 10. 5.12.-9.12. 11. 12.12.-16.12. PRIMARY HEALTH CARE 12. 19.12.-23.12. 2nd group clinical rotations 13. 26.12.-30.12. 14. 2.1.-6.1. Holidays 15. 9.1.-13.1. VI. Year 16. 16.1.-20.1. CR (different subfields) PRIMARY HEALTH CARE GYNECOLOGY 5th year course 17. 23.1.-27.1. 18. 30.1.-3.2. Clinical Rotations 19. 6.2.-10.2. 20. 13.2.-17.2. 21. 20.2.-24.2. PEDIATRICS I (5th year 22. 27.2.-3.3. course) and 23. 6.3.-10.3. PEDIATRICS II (6th year 24. 13.3.-17.3. 3rd group clinical rotations course with CR) 25. 20.3.-24.3. CR (different subfields) 26. 27.3.-31.3. 27. 3.4.-7.4. 28. 10.4.-14.4. 29. 17.4.-21.4. 30. 24.4.-28.4. 31. 1.5.-5.5. holidays 32. 8.5.-12.5. 33. 15.5.-19.5. 4th group clinical rotations CR (different subfields) 34. 22.5.-26.5. 35. 29.5.-2.6. 36. 5.6.-9.6. 37. 12.6.-16.6. 38. 19.6.-23.6. * Students are required to take maximum three departments/rotation (minimal period in each department is 2 weeks; Places per week for the following number of Erasmus+ students: General Surg. (1 student), Oncologic Surg. (2 students), Thoracic Surg. (1 student), Urology (2 students), Abdominal Surg. (2 students), Cardiovascular Surg. (2 students), Plastic Surg. (2 students), Neurosurgery (2 students), Traumatology (2 students) ** Students will be placed to nominated mentors outside Ljubljana, practice hours are variable, everyday presence is required, sufficient knowledge of Internal Medicine and practical skills is required *** Students can choose max. three departments/rotation (minimal period in each department is 2 weeks) **** Clinical rotations are available only for those students, who have already completed the theoretical part of the subject and passed the exam (that should be evident from the Transcript of Records). prof. Tomaž Marš, MD, PhD slide /16 15 Introduction to International office and Erasmus program Welcome Address DRAFT prof. Tomaž Marš, MD, PhD slide /16 16 HEPMP Ljubljana Education DRAFT Lecture series 2 Education 2.1 What graduate students learn about pain medicine 2.2 What residents learn about pain medicine 2.3 Pain medicine education for family medicine practitioners 2.4 Pain medicine education for healthcare providers Lectures 2.1 - 2.3 page 107 - 196 HEPMP Ljubljana - Day 1 Education DRAFT Lecture 2.1 What do graduate students learn about pain medicine at the Faculty of Medicine Ljubljana Blaž M. Geršak, MD Resident, Anaesthesiology, reanimatology and perioperative intensive care medicine Lecture 2.1 page 108 - 127 What graduate students learn about pain medicine Education Study years DRAFT PRE-CLINICAL 4 SUBJECTS 1 3 CLINICAL 2 SUBJECTS 5 6 Blaž M. Geršak, MD slide /19 1 What graduate students learn about pain medicine Education Biophysics DRAFT Anatomy 1 Cell Biology Introduction to Study year 1 Medicine Concepts in Biochemistry Communication Emergency Medical Care 1 Blaž M. Geršak, MD slide /19 2 What graduate students learn about pain medicine Education Anatomy 1 - peripheral nerves DRAFT Blaž M. Geršak, MD slide /19 3 What graduate students learn about pain medicine Education Biophysics - nerve transmission DRAFT Blaž M. Geršak, MD slide /19 4 What graduate students learn about pain medicine Education Introduction to Medicine - history of medicine DRAFT development of 19th century medicine therapeutic “boom” (morphine, caffeine, atropine, …) advances in surgery + anaesthesia (systemic, local) Blaž M. Geršak, MD slide /19 5 What graduate students learn about pain medicine Education Medical Biochemistry and DRAFT Anatomy 2 Molecular Genetics Physiology Basics of Study year 2 Biostatistics Histology and Embryology Contact with the Patient Health and Environment Blaž M. Geršak, MD slide /19 6 What graduate students learn about pain medicine Education Anatomy 2 - central/peripheral nervous system DRAFT Blaž M. Geršak, MD slide /19 7 What graduate students learn about pain medicine Education Physiology - somatosensory system DRAFT Blaž M. Geršak, MD slide /19 8 What graduate students learn about pain medicine Education Physiology - somatosensory system DRAFT Blaž M. Geršak, MD slide /19 9 What graduate students learn about pain medicine Education Histology and Embryology: nervous system receptors DRAFT Blaž M. Geršak, MD slide /19 10 What graduate students learn about pain medicine Education General Pharmacology Special Pharmacology and Toxicology and Toxicology DRAFT Investigative Study year 3 Methods Propaedeutics Methods of Emergency Public Health Medical Care 2 Basic Microbiology and Pathophysiology Immunology Pathology Blaž M. Geršak, MD slide /19 11 What graduate students learn about pain medicine Education Special Pharmacology and T ecial Pharmacology o and T xicology o : analgesic drugs, control of pain DRAFT Blaž M. Geršak, MD slide /19 12 What graduate students learn about pain medicine Education Special Pharmacology and Toxicology: analgesic drugs, control of pain DRAFT Blaž M. Geršak, MD slide /19 13 What graduate students learn about pain medicine Education Pathophysiology - pain sensing theories, nervous system modulation, TENS, DRAFT action potential freq. and thresholds, TENS, … Blaž M. Geršak, MD slide /19 14 What graduate students learn about pain medicine Education Pathophysiology - pain sensing theories, nervous system modulation, TENS, DRAFT action potential freq. and thresholds, … Blaž M. Geršak, MD slide /19 15 What graduate students learn about pain medicine Education DRAFT CLINICAL SUBJECTS Study years 4 - 6 Blaž M. Geršak, MD slide /19 16 What graduate students learn about pain medicine Education Study years 4 - 6: Oncology DRAFT Blaž M. Geršak, MD slide /19 17 What graduate students learn about pain medicine Education Study years 4 - 6: Gynaecology and obstetrics DRAFT Blaž M. Geršak, MD slide /19 18 What graduate students learn about pain medicine Education Study years 4 - 6: DRAFT Internal medicine, Surgery, Family medicine, … P + elective subject: “Pain” AIN MANA GEMENT Blaž M. Geršak, MD slide /19 19 HEPMP Ljubljana - Day 1 Education Lecture 2.2 DRAFT What do residents learn about pain medicine: Curriculum of the anesthesiology, reanimatology and intensive care medicine residency in Slovenia prof. Vesna Novak Jankovič, MD, PhD Head, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 2.2 page 128 - 174 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 1 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 2 What residents learn about pain medicine Education Duration and structure – old vs new Domain Old New DRAFT (months) (months) General and regional anaesthesia 14 11,5 Special anaesthesia 15 15,5 ICU 24 23,5 Respiratory therapy 2 1 Pain management (acute ,chronic) 3 2 Reanimatology and emergency medicine 2 2 Selected programme 2 5 Simulation centre - 1 Courses - 1,5 = 62 = 63 + study time - 2 + holidays 10 7 Skupaj 72 72 prof. Vesna Novak Jankovič, MD, PhD slide /46 3 What residents learn about pain medicine Education Curriculum - new vs old Domain Duration Number of cases DRAFT (old) (old) Introduction and preoperative evaluation 1 month 20 (1) (50-10) Abdominal surgery 2 months 100 anesthesias (300) (3) 20 emergency(50), 20 laparoscopic (10), 20 epidural blocks (0) Gynecology 0,5 month 20 anesthesias (100) (1) 10 emergency operations (10) Ortopedic surgrgery 1 month 50 anesthesias (100) (1) 10 Special operations (10) Day case surgery 2 months 150 anesthesas (150) (2) 20 inhalat. (50), 130 i.v. (50), 0 (50 regional) prof. Vesna Novak Jankovič, MD, PhD slide /46 4 What residents learn about pain medicine Education General anaesthesia - curriculum DRAFT Traumatology 2 months 100 anesthesias (200) (2) 20 emergency (50), 10 shock(20), 20 peripheral nerve blocks (0) Urology 1 month 60 anesthesiasj (75) (2) 30 TUR (25), 5 mayor surgery (5) Plastic surgery 1 month 30 operations (30) (1) 2 free flap (0) CPR and emergency 1 month 10 CPR (10) (1) 15 emergency(25) Skupaj: 11,5 months (14) prof. Vesna Novak Jankovič, MD, PhD slide /46 5 What residents learn about pain medicine Education Special anaesthesia Special domain duration number of procedures DRAFT Cardiovascular surgery 2 months 50 anaesthesias(50) (1) 20 ECC (20) Maksilofacial and oral surgery, 1 month 45 anesthesias(45) stomatology (1) 5 anesthesias(5) Neurosurgery 2 month 40 anesthesias (30) (2) 20 intracranial (20), 4 beach chair position (4) Ophtalmology 1 month 45 anesthesias (45) (1) ORL 2 month 130 anesthesias(130) (2) Pediatric surgery 2 month 70 anesthesias (70) (2) 10 newborn 1<1y (10) Major Plasic surgery and burns 0,5 month 10 anestezij (30) (1) 5 major burns (5) prof. Vesna Novak Jankovič, MD, PhD slide /46 6 What residents learn about pain medicine Education Special domain DRAFT Obstetric 2 months 25 anestezij – 15 regional (25), (1) 5 CPR new borns (10), 25 epidural, 25 iv. (25 analgesias, 15 regional.) Radiologic procedures 1 month 30 anestezij (30) (1) 5 catheterisations(5), 10 MRI (5), 10 CT scans (10), 5 emergency CT (5 + 5 bronhografij) Thoracic surgery 2 months 50 anaesthesias (50) (2) 20 lung surgery (20) During circulation 5 procedures(5) Organ transplantation (-) explantation 2-3 (=) Kidney implantation 2 (=) Heart and liver (=) Sum: 15,5 months (15) prof. Vesna Novak Jankovič, MD, PhD slide /46 7 What residents learn about pain medicine Education ICU Domain New Old DRAFT Surgical Intensive care unit A degree (III) 13 months 12 Cardiovascular surgery 2 m 0 Department for cardiovascular disease - 1 Internal intensive care unit A degree 3 m 2 Infectios diseases 2 m 2 Pulmonology - 2 ICU pediatric 0,5 m 1 ICU newborns - 1 Neurology 1 m 1 Endocrinology - 1 Dialysis - 1 23,5 m 24 prof. Vesna Novak Jankovič, MD, PhD slide /46 8 What residents learn about pain medicine Education Education modules DRAFT General anesthesia 1 1. modul Physic,Statistic Documentation Anaesthetic machines Anaesthetic systems Monitoring Preoperative evaluation 2. modul General anaesthesia 2 Mechanism of action of anaesthetics Intravenous (TIVA, TCI) and,inhalational anaesthesia Pharmacology Neurophysiology (BIS, INVOS…) Physiology of neuromuscular junction-muscle relaksants prof. Vesna Novak Jankovič, MD, PhD slide /46 9 What residents learn about pain medicine Education 3. modul General anaesthesia 3 DRAFT Gynecology and obstetrics (epidural and iv analgesia, eclampsy…) Abdominal surgery ,major, liver…) Urology Traumatology Orthopaedic surgery Day case surgery 4. modul Regional anaesthesia Pharmacology of local anaesthetics Central nerve blocks Peripheral nerve blocks Ultrasound guided regional anaesthesia Cadaver workshop prof. Vesna Novak Jankovič, MD, PhD slide /46 10 What residents learn about pain medicine Education 5. modul Special anaesthesia 1 DRAFT Cardiovascular surgery (pharmacology of inotrope and vasoactive drugs, US - TEE, ECMO, 0n-pump,off-pump…) Thoracic(bronchoscopy, drainage, VATS..) Transplantation Anaesthesia (TAVI, radiophreqency ablation,catheterisation, 6. modul Special anaesthesia 2 ORL Maxilofacial surgery and stomatology Neurosurgery Neuroradiologic procedures Ophtalmology prof. Vesna Novak Jankovič, MD, PhD slide /46 11 What residents learn about pain medicine Education 7. modul Specialna anaesthesia 3 DRAFT Pediatric surgery Procedural sedation Recovery Difficult airway management 8. modul Intensive medicine 1 Haemodynamic management (LiDCO, PiCCO, VIGILEO…) Fluids Drugs Shock Coagulation- ROTEM, Multiplate… Blood, blood products prof. Vesna Novak Jankovič, MD, PhD slide /46 12 What residents learn about pain medicine Education 9. modul Intensive medicine 2 DRAFT Respiratory phisiology and pathophisiology Acidobase state Respiratory failure Mechanical ventilation Coma Head injuries Politrauma 10. modul Intensive medicine 3 Enteral nutrition Parenteral nutrition Electrolyte disturbances Acute renal failure Sepsis, pancreatitis, acute abdomen… prof. Vesna Novak Jankovič, MD, PhD slide /46 13 What residents learn about pain medicine Education DRAFT 11. modul BLS, ALS, ATLS.PLS 12. modul Pain management Pathophisiology of pain Pharmacology Acute pain management Chronic pain management Acupuncture, TENS…. prof. Vesna Novak Jankovič, MD, PhD slide /46 14 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 15 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 16 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 17 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 18 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 19 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 20 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 21 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 22 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 23 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 24 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 25 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 26 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 27 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 28 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 29 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 30 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 31 What residents learn about pain medicine Education Delavnica epiduralna anestezija DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 32 What residents learn about pain medicine Education Delavnica epiduralna anestezija DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 33 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 34 What residents learn about pain medicine Education Debriefing DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 35 What residents learn about pain medicine Education DRAFT 1st Module basic sciences 02.02.2018 prof. Vesna Novak Jankovič, MD, PhD slide /46 36 What residents learn about pain medicine Education Institute of anatomy MF Maribor DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 37 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 38 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 39 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 40 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 41 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 42 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 43 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 44 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 45 What residents learn about pain medicine Education DRAFT prof. Vesna Novak Jankovič, MD, PhD slide /46 46 HEPMP Ljubljana - Day 1 Education DRAFT Lecture 2.3 Education on pain medicine for family medicine practitioners assoc. prof. Aleksander Stepanović, MD, PhD Specialist, Family Medicine Lecture 2.3 page 175 - 196 Pain medicine education for family medicine practitioners Education Slovenia in numbers DRAFT • Area: 20.273 km2 • Population: 2.065.895 • GDP: 21.304 $ per capita (2016) • Approx. 950 family medicine practices assoc. prof. Aleksander Stepanović, MD, PhD slide /21 1 Pain medicine education for family medicine practitioners Education Are we any good? DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 2 Pain medicine education for family medicine practitioners Education Are we any good? DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 3 Pain medicine education for family medicine practitioners Education Provision of primary health care services DRAFT ! jurisdiction of municipalities, which are: ! responsible for health policy development at local level ! owners of community-level primary health care centres. ! 65 health care centres, delivering primary health care through 459 locations assoc. prof. Aleksander Stepanović, MD, PhD slide /21 4 Pain medicine education for family medicine practitioners Education Provision of primary health care services DRAFT ! 76% of all physicians and 42% of dentists working in primary care are based in publicly owned primary health care centres ! primary care is also provided by contracted, office-based physicians in private practice, including GPs, paediatricians and gynaecologists assoc. prof. Aleksander Stepanović, MD, PhD slide /21 5 Pain medicine education for family medicine practitioners Education DRAFT Remuneration ! combined system of capitation and fee-for-service payments ! financial incentives to reduce the number of referrals and provide preventive services ! health workers working in publicly owned health centres are salaried public servants assoc. prof. Aleksander Stepanović, MD, PhD slide /21 6 Pain medicine education for family medicine practitioners Education Primary health care versus other health services DRAFT ! Slovenia operates a gatekeeper system: patients need a referral from their personal physician to be treated by a clinical specialist. ! aim to strengthen the public health role of primary health care centres. Several interventions have been carried out through primary care: ! early detection of cardiovascular risk factors ! establishment of health-promoting centres in primary health care centres. assoc. prof. Aleksander Stepanović, MD, PhD slide /21 7 Pain medicine education for family medicine practitioners Education The Core Competencies of a Family Doctor in Slovenia DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 8 Pain medicine education for family medicine practitioners Education Curriculum of the family medicine DRAFT residency in Slovenia • Duration: 4 years (48 months) • Ambulatory – modular work, lasting 24 months, divided in two parts • introduction in family medicine, lasting 2 to 6 months • study of family medicine, lasting 18 to 22 months • Clinical rotation – working in specialist outpatient clinics and hospital departments, lasting 24 months assoc. prof. Aleksander Stepanović, MD, PhD slide /21 9 Pain medicine education for family medicine practitioners Education The modular part consists of the following topics in the modules: DRAFT ! Introduction into specialisation ! Physical and rehabilitation medicine ! Principles of family medicine ! Communication in special situations ! Family in health and illness ! Prescribing medicines ! Basics of communication ! Prehospital emergency medical help ! Health system ! Home visits and home care ! Organisation of the practice ! Dying patient and palliative treatment ! Quality Assurance ! Teamwork ! Ethics, professionalism and health ! Changing your lifestyle legislation ! Medical unexplained conditions in the ! Evidence-based medicine and an family medicine dispensary introduction to scientific research ! Collaboration with clinical specialists ! Preventive ! Family medicine in the community ! Health care for the elderly ! Medical anthropology and humanism ! Healthcare workers ! Management of patients with chronic ! Health care in the pre-school and school disease period ! Co-morbidity ! Diseases of addiction assoc. prof. Aleksander Stepanović, MD, PhD slide /21 10 Pain medicine education for family medicine practitioners Education Ambulatory work DRAFT ! Resident regularly follows at least 50 patients: ! 10 patients with arterial hypertension, ! 5 patients with diabetes, ! 5 patients with pain in the spine or joints - arthrosis, ! 5 patients with neurosis, depression, dementia or psychosis, ! 3 patients with cancer, ! 3 with addiction or harmful use of psychotropic substances, ! 3 patients with other chronic diseases ! 1 or 2 patients who are mainly treated at home. assoc. prof. Aleksander Stepanović, MD, PhD slide /21 11 Pain medicine education for family medicine practitioners Education DRAFT Clinical rotation – obligatory part 20 months ! INTERNAL MEDICINE 5-7 m ! NEUROLOGY 1-2 m ! INFECTOLOGY 1-2 m ! DERMATOLOGY 1-2 m ! SURGERY 2-4 m ! ORTHOPEDICS 1-2 m ! PEDIATRICS 3-4 m ! OPHTALMOLOGY 1-2 m ! GYNECOLOGY 2-3 m ! ORL 1-2 m ! PSYCHIATRY 2-3 m ! ONCOLOGY 1-2 m assoc. prof. Aleksander Stepanović, MD, PhD slide /21 12 Pain medicine education for family medicine practitioners Education DRAFT Clinical rotation – optional part 4 months ! PHYSIATRY 1-2 m ! CLINICAL PSYCHOLOGY 1-2 m ! UROLOGY 1-2 m ! GERIATRICS 1-2 m ! EMEGRENCY MEDICINE 1-2 m ! RADIOLOGY 1-2 m assoc. prof. Aleksander Stepanović, MD, PhD slide /21 13 Pain medicine education for family medicine practitioners Education Medical Chamber of Slovenia Licence to work as a specialist of family medicine DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 14 Pain medicine education for family medicine practitioners Education Medical Chamber of Slovenia Licence to work as a specialist of family medicine DRAFT Prolongation of licence: collect credit points (professional achievements as proof of professional competence). fulfill the condition that a medical service is performed in the professional field for which the licence has been granted assoc. prof. Aleksander Stepanović, MD, PhD slide /21 15 Pain medicine education for family medicine practitioners Education SLOVENIAN MEDICAL ASSOCIATION DRAFT - SLOVENIAN FAMILY MEDICINE SOCIETY Meetings Workshops Web site Literature assoc. prof. Aleksander Stepanović, MD, PhD slide /21 16 Pain medicine education for family medicine practitioners Education DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 17 Pain medicine education for family medicine practitioners Education Online professional education DRAFT 27 different topics: Measuring, evaluating and classifying pain Spondyloarthritis Rheumatoid arthritis …. assoc. prof. Aleksander Stepanović, MD, PhD slide /21 18 Pain medicine education for family medicine practitioners Education Professional meetings DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 19 Pain medicine education for family medicine practitioners Education DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 20 Pain medicine education for family medicine practitioners Education Literature Collaboration with Slovenian society of pain medicine DRAFT assoc. prof. Aleksander Stepanović, MD, PhD slide /21 21 HEPMP Ljubljana Office of Outpatient Pain Management Lecture series 3 DRAFT Office of Outpatient Pain Management 3.1 Establishment of Office of Outpatient Pain Management 3.2 Multidisciplinary approach to chronic pain management 3.3 The role of Slovenian Society of Pain Medicine joined lectures 2.4 Pain medicine education for healthcare providers Lectures 3.1 - 3.3 & 2.4 page 197 - 269 HEPMP Ljubljana - Day 2 Office of Outpatient Pain Management Lecture 3.1 DRAFT The establishment of Office of Outpatient Pain Management as a part of the Clinical Department of Anesthesiology and Surgical Intensive Therapy at University Medical Center Ljubljana prim. Gorazd Požlep, MD Office of Outpatient Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana President, Slovenian Society of Pain Medicine Lecture 3.1 page 198 - 213 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT Začetki pro�bolečinske ambulante v UKC Ljubljana prim. Gorazd Požlep, MD slide /15 1 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT 40 let ATB • 6 marec 1978 – 6 marec 2018!!! prim. Gorazd Požlep, MD slide /15 2 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 3 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 4 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 5 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 6 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 7 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 8 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT 1998 APS prim. Gorazd Požlep, MD slide /15 9 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 10 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT • Do 2005, 1 do 2 specialist • 3 sestre • 1 administrator • AKP, blokade, konzilijarna služba, … prim. Gorazd Požlep, MD slide /15 11 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT 2013 • Nova lokacija – BPD • Od 2016 samo BPD (blokade) • 4 specialist, 1 – 3 specializan� • 1 – 2 administrator • 4 – 7 MS, DMS, VMS prim. Gorazd Požlep, MD slide /15 12 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 13 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /15 14 Establishment: Office of Outpatient Pain Mgmt Office of Outpatient Pain Management Cilji do 2020 DRAFT • 6 do 8 specialistov anesteziologov + specializan� • 10 – 15 MS, VMS, DMS • 2 administratorja • Psiholog 1 – 2 • psihiater 1 – 2 • Fiziater 1 • Fth ? prim. Gorazd Požlep, MD slide /15 15 HEPMP Ljubljana - Day 2 Office of Outpatient Pain Management Lecture 3.2 DRAFT Multidisciplinary approach to chronic pain management prim. Gorazd Požlep, MD Office of Outpatient Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana President, Slovenian Society of Pain Medicine Lecture 3.2 page 214 - 248 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Why do we need a DRAFT pain clinic? (multidisciplinary, interdisciplinary, transprofessional) prim. Gorazd Požlep, MD slide /34 1 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Introduction DRAFT • Chronic pain is • Great impact on the most common life, causes many cause for a limitations doctor's visit • Personal • It is one of the • Professional most common • Academic causes of the sick stock • Social • Familiar prim. Gorazd Požlep, MD slide /34 2 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Main pain syndromes in our pain clinic DRAFT 5% 10% 25 50 92 12% 54 19% postzosterična glavoboli lumbalgija cervikobrah. 14% 68 crps ostalo bolečina v udu 116 24% 77 N= 482 15% prim. Gorazd Požlep, MD slide /34 3 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management DRAFT • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage “Pain is what the patient says it is and exists when the patient says so.” The person who comes to the outpatient clinic because of the pain has a problem! prim. Gorazd Požlep, MD slide /34 4 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Acute pain DRAFT • Acute pain is a system that allows us to detect potentially harmful and harmful stimuli • It represents a defense mechanism, without which we would have a significantly lower chance of survival • It takes a limited time, it responds well to treatment • It's useful! prim. Gorazd Požlep, MD slide /34 5 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Relationship between acute and DRAFT chronic pain ACUTE CHRONIC prim. Gorazd Požlep, MD slide /34 6 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Acute and chronic pain DRAFT prim. Gorazd Požlep, MD slide /34 7 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Relationship between DRAFT acute and chronic pain Noksa Acute pain > 3 – 6 months Chronic pain It has a protective function Loses the protection function The cause is known Deteriorates the quality of life Are the mechanisms of AP and CP the same? prim. Gorazd Požlep, MD slide /34 8 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Chronic pain DRAFT It often remains when the trigger factor is no longer persistent (exceeding the time of healing) It is caused by: chronic pathological events in somatic structures or internal organs disturbance of the peripheral or central nervous system It is not a symptom of a disease, it is itself a disease (depression, anxiety, insomnia ...) prim. Gorazd Požlep, MD slide /34 9 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management DRAFT What is chronic pain? • We only have a time definition for CP!!! • CP includes many very different conditions, so we compare apples, oranges, …. • Many times in patients with CP, pain is not the main problem prim. Gorazd Požlep, MD slide /34 10 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Example of chronic pain DRAFT • Chronic • Chronic pain after generalised polytrauma musculoskeletal pain • Chronic tension headache • CP in a patient who has survived • Chronic cancer headache after injury prim. Gorazd Požlep, MD slide /34 11 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management The main causes for the transition DRAFT of acute to chronic pain • Genetic predisposition • Expecting chronic pain • Epigenetics - ? • Belief in pain • Strong, poorly treated • Low economic status acute pain • Lack of education • Great use of analgesics • Patient's attitude to pain (catastrophysing) Preventing chronic pain? prim. Gorazd Požlep, MD slide /34 12 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management C Chronic pain Pain behaviour H syndrome DRAFT R O Suffering N I ? Pain C A C Nociception U T Loeser pain E model prim. Gorazd Požlep, MD slide /34 13 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Pain perception - DRAFT a biological model • Nociceptors - free nerve • Nociceptive stimuli endings in peripheral tissues • Mechanical (punch) Thermal (hot, cold) • They only respond to Chemical (internal, very strong, potentially external) harmful stimuli • Electricity (artificial • A delta and C fiber stimulus) prim. Gorazd Požlep, MD slide /34 14 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Pain = injury DRAFT Pain is a direct consequence of injury, stimuli are transmitted through "hollow tubes" to the brain, where pain occurs prim. Gorazd Požlep, MD slide /34 15 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management DRAFT • The traditional model assumes that symptoms ALWAYS have an organic cause, but they try to eliminate it, and when this is not possible, they would want to interrupt or block the pain pathways pharmacologically or even surgically. prim. Gorazd Požlep, MD slide /34 16 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Components of pain sensation DRAFT • Stimulation of pain receptors is not enough to cause pain • The stimuli must be sufficiently strong (overhanging) • Many mechanisms can block or reinforce these stimuli • Basically, nociception involves two components: Sensory discriminative and Affective motivational prim. Gorazd Požlep, MD slide /34 17 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Components of pain sensation DRAFT Sensory discriminative Affective motivational • Rarely appears alone, • Is probably older and more isolated primitive • Example: a person in a • It represents an emotional laboratory, only a verbal response to the occurrence response to pain of pain • The person does not suffer, because the conditions are under control (he can stop the pain) • Strength, location, features Treating chronic pain must address both components ! prim. Gorazd Požlep, MD slide /34 18 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Specialists involved in the DRAFT treatment of chronic pain • Family medicine • Algology • Physiatrist • Psychiatrist • Internal medicine • Psychologist • Surgeon • Emergency medicine, • Radiologist • ... • Neurologist prim. Gorazd Požlep, MD slide /34 19 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Patient’s “journey” DRAFT • Family medicine • Anaesthesiologist • Physiatrist (Algologist) • Int. med. • Psychiatrist • Surgeon • Psychologist • X ray • Emergency medicine • Neurologist • … How long? prim. Gorazd Požlep, MD slide /34 20 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management PAIN PERCEPTION: Biopsychosocial model DRAFT CHRONIC PAIN IS A BIOPSYCHOSOCIAL PHENOMENON!!! A biopsy-social (BPS) view of CP is now a widely accepted model for understanding and treating chronic pain, replacing the old biomedical reductionistic model BPS model looks at CP as a complex, dynamic interaction between biological, psychological and social factors that maintain or even exacerbate CP prim. Gorazd Požlep, MD slide /34 21 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Factors that can affect pain experience DRAFT Psychological factors Socioeconomic factors • Mood • Family • Beliefs • Work • Spirituality • Cultural environment • Religion • Anxiety and fear prim. Gorazd Požlep, MD slide /34 22 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management DRAFT What is a pain clinic and why we need it? • The pain clinic offers an interdisciplinary approach to the patient!!! prim. Gorazd Požlep, MD slide /34 23 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Interdisciplinary approach to CP DRAFT • Simultaneous treatment of a patient by a team of various experts (med. and nonmedical) • Faster and better treatment • Shorter hospital stay • Cheaper treatment - ??? • In any case, many patients are more satisfied with the treatment, as the treatment objectives are more realistic prim. Gorazd Požlep, MD slide /34 24 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management The pain team DRAFT • Opinions on the composition of such a team are not completely uniform; according to the prevailing biopsychosocial model of chronic pain, it is imperative that the team exceeds the involvement of only one profile - like medical doctors. Experts from other profiles must also be involved such as a psychologist, social worker, work therapist ... • Only the team that will treat the patient and at the same time coordinate their activities and therapeutic goal, can offer the patient "something more" prim. Gorazd Požlep, MD slide /34 25 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Pain team DRAFT • Team members must co-ordinate and co- operate. • The therapeutic approach must be comprehensive, integrative and include different methods of treatment. • Treatment should not only focus on biological, but also psychological, social and professional factors, as they can greatly affect pain. prim. Gorazd Požlep, MD slide /34 26 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Operation of the team DRAFT • The patient is part of the team. We must be aware that the patient is the greatest "expert" for his pain. He needs to know this. This automatically increases the level of communication between the patient and the doctor, which is crucial for treatment. • In the "unilateral” communication where the doctor and patient are in different positions, often leads to frustration on both sides. prim. Gorazd Požlep, MD slide /34 27 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Operation of the team DRAFT • Continuity of therapy and maintenance of stability. • Most patients with chronic pain will need care in the long run. It is difficult to expect patients to be healed at some point - even after successful therapy. • The vast majority of patients will need additional care in the future. • Ensuring the availability of all (different) treatment methods that are foreseen, otherwise the system can not come to life in practice. prim. Gorazd Požlep, MD slide /34 28 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management DRAFT • We help the patient to stay functional - !!! prim. Gorazd Požlep, MD slide /34 29 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management ”Pain clinic “ in UKC Ljubljana DRAFT • 4 specialists anesthesiologists • Neurologist • Orthopedic surgeon • Psychologist • Psychiatrist • 5 to 8 nurses • 1 medical administrator prim. Gorazd Požlep, MD slide /34 30 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Goals of the treatment ? DRAFT Two main goals: reduce pain and disability improve function (physical, psychological and social) Improve the quality of life! prim. Gorazd Požlep, MD slide /34 31 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Criteria for the evaluation of the treatment DRAFT Gatchel JR, Okifuji A: Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain. The Journalof Pain Vol 7, No 11,2006 pp 779 – 793. prim. Gorazd Požlep, MD slide /34 32 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Take home message I DRAFT • Pain is a complex sensory and emotional experience. • Today a biopsychosocial model of chronic pain is widely accepted. • For resistant cases, we wil only be able to help patients with such an approach. • We all need an (interdisciplinary) pain treatment clinic (s) to relieve resistant cases of chronic pain. prim. Gorazd Požlep, MD slide /34 33 Multidisciplinary approach: chronic pain mgmt Office of Outpatient Pain Management Take home message II DRAFT • Effective interdisciplinary care for the patient is more than just the sum of efforts of individuals. • Team members must effectively combine different treatment strategies to achieve the same goal. • Despite extensive knowledge, we can never eliminate all of the chronic pain (relief) because it is much more than just biological events (lack of ability to influence the psychological and in particular, the social component of the pain). prim. Gorazd Požlep, MD slide /34 34 HEPMP Ljubljana - Day 2 Office of Outpatient Pain Management Lectures 3.3 and 2.4 The role of Slovenian Society of DRAFT Pain Medicine in the development of better pain management on all levels of healthcare The organization of education on pain medicine for healthcare providers in Slovenia: The role of Slovenian society of pain medicine prim. Gorazd Požlep, MD Office of Outpatient Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana President, Slovenian Society of Pain Medicine Lectures 3.3 and 2.4 page 249 - 269 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT 20 let SZZB Od ideje do danes prim. Gorazd Požlep, MD slide /20 1 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 2 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 3 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 4 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 5 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 6 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management 80 priznanih strokovnjakov iz DRAFTtujine Maribor, 2001 Maribor, 2005 Interdisciplinarna strokovna srečanja 454 domačih avtorjev Maribor, 2010 vseh medicinskih strok prim. Gorazd Požlep, MD slide /20 7 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 8 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT IASP programski odbor, Ptuj, 2000 prim. Gorazd Požlep, MD slide /20 9 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT Maribor, 1998 prim. Gorazd Požlep, MD slide /20 10 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFTMaribor,1999 prim. Gorazd Požlep, MD slide /20 11 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 12 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 13 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 14 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT 2001: Evropska deklaracijao kronični bolečini 2010:Akutnabolečina 2002: Ne trpite vtišini 2011: Glavobol 2003: Bolečina kot osnovna človekovapravica 2012: Visceralna bolečin 2004: Pravica do lajšanja bolečine 2013:Bolečina vustihinobrazu 2005: Bolečina pri otrocih 2014. Nevropatskabolečina 2006: Bolečina pri starostnikih 2015: Bolečina vsklepih 2007:Bolečina pri ženskah 2016: Bolečina po operaciji 2008: Bolečina zaradi raka 2017: Odličnost vedukaciji o bolečini 2009: Mišično-kostna bolečina prim. Gorazd Požlep, MD slide /20 15 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 16 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT Bled, 2006 prim. Gorazd Požlep, MD slide /20 17 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 18 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT prim. Gorazd Požlep, MD slide /20 19 The role of Slovenian Society of Pain Medicine Office of Outpatient Pain Management DRAFT Leta prihodnosti SZZB prim. Gorazd Požlep, MD slide /20 20 HEPMP Ljubljana Obstetric Analgesia DRAFT Lecture series 4 Obstetric Analgesia 4.1 Establishment of a modern obstetric anesthesia service 4.2 Multidisciplinary obstetric anaesthesia research projects 4.3 10-year experience with remifentanil labor analgesia Lectures 4.1 - 4.3 page 270 - 348 HEPMP Ljubljana - Day 3 Obstetric Analgesia Lecture 4.1 DRAFT The establishment of a modern obstetric anesthesia service at University Medical Center Ljubljana prof. Tatjana Stopar Pintarič, MD, PhD Office of Obstetric Anesthesia, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 4.1 page 271 - 304 Establishment of a modern obstetric anesthesia service Obstetric Analgesia History DRAFT 1660 „Mestni špital“ 1789 Maternity room and midwifery school 1879 „Frauenklinik“ 1923 First independent clinic for ob /gyn prof. Tatjana Stopar Pintarič, MD, PhD slide /33 1 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT Porodnišnica Ljubljana 1987 prof. Tatjana Stopar Pintarič, MD, PhD slide /33 2 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Department of Perinatology DRAFT prof. Tatjana Stopar Pintarič, MD, PhD slide /33 3 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Department of Perinatology DRAFT prof. Tatjana Stopar Pintarič, MD, PhD slide /33 4 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Department of Perinatology DRAFT prof. Tatjana Stopar Pintarič, MD, PhD slide /33 5 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT Porodnišnica Ljubljana prof. Tatjana Stopar Pintarič, MD, PhD slide /33 6 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Quality indicators in obstetrics DRAFT • Cesarean section rate (15% (2002) → 21,5% (2017) • Severe injuries - vaginal births (3rd, 4th degree lacerations) (0,3% (2002) → 0,7% (2014) • Severe loss of blood (>500 ml) 3% → 6% • Transfusion rate (1%) • Induction of labour (15% (2002) → 20% (2014) • Preterm births(9,6% (2002) → 11% (2014) • Neonatal mortality (2,5%) of total • Apgar ˂7 at 5 min (2,5% of total) prof. Tatjana Stopar Pintarič, MD, PhD slide /33 7 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Quality indicators in obstetrics DRAFT • Births without medical interventions (spontaneous onset, no augmentation, no episiotomy, no operative delivery) (2002) 23,4% (2013) 31,9% • Rate of episiotomy (2002) 50% (2013) 30% • Breastffeding prof. Tatjana Stopar Pintarič, MD, PhD slide /33 8 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Quality indicators in DRAFT obstetric anaesthesia • The incidence of postpuncture NO REGIONAL headache ANAESTHESIA IN OBSTETRICS • The rate of conversion from RA to GA during CS • Patient satisfaction NO QUALITY OF OBSTETRIC ANAESTHESIA SOAP, Boston 2016 prof. Tatjana Stopar Pintarič, MD, PhD slide /33 9 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Regional anaesthesia in obstetrics DRAFT (up to 2014) • Epidural rate (0,5%) • RA for SC (10%) • 24/7 analgesic service not provided • Staff shortage prof. Tatjana Stopar Pintarič, MD, PhD slide /33 10 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Regional anaesthesia in obstetrics (up to 2014) DRAFT • KOAIT (full 24/7 analgesic service) • 2 specialists + 2 nurses ± residents (8h) • 1 specialist + 1 resident + 2 nurses (16h) • Epidural rate (28%) • RA for SC (70%) • Remifentanil (26%) prof. Tatjana Stopar Pintarič, MD, PhD slide /33 11 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Opposition/critiques of RA DRAFT • EA affects the progress and outcome of labour • It takes too long to place the epidural catheter/spinal block • Spinal block drops the pressure and causes vomiting during CS These statements are true when RA is not provided as a routine clinical practice!!! prof. Tatjana Stopar Pintarič, MD, PhD slide /33 12 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT The prerequisite for a successful establishment of RA as state of the art prof. Tatjana Stopar Pintarič, MD, PhD slide /33 13 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT The practice of OB anaesthesia, more than any other subspecialty area within current anaesthesia practice, is rooted in RA techniques, primarily neuraxial blockade. Palmer CM: Obstetric anesthesia. Oxford University Press. 2011 prof. Tatjana Stopar Pintarič, MD, PhD slide /33 14 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT RA for SC prof. Tatjana Stopar Pintarič, MD, PhD slide /33 15 Establishment of a modern obstetric anesthesia service Obstetric Analgesia RA DRAFT and a neonate • ↓drug transfer • ↓early foetal respiratory depression • important for preterm neonates more susceptible to anaesthetics • in case of prolonged extraction times (high BMI, previous abdominal surgery, multiple pregnancies) prof. Tatjana Stopar Pintarič, MD, PhD slide /33 16 Establishment of a modern obstetric anesthesia service Obstetric Analgesia RA and a parturient DRAFT • Difficult intubation is the leading cause of maternal morbidity and mortality due to anaesthesia • The incidence is 1:250 • Anatomical and physiological characteristics of pregnancy prof. Tatjana Stopar Pintarič, MD, PhD slide /33 17 Establishment of a modern obstetric anesthesia service Obstetric Analgesia • Less intraoperative awareness DRAFT • Less uteral atony • 4x lower risk of transfusion • Better and longer postoperative pain relief • Faster postoperative recovery • Faster bonding between the mother and the baby • Additional DVT prophylaxis • Less chronic pain prof. Tatjana Stopar Pintarič, MD, PhD slide /33 18 Establishment of a modern obstetric anesthesia service Obstetric Analgesia RA and obstetrician and neonatologist DRAFT No time pressure Less interventions prof. Tatjana Stopar Pintarič, MD, PhD slide /33 19 Establishment of a modern obstetric anesthesia service Obstetric Analgesia RA and anaesthesiologist DRAFT Proactive vasoactive and fluid support prof. Tatjana Stopar Pintarič, MD, PhD slide /33 20 Establishment of a modern obstetric anesthesia service Obstetric Analgesia RA in preeclamptic patients Beneficial due to DRAFT - therapeutical reduction of blood pressure in spite of high level sympathetic block - Increased perfusion of placenta up to 70% - but danger of fluid overload due to ✓ increased vessel permeability ✓ reduced intravascular volume up to 40% ✓ diastolic disfunction - restrictive haemodynamic approach - fluid therapy!!!! Barash, Cullen, Stoelting. Clinical Anesthesia, 2nd Edn. Chapter 46 prof. Tatjana Stopar Pintarič, MD, PhD slide /33 21 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT Postoperative pain relief using RA techniques • Intrathecal morphine (0,1 mg) • Epidural morphine (2-4 mg) • PCEA LA+fentanil • TAP or QL blocks prof. Tatjana Stopar Pintarič, MD, PhD slide /33 22 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT TAP block prof. Tatjana Stopar Pintarič, MD, PhD slide /33 23 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT QL blocks prof. Tatjana Stopar Pintarič, MD, PhD slide /33 24 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT prof. Tatjana Stopar Pintarič, MD, PhD slide /33 25 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Neuraxial analgesia DRAFT • The most efficient analgesia technique and a • Therapy for dysfunctional labour prof. Tatjana Stopar Pintarič, MD, PhD slide /33 26 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT EA and labour outcome in Slovenia between 2003-13 prof. Tatjana Stopar Pintarič, MD, PhD slide /33 27 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT Obstetrical reasons for higher risk of vacuum extractions and longer labours • Primiparae • Induced labours • OP presentations prof. Tatjana Stopar Pintarič, MD, PhD slide /33 28 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Anaesthesiological reasons DRAFT for higher risk of vacuum extractions and longer labours • Higher concentrations/dosages of LA • Continuous infusions →higher incidence of a motor block and OP presentations • Combination of 0,1% bupivacaine + fentanil 2µg/ml (Bufend) • Combination of intermittent mandatory boluses + PCB without continuous infusion prof. Tatjana Stopar Pintarič, MD, PhD slide /33 29 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Protocols DRAFT Standard operative procedures (SOP) for - accidental dural puncture - perioperative management of preeclamptic parturient - usage of ROTEM for managing peripartal bleeding - anaesthesia for cesarean section - anaesthesia for minor obstetric procedures - managing labour pain with neuraxial techniques - managing labour pain with remifentanil - the role of anaesthesiologist during vaginal delivery of twins and a neonate in breech presentation Guidelines for managing obstetric haemorrhage prof. Tatjana Stopar Pintarič, MD, PhD slide /33 30 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Teaching DRAFT • Teaching institution for neuraxial blocks • US guided truncal blocks • Obstetric anaesthesia subspecialty topics • Contribution to Slovene Obstetric anaesthesia Association, SSRA; SSAiCM, Slovene School of RA • Organization of meetings „Advances in patient safety“ in collaboration with Mayo Clinic from Rochester prof. Tatjana Stopar Pintarič, MD, PhD slide /33 31 Establishment of a modern obstetric anesthesia service Obstetric Analgesia Tertiary funding DRAFT prof. Tatjana Stopar Pintarič, MD, PhD slide /33 32 Establishment of a modern obstetric anesthesia service Obstetric Analgesia DRAFT Conclusion • Modern obstetric anaesthesia is based on ✓24/7 regional anaesthesia and analgesia service ✓supported by institutional SOP and interdisciplinary guidelines ✓sufficient fundings for obtaining modern technology prof. Tatjana Stopar Pintarič, MD, PhD slide /33 33 HEPMP Ljubljana - Day 3 Obstetric Analgesia DRAFT Lecture 4.2 Multidisciplinary research projects in the fields of obstetrics and obstetric anesthesia assoc. prof. Miha Lučovnik, MD, PhD Specialist, Obstetrics and Gynaecology Lecture 4.2 page 305 - 319 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Medicine is becoming more and more sub-specialised DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 1 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Medicine is becoming more and more sub-specialised DRAFT Simulation team training in OB emergencies, Medical Simulation Center Ljubljana assoc. prof. Miha Lučovnik, MD, PhD slide /14 2 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Conducting multidisciplinary research DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 3 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Does epidural analgesia increase cesarean section/ operative vaginal delivery rates? DRAFT Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour. Cochrane Database Syst Rev. 2000. assoc. prof. Miha Lučovnik, MD, PhD slide /14 4 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Does one size answer fit all? DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 5 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Multidisciplinary Commitment to Quality Care DRAFT Classification of Information Pre Labour outcomes and events Labour Assessment of outcome Audit management Labour events Modification of management assoc. prof. Miha Lučovnik, MD, PhD slide /14 6 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia DRAFT National Perinatal Information System • Established in 1987 • Registration is mandatory by law • Registers all deliveries ≥ 500 g/ ≥ 22 wks in Slovenia • >140 variables are entered immediately postpartum assoc. prof. Miha Lučovnik, MD, PhD slide /14 7 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia National Perinatal Information System DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 8 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia National Perinatal Information System DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 9 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia Multidisciplinary Commitment to Quality Care DRAFT Classification of Information Pre Labour outcomes and events Labour Assessment of outcome Audit management Labour events Modification of management assoc. prof. Miha Lučovnik, MD, PhD slide /14 10 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia The Ten Group Classification System DRAFT Group 1 Nulliparous, single cephalic, ≥ 37 weeks, in spontaneous labour Group 2 Nulliparous, single cephalic, ≥ 37 weeks, induced or CS before labour Group 3 Multiparous (excluding prev. CS), single cephalic, ≥ 37 weeks, in spontaneous labour Group 4 Multiparous (excluding prev. CS), single cephalic, ≥ 37 weeks, induced or CS before labour Group 5 Previous CS, single cephalic, ≥ 37 weeks Group 6 All nulliparous breeches Group 7 All multiparous breeches (including prev. CS) Group 8 All multiple pregnancies (including prev. CS) Group 9 All abnormal lies (including prev. CS) Group 10 All single cephalic, ≤ 36 weeks (including prev. CS) Robson M et al. Methods of achieving and maintaining an appropriate caesarean section rate. Best practice & research Clinical obstetrics & gynaecology 2013 assoc. prof. Miha Lučovnik, MD, PhD slide /14 11 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia DRAFT assoc. prof. Miha Lučovnik, MD, PhD slide /14 12 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia DRAFT Summary In most TGCS groups women with epidural analgesia had lower cesarean delivery rates. Women in group 1 with epidural analgesia had higher cesarean delivery rate. In most TGCS groups women with epidural analgesia had higher vacuum delivery rates. assoc. prof. Miha Lučovnik, MD, PhD slide /14 13 Multidisciplinary obstetric anaesthesia research projects Obstetric Analgesia DRAFT Conclusions Embrace differences Communicate Learn from each other assoc. prof. Miha Lučovnik, MD, PhD slide /14 14 HEPMP Ljubljana - Day 3 Obstetric Analgesia Lecture 4.3 DRAFT The 10-year experience with remifentanil usage for labor analgesia at University Medical Center Ljubljana Iva Blajić, MD Specialist, Anaesthesiology, reanimatology and perioperative intensive care medicine Lecture 4.3 page 320 - 348 10-year experience with remifentanil labor analgesia Obstetric Analgesia Neuraxial labor analgesia DRAFT • is most effective method of pain relief during labor • is not available in all obstetric units • Its use may be contraindicated • Parturient may prefer less invasive treatment • Alternative method of pain relief may be required Iva Blajić, MD slide /28 1 10-year experience with remifentanil labor analgesia Obstetric Analgesia Parenteral opioid-based analgesia DRAFT • Pethidine, fentanil, tramadol, alfentanil or sufentanil • Last two decades, remifentanil has been studied as either an alternative to neuraxial analgesia or as the preferred parenteral opioid to treat labor pain • Remifentanil is a potent opioid with pharmacological properties that potentially makes it an ideal parenteral analgesic for labor • Off-label use of remifentanil Iva Blajić, MD slide /28 2 10-year experience with remifentanil labor analgesia Obstetric Analgesia 10 recent years DRAFT LOW RATE OF EPIDURAL ANALGESIA (less than 1%) REMIFENTANIL was introduced as a response to the need for an effective alternative to epidural analgesia. 2011 2012 2013 2015 2017 Remifentanil 281 (4,4%) 450 (7%) 375 (6%) 758 (15%) 1210 (26%) Iva Blajić, MD slide /28 3 10-year experience with remifentanil labor analgesia Obstetric Analgesia Remifentanil - pharmacokinetics DRAFT • Selective mu opioid agonist with rapid onset and offset of action • Remifentanil has a quick onset of action in 1 minute, peak effect at 2 minutes and constant context-sensitive half life of 3 minutes • Due to ester linkage, remifentanil is subject to rapid metabolism by nonspecific blood and tissue esterase by both mother and foetus Iva Blajić, MD slide /28 4 10-year experience with remifentanil labor analgesia Obstetric Analgesia Remifentanil and pregnancy DRAFT • Plasma concentration in pregnancy is ½ of that in non-pregnancy due to a larger volume of distribution and higher clearance • Crosses the placenta rapidly but is rapidly metabolised in foetus • Large patient variability in pregnant individuals – be explained by heterogeneity in uterine contractions as labor progresses • The rapid onset and offset of remifentanil with effect-site concentration peaking at 1-2 min might be beneficial for labor analgesia, especially if timing of remifentanil peak effect can be matched to uterine contractions. Iva Blajić, MD slide /28 5 10-year experience with remifentanil labor analgesia Obstetric Analgesia DRAFT Fetal exposure • Uterine vein/Maternal artery ratio: 0.88 • Umbilical artery/umbilical vein ratio: 0.29 • redistribution, rapid fetal metabolism Iva Blajić, MD slide /28 6 10-year experience with remifentanil labor analgesia Obstetric Analgesia DRAFT Current practice • In Europe, remifentanil PCIA is increasingly used either as a primary mode of labor analgesia or as an alternative to neuraxial analgesia, when the later is contraindicated • This practice is not uniform over Europe • There are many different protocols, which have been investigated Iva Blajić, MD slide /28 7 10-year experience with remifentanil labor analgesia Obstetric Analgesia Van De Velde and Carvalho IJOA 2016; 15: 66-74 DRAFT Iva Blajić, MD slide /28 8 10-year experience with remifentanil labor analgesia Obstetric Analgesia Current practice DRAFT Literature Our practice • A bolus of 20–40 µg (0.25–0.5 • Bolus 10 –40 µg with µg/kg) is used most widely lockout of 2 min with a lockout of 1–5 min. • Background infusions are less • No background infusion frequently applied due to maternal side effects and safety concerns, but are occasionally used as they may improve analgesic efficacy. Iva Blajić, MD slide /28 9 10-year experience with remifentanil labor analgesia Obstetric Analgesia Analgesic efficacy DRAFT • remifentanil PCIA used in labor can reduce pain scores from the severe (e.g. 8 out of 10) to the moderate (e.g. 4 out of 10) range • provides better analgesia than nitrous oxide • provides better pain relief than other opioids, but only during the first two hours • Less effective compared to neuraxial analgesia Iva Blajić, MD slide /28 10 10-year experience with remifentanil labor analgesia Obstetric Analgesia Analgesic efficacy of remifentanil DRAFT • Remifentanil appears most effective during the first few hours of use, after which pain scores gradually return to baseline preanalgesia levels. • This is due to opioid-induced hyperalgesia, increase of pain as labor progresses and more difficulty timing peak remifentanil effect with regular and frequent contractions • Douma MR. BJA 2010 and Tveit TO. IJOA 2013 Iva Blajić, MD slide /28 11 10-year experience with remifentanil labor analgesia Obstetric Analgesia Analgesic efficacy of remifentanil DRAFT • Epidural analgesia is superior analgesic option with better pain scores • The effect size difference between remifentanil PCIA and epidural as measured by pain score (0-10 cm) 2 h after initiation is estimated to be 3.0 cm (95% CI 0,7to5,2) (Schnabel, Eur J Anaesth 2012) Iva Blajić, MD slide /28 12 10-year experience with remifentanil labor analgesia Obstetric Analgesia Satisfaction with pain relief - remifentanil DRAFT Our experience Literature • Primiparae with long • PCA with RF vs EA in labour: and painfull labour less randomised multicentre equivalence satisfied with RF. trail; (Freeman LM, BMJ 2015) • 1414 parturients • Multiparae with shorter • Epidural analgesia produced labours show similar significantly better labor analgesia satisfaction with RF as than remifentanil, but maternal compared to neuraxial satisfaction seemed unaffected indicating that many women were analgesia. satisfied with analgesia despite pain remaining relatively high. Iva Blajić, MD slide /28 13 10-year experience with remifentanil labor analgesia Obstetric Analgesia Remifentanil: standard operative procedure DRAFT • Indications: - medical contraindications for EA - refusal of EA • Patient selection: - ↑34 weeks of gestation - no fetal distress - no previous strong opiates • Patient preparation: - informed consent - i.v. access - nasal oxygen - monitoring (EKG, BP, pulse oximeter, capnography, CTG ) Iva Blajić, MD slide /28 14 10-year experience with remifentanil labor analgesia Obstetric Analgesia DRAFT Informed consent • The patient should be issued with, and have read the remifentanil PCA patient information leaflet and had the opportunity to ask questions. • The patient should be informed of the possible side-effects including drowsiness, itching, nausea, dizziness and respiratory depression • Every patient must sign inform consent before procedure Iva Blajić, MD slide /28 15 10-year experience with remifentanil labor analgesia Obstetric Analgesia Remifentanil: standard operative procedure DRAFT Preparation of the drug • Mix 2mg remifentanil with 50mls 0.9% sodium chloride • concentration 40 µg/ml • PCA bolus dose 10-40µg • bolus duration 20 sec • lockout interval 2 min • no continuous infusion Iva Blajić, MD slide /28 16 10-year experience with remifentanil labor analgesia Obstetric Analgesia Remifentanil: standard operative procedure DRAFT Patient observation • midwife 1:1 • vital signs (RR,SpO2, CTG) • end-tidal CO2 and apnea monitor • sedation scoring (Ramsey) • VAS scoring Iva Blajić, MD slide /28 17 10-year experience with remifentanil labor analgesia Obstetric Analgesia Maternal side effects - literature Reference Bolus (mcg/kg) Mean total dose Sedation Number of Apgar scores at Fetal heart rate DRAFT or infusion (mcg/ (mcg) respiratory 1 and 5 min changes kg/min) desaturation episodes Blair Bolus: 0.25–0.5 2241 9.5% (2/21) 23.8% (5/21) Median 8 and 9 9.5% (2/21) Volmanen Bolus: 0.2–0.8 NR 100% (17/17) 59% (10/17) Median 9 and 9 29% (5/17) mild sedation Douma Bolus: 0.7 1840 NR 74% (37/50) Mean 8.9 and 9.9 NR Infusion: 0.025 Shahriari Bolus: 0.35–0.7 NR 5% (1/20) 5% (1/20) ≥7 and ≥9 NR Thurlow Bolus: 0.3 NR NR 39% (7/18) NR NR Blair Bolus: 0.5 NR NR NR Median 8 and 9 7% (1/15) Volikas Bolus: 0.5 3670 NR NR Median 9 and 10 NR Douma Bolus: 0.5 2817 10% (1/10) 5% (1/20) NR NR Ismail Bolus: 0.1–0.9 NR 0 0 NR NR Tveit Bolus: 0.15 + 0.15 NR 65% (11/19) 65% (11/19) Median 9 and 9 10.5% (2/19) mcg/kg increments until relief Stourac Bolus: 0.24 NR NR NR NR 8.3% (1/12) Volmanen Bolus: 0.3–0.7 NR 29% (7/24) 54% (13/24) Median 9 54% (13/24) Marwah Bolus: 0.25 NR 2.3% (1/47) 14.9% (7/47) Median 9 and 9 NR Infusion: 0.025– 0.05 mcg/kg/min Iva Blajić, MD slide /28 18 10-year experience with remifentanil labor analgesia Obstetric Analgesia Stocki D et ali. A Randomized Controlled Trial of the Efficacy and Respiratory Effects of Patient-Controlled Intravenous Remifentanil Analgesia and Patient-Controlled Epidural Analgesia in Laboring Women. Anesthesia Analgesia 2014 DRAFT Iva Blajić, MD slide /28 19 10-year experience with remifentanil labor analgesia Obstetric Analgesia Maternal side effects - literature DRAFT • This figure presents an example of an etCO2 wave graph and saturation graph during an apnea event. • The apnea event lasted over 30 seconds without a decrease in SpO2. • The SpO2 does not alert the staff to a respiratory problem, whereas the respiratory rate monitoring would prompt a response (Stocki at all.2014) Iva Blajić, MD slide /28 20 10-year experience with remifentanil labor analgesia Obstetric Analgesia Side effects - our observations DRAFT • No major adverse effects (respiratory or cardiac arrest) were observed • Apnea without desaturation • Dizziness • Oversedation >3 according to Ramsey scoring • Reduced foetal heart rate variability Iva Blajić, MD slide /28 21 10-year experience with remifentanil labor analgesia Obstetric Analgesia Neonatal side effects DRAFT • Stourac et al. 2012 • No Apgar score differences at 1 and 5 min • Ismail and Hassanin 2012 were observed in any of the trials between PCA • Tveit et ali. 2012 with remifentanil and epidural analgesia. • Douma et ali. 2011 • Volmanen et ali. 2008 Iva Blajić, MD slide /28 22 10-year experience with remifentanil labor analgesia Obstetric Analgesia Complications DRAFT • Cardiorespiratory arrest in patient diagnosed with IUD who received for pain relief for vaginal delivery (RF PCA + Entonox + codein 60 mg and diamorphine 40 mg) – Marr et al. Anaesthesia 2013 • Respiratory arrest in obstetric patient diagnosed with IUD who received for pain relief for vaginal delivery (PCA 40 µg, LO 2min and Entonox) – Bonner JC et al. Anaesthesia 2012 • REASONS: - large remifentanil dosages - concomitant administration of potent opiates - addition of Entonox - insufficient monitoring Iva Blajić, MD slide /28 23 10-year experience with remifentanil labor analgesia Obstetric Analgesia DRAFT Dosage regimen • There are large variations between individuals. • We use stepwise adjustable dosing regimen starting with a bolus of 15µg and increasing it up to 30, rarely 40 µg with no background infusion. • Sedation level rather than VAS scoring is decisive when modifying the dosage. Iva Blajić, MD slide /28 24 10-year experience with remifentanil labor analgesia Obstetric Analgesia Monitoring to determine respiratory DRAFT depression should consist of • continues uninterrupted one- to-one midwifery care to evaluate respiratory rate and sedation • monitoring for adequate ventilation: apnea monitoring and capnography • continuous maternal pulse oximetry oxygen saturation Iva Blajić, MD slide /28 25 10-year experience with remifentanil labor analgesia Obstetric Analgesia Observation chart DRAFT • We must every 30-40 min to document time, blood pressure, etCO2, Ramsey sedation score and pain score • Ramsey scale (1-6) Iva Blajić, MD slide /28 26 10-year experience with remifentanil labor analgesia Obstetric Analgesia Conclusion DRAFT • RF has a unique profile to be used in obstetrics. • When is neuraxial analgesia contraindicated • It should be an alternative to meperidine as it provides better pain relief with less neonatal depression. • Apart from medical indication, remifentanil is not an alternative for epidural analgesia in parturients where long and painful labour is expected (primiparae, parturients with induced labours with PG and low pain tolerance) • Remifentanil could be an alternative to neuraxial analgesia in parturients where short labour is expected (multiparae). • Remifentanil requires permanent midwife presence with careful monitoring of sedation, saturation and ventilation Iva Blajić, MD slide /28 27 10-year experience with remifentanil labor analgesia Obstetric Analgesia There are many ways DRAFT Iva Blajić, MD slide /28 28 HEPMP Ljubljana Acute Pain Management DRAFT Lecture series 5 Acute Pain Management 5.1 Establishment of acute pain management service 5.2 Role of the Anesthesiology department in acute pain management service 5.3 Implementation of protocols for acute pain management 5.4 Education of healthcare providers on acute postoperative pain management Lectures 5.1 - 5.4 page 349 - 431 HEPMP Ljubljana - Day 4 Acute Pain Management Lecture 5.1 DRAFT The establishment of acute pain management service at University Medical Center Ljubljana assoc. prof. Neli Vintar, MD, PhD Office of Acute Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 5.1 page 350 - 382 Establishment of acute pain management service Acute Pain Management DOES APS IMPROVE POSTOPERATIVE OUTCOME? DRAFT • Werner, MU et al. Does APS improve postoperative outcome? Anesth Analg 2002;95:1361-72. • Lee A et al. The costs and benefits of extending the role of APS on clinical outcomes after major elective surgery. Anesth Analg 2010;111:1042-50 • Kainzwaldner V et al. Qualitat der postoperativen Schmerztherapie. Der Anaesthesist 2013;62:453-9. • Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol 2016;33:160-71. assoc. prof. Neli Vintar, MD, PhD slide /32 1 Establishment of acute pain management service Acute Pain Management ACUTE PAIN SERVICE LJUBLJANA DRAFT Prim Godec / prof Rawal: N Rawal. Pain 1994 Organization of APS. Nurse- based anesthesiologist-supervised low-cost model. Prim Godec: National project of postoperative pain management (1998) assoc. prof. Neli Vintar, MD, PhD slide /32 2 Establishment of acute pain management service Acute Pain Management DRAFT IS POSTOPERATIVE PAIN SUCCESSFULLY TREATED? Rawal N. Current issues in postoperative pain management. EJA 2016;33:160-71. • No optimal postoperative pain control in Europe and USA • Written protocols only in 60% hospitals • Nurses are not allowed to adjust the treatment • Postoperative analgesia is most often prescribed by surgeons assoc. prof. Neli Vintar, MD, PhD slide /32 3 Establishment of acute pain management service Acute Pain Management AIMS OF EFFECTIVE POSTOPERATIVE PAIN RELIEF DRAFT • PATIENT SATISFACTION patient wellbeing, good sleep and appetite • GOOD OUTCOME SUPPORT : effective and quick recovery intact immune system: good wound heeling effective mobilisation and rehabilitation short hospital staying lower costs assoc. prof. Neli Vintar, MD, PhD slide /32 4 Establishment of acute pain management service Acute Pain Management UNSUCCESSFULLY TREATED POSTOPERATIVE PAIN DRAFT • Increased stress, sleep disturbance, eating disturbance • Immune system suppression: postoperative infection, impaired wound healing, respiratory infection, prolonged recovery, prolonged hospital stay • Hypercoagulability, thrombotic complications • Severe postoperative pain: leads to chronic pain syndrome (5 – 50% incidence) Institute of Medicine. Relieving pain in America. USA: National Academies Press; 2011; Chaparro LE, Smith SA, Moore RA, et al. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev (7):2013; Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013; assoc. prof. Neli Vintar, MD, PhD slide /32 5 Establishment of acute pain management service Acute Pain Management HOW TO START WITH APS? DRAFT • Written protocols for postoperative analgesia • New nurse profile: pain nurse • Education of surgeons, ward nurses and patients • Make pain visible: pain assessment • Recording VAS and analgesic consumption • Recording side effects and complications • Statistical analysis • Regular meetings and improvement plans assoc. prof. Neli Vintar, MD, PhD slide /32 6 Establishment of acute pain management service Acute Pain Management Prim Godec et al PROTOCOLS DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 7 Establishment of acute pain management service Acute Pain Management DRAFT Information flyer for patients assoc. prof. Neli Vintar, MD, PhD slide /32 8 Establishment of acute pain management service Acute Pain Management 1998 The first pain nurse DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 9 Establishment of acute pain management service Acute Pain Management Bed side surgical ward nurse education DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 10 Establishment of acute pain management service Acute Pain Management DRAFT Postoperative pain treatment is started in the operating room, continued in the recovery room assoc. prof. Neli Vintar, MD, PhD slide /32 11 Establishment of acute pain management service Acute Pain Management SVAKI POČETAK JE TEŽAK DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 12 Establishment of acute pain management service Acute Pain Management FIRST AWARDS IN 2011 DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 13 Establishment of acute pain management service Acute Pain Management PAIN NURSE DRAFT • DAILY VISITS OF PATIENTS WITH PCA PUMPS (recording VAS scores, calculating analgesic consumption, adjusting PCA pumps programme to patient‘s needs, recording side effects) • DAILY VISITS OF PATIENTS WITH CATHETERS (catheter nursing, recording complications, safe epidural catheter removal) • EDUCATION OF WARD NURSES: REGULAR EDUCATION PROGRAMS • STATISTICAL ANALYSIS, ANNUAL REPORTS assoc. prof. Neli Vintar, MD, PhD slide /32 14 Establishment of acute pain management service Acute Pain Management APS ANESTHESIOLOGIST DRAFT • ON CALL FOR ANALGESIC PROTOCOL ADJUSTMENTS • SOLVING PROBLEMS AND COMPLICATIONS • PALLIATIVE CARE AND PAIN TREATMENT OF CHRONIC PAIN PATIENTS AT ALL DEPARTMENTS OF UMC • RECORDING DAILY VISITS • COMMUNICATION WITH TEAM ANAESTHESIOLOGISTS • RESPONSIBLE FOR STANDARDS AND PROTOCOLS • COMMUNICATION WITH HOSPITAL PHARMACY • ANNUAL MEETINGS WITH SURGEONS assoc. prof. Neli Vintar, MD, PhD slide /32 15 Establishment of acute pain management service Acute Pain Management ACUTE PAIN SERVICE IN LJUBLJANA TODAY DRAFT • DAILY 1 anaesthesiologist on call (phone 7200) • DAILY 2 -4 pain nurses (phone 8623, 7243) • 100 PCA pumps in use daily • Per 1 year: ≥ 5000 patients with IV PCA, PCEA, peripheral catheters • Each patient PCA for 3 days: ≥ 15000 visits per year assoc. prof. Neli Vintar, MD, PhD slide /32 16 Establishment of acute pain management service Acute Pain Management DRAFT APS : not only acute pain… • Perioperative pain • Non surgical pain: untraceable pain of different aetiologies (neurological causes, infections, vascular / ishemic pain…) • Paliative care assoc. prof. Neli Vintar, MD, PhD slide /32 17 Establishment of acute pain management service Acute Pain Management PROTOCOL FOR TREATMENT OF SIDE EFFECTS AND COMPLICATIONS OF POSTOPERATIVE ANALGESIA TECHNIQUES DRAFT assoc. prof. Neli Vintar, MD, PhD slide /32 18 Establishment of acute pain management service Acute Pain Management MAKING PAIN VISIBLE DRAFT Ward nurses record VAS pain scores : in intensive care units 1x / hr on surgical wards: 1x / 3 hrs assoc. prof. Neli Vintar, MD, PhD slide /32 19 Establishment of acute pain management service Acute Pain Management DRAFT SHEET OF ANALGESIA AND COMPLICATIONS „YELLOW PAPER“ • WRITTEN BY ANAESTHESIOLOGIST IN OPERATING ROOM • RECOVERY ROOM: VAS SCORES • SURGICAL WARD: PAIN NURSE RECORDING DURING DAILY VISITS • EPIDURAL CATHETER REMOVAL / IV PCA REMOVAL: 1 COPY IN PATIENT’S DOCUMENTATION, 1 COPY FOR APS DATA ANALYSIS assoc. prof. Neli Vintar, MD, PhD slide /32 20 Establishment of acute pain management service Acute Pain Management RECORDINGS ON „YELLOW PAPER“ DRAFT • PAIN SCORES • ADDITIONAL ANALGESIC REQUIREMENTS • NUMBER OF DAILY BOLI of PCA • SIDE EFFECTS • COMPLICATIONS • CATHETER REMOVAL assoc. prof. Neli Vintar, MD, PhD slide /32 21 Establishment of acute pain management service Acute Pain Management MONTHLY STATISTICAL ANALYSIS QUALITY ASSESSMENT REPORTS 1 X PER YEAR DRAFT • NUMBERS OF DIFFERENT TECHNIQUES • NUMBERS OF DAILY VAS ASSESSMENTS • AVERAGE DAILY VAS SCORES • NUMBERS OF SIDE EFFECTS AND COMPLICATIONS ALL TOGETHER AND SEPARATELY FOR EACH SURGICAL DEPARTMENT assoc. prof. Neli Vintar, MD, PhD slide /32 22 Establishment of acute pain management service Acute Pain Management DRAFT ANNUAL REPORTS • REPORTS PRESENTED ANNUALLY AT QUALITY ASSESSMENT MEETINGS OF CLINICAL DEPARTMENT FOR ANAESTHESIA AND INTENSIVE CARE • ANALYSIS OF EFFECTIVENESS AND SAFETY • IMPROVEMENT SUGGESTIONS assoc. prof. Neli Vintar, MD, PhD slide /32 23 Establishment of acute pain management service Acute Pain Management DRAFT ANNUAL MEETINGS WITH SURGICAL DEPARTMENTS PRESENTED BY APS ANAESTHESIOLOGIST, PAIN NURSE, TEAM ANAESTHESIOLOGISTS • PRESENTATION OF RESULTS • DISCUSSION WITH SURGEONS AND WARD NURSES • IMPROVEMENT SUGGESTIONS assoc. prof. Neli Vintar, MD, PhD slide /32 24 Establishment of acute pain management service Acute Pain Management SAFETY STANDARDISED ANALGESIC MIXTURES FOR REGIONAL ANALGESIA PREPARED BY UMC PHARMACY DRAFT Substance Analgesic Analgesic Analgesic Analgesic mixture A mixture M mixture G mixture C Levobupivakainijev 200 ml 200 ml 200 ml 200 ml klorid 0,125% (1,25 mg/ml) Levobupivakainijev - 20 ml 40 ml 20 ml klorid 0,75% (7,5 mg/ml) Morfinijev klorid 4 mg 4 mg - - Klonidinijev klorid 75 mcg - - - Total volume 200 ml 220 ml 240 ml 220 ml assoc. prof. Neli Vintar, MD, PhD slide /32 25 Establishment of acute pain management service Acute Pain Management NUMBER OF PATIENTS WITH DIFFERENT TYPES OF ANALGESIA: DRAFT changed with development of new techniques of analgesia and new surgical techniques YEAR i.v. opioid epidural Peripheral Single shot Wound Paliative PCA PCEA catheter PB catheter care analgesia analgesia analgesia analgesia analgesia – elastomeric pumps 2009 3061 774 9 ? 75 - 2012 2803 622 12 ? 62 - 2014 3764 559 32 ? 83 - 2016 4023 426 202 343 175 50 2017 3586 409 503 458 144 73 assoc. prof. Neli Vintar, MD, PhD slide /32 26 Establishment of acute pain management service Acute Pain Management EFFECTIVE POSTOPERATIVE PAIN RELIEF IN UMC LJUBLJANA in 2017 DRAFT Type of analgesia VAS/NRS 0 - 3 VAS /NRS 4 - 7 VAS/NRS 8 -10 IV PCA 93,7% 6,2% 0,3% Epidural PCEA 92,5% 7,2% 0,3% Wound catheter analgesia 95,5% 4,5% 0,0% Continuous peripheral blocks 87,7% 11,7%, 0,4% Single shot peripheral blocks 84,8% 14,6% 0,6% assoc. prof. Neli Vintar, MD, PhD slide /32 27 Establishment of acute pain management service Acute Pain Management FEW COMPLICATIONS OF EPIDURAL PCA ( PCEA 409) in 2017 DRAFT Complication Number % Sensoric blockade 23 5,7 Motor blockade 21 5,1 Pain in the injection site 1 0,4 Tachnical problems: 25 6,2 catheter fell out, not functioning.. assoc. prof. Neli Vintar, MD, PhD slide /32 28 Establishment of acute pain management service Acute Pain Management FEW COMPLICATIONS OF IV PCA (3586) DRAFT PCA PIRITRAMID 0,5 MG / ML Complication number % nausea 150 4,2 vomiting 161 4,5 Sedation level 2-3 150 4,2 assoc. prof. Neli Vintar, MD, PhD slide /32 29 Establishment of acute pain management service Acute Pain Management ACHIEVEMENTS OF 20 YRS ACUTE PAIN SERVICE IN UMC LJUBLJANA DRAFT • Pain is REGULARLY assessed and recorded as 5th vital sign on all surgical wards • Effective postoperative pain relief in all recovery rooms and surgical wards: VAS ≤ 3 • There are few side effects and no serious complications: about 5% • Regular monthly education programs for ward nurses : obligatory attended, positive results • High patient satisfaction with quality of postoperative pain relief: results of regular inquiries 4,9 points ( of 5 possible) assoc. prof. Neli Vintar, MD, PhD slide /32 30 Establishment of acute pain management service Acute Pain Management APS PLANS FOR THE FUTURE DRAFT • REGULAR APS ANAESTHESIOLOGISTS AND PAIN NURSES • APS NURSES TILL 8pm AND ON WEEKENDS • MORE ANALGESIC MIXTURES PREPARED IN ADVANCE BY HOSPITAL PHARMACY • IMPROVEMENT OF PALLIATIVE CARE • EDUCATION PROGRAM FOR PATIENTS • COMPUTERISED DATA COLLECTION AND ANALYSIS assoc. prof. Neli Vintar, MD, PhD slide /32 31 Establishment of acute pain management service Acute Pain Management SVAKOG DANA U SVAKOM POGLEDU DRAFT SVE VIŠE NAPREDUJEM! assoc. prof. Neli Vintar, MD, PhD slide /32 32 HEPMP Ljubljana - Day 4 Acute Pain Management Lecture 5.2 DRAFT Role of the Clinical Department of Anesthesiology and Surgical Intensive Therapy in implementation of the acute pain management service at University Medical Center Ljubljana assoc. prof. Neli Vintar, MD, PhD Office of Acute Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 5.2 page 383 - 391 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT FOR APS ORGANISATION: MAJOR ROLE OF CLINICAL DEPARTMENT • HUMAN RESOURCES • PROTOCOLS • EQUIPMENT • EDUCATION assoc. prof. Neli Vintar, MD, PhD slide /8 1 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT APS: LOW COST MODEL nurse-based anaesthesiologist supervised NO EXTRA MONEY FOR APS for National insurance: NO COST MODEL assoc. prof. Neli Vintar, MD, PhD slide /8 2 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management MAJOR ROLE OF CLINICAL DEPARTMENT DRAFT HUMAN RESOURCE MANAGEMENT: RECRUITMENT A NEW POSITION ON EVERYDAY PROGRAMME: 1 ANAESTHESIOLOGIST AND 3-4 PAIN NURSES assoc. prof. Neli Vintar, MD, PhD slide /8 3 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT WRITTEN PROTOCOLS • GENERAL PROTOCOLS: IV AND REGIONAL ANALGESIA • INSTRUCTIONS FOR SIDE EFFECTS MANAGEMENT • INSTRUCTIONS FOR CATHETER NURSING assoc. prof. Neli Vintar, MD, PhD slide /8 4 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT EQUIPMENT • PERIOPERATIVE: US machines for peripheral nerve blocks catheters and needles • POSTOPERATIVE: PCA pumps, elastomeric pumps assoc. prof. Neli Vintar, MD, PhD slide /8 5 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT COLLABORATION WITH HOSPITAL PHARMACY STANDARDIZED ANALGESIC MIXTURES: • PREPARED IN STERILE ENVIRONMENT • PREPARED IN ADVANCE (NOT ON SURGICAL WARDS!) • LABELLED: AVOIDING ERRORS assoc. prof. Neli Vintar, MD, PhD slide /8 6 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management DRAFT EDUCATION • SURGEONS: annual meetings • SURGICAL WARD NURSES: regular education • PATIENTS: instructions assoc. prof. Neli Vintar, MD, PhD slide /8 7 Role of Anesthesiology dept in acute pain mgmt service Acute Pain Management STATISTICAL ANALYSIS AND QUALITY ASSESSMENT DRAFT • DAILY VISITS: VAS scores, side effects, technical problems, All data noted by pain nurses and then written in computer programme for analysis • MONTHLY statistical analysis • ANNUAL reports and AUDITS assoc. prof. Neli Vintar, MD, PhD slide /8 8 HEPMP Ljubljana - Day 4 Acute Pain Management Lecture 5.3 DRAFT Implementation of protocols for acute pain management in clinical practice assoc. prof. Neli Vintar, MD, PhD Office of Acute Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 5.3 page 392 - 417 Implementation of protocols for acute pain management Acute Pain Management POSTOPERATIVE PAIN: acute pain model DRAFT assoc. prof. Neli Vintar, MD, PhD slide /25 1 Implementation of protocols for acute pain management Acute Pain Management POSTOPERATIVE PAIN MANAGEMENT DRAFT SYSTEMIC TECHNIQUES • IV analgesia • Oral analgesia REGIONAL TECHNIQUES • Continuous epidural blockade • Peripheral nerve blocks • Wound catheter analgesia assoc. prof. Neli Vintar, MD, PhD slide /25 2 Implementation of protocols for acute pain management Acute Pain Management DRAFT assoc. prof. Neli Vintar, MD, PhD slide /25 3 Implementation of protocols for acute pain management Acute Pain Management Blaga bolečina Srednje močna Močna bolečina bolečina VAS ≤4 VAS 7-10 VAS 5-7 -hernioplastika -torakotomija DRAFT -laparoskopije -operacija kolka -serijske frakture reber -varice -odstranitev -totalna endoproteza kolena -manjša travma žolčnika -večje abdominalne operacije -artroskopije -nevrokirurške operacije Epiduralna analgezija (PCEA), blokada živčnega pleteža, šibki opioidi IV močni opioidi IV (PCA) NSAR , paracetamol Paracetamol + infiltracija rane z LA NSAR Blokada perifernega živca (enkratno ali preko katetra) ESRA.Postoperative Pain Management assoc. prof. Neli Vintar, MD, PhD slide /25 4 Implementation of protocols for acute pain management Acute Pain Management DRAFT NONOPIOIDS FOR POSTOPERATIVE PAIN Paracetamol Metamizol Nonsteroidal antiinflammatory drugs (NSAIDs) - sometimes controversial - (wound healing? Intestinal oxygen supply?) assoc. prof. Neli Vintar, MD, PhD slide /25 5 Implementation of protocols for acute pain management Acute Pain Management WEAK AND STRONG OPIOIDS DRAFT • WEAK: tramadol IV and oral, longacting and shortacting • STRONG: IV: piritramid, morphin, oxycodone oral longacting tapentadol, oxycodone, morphin, hydromorphon; oral shortacting tapentadol, morphin, fentanil transcutaneous: fentanil, buprenorphin assoc. prof. Neli Vintar, MD, PhD slide /25 6 Implementation of protocols for acute pain management Acute Pain Management RECOMMENDED ANALGESIC COMBINATIONS DRAFT • OPIOIDS ARE COMBINED WITH PARACETAMOL, METAMIZOL AND NSAIDs • OPIOIDS ARE NEVER PRESCRIBED AS MONOTHERAPY • DO NOT COMBINE DIFFERENT NSAIDs : decide for one and use it up to max. dose • DO NOT COMBINE DIFFERENT OPIOIDS • USE LONGACTING ORAL OPIOIDS FOR PREDICTABLE PAIN, • SHORTACTING OPIOIDS FOR TITRATION AND BREAKTHROUGH PAIN assoc. prof. Neli Vintar, MD, PhD slide /25 7 Implementation of protocols for acute pain management Acute Pain Management DRAFT STANDARDIZED ANALGESIC PROTOCOLS • STANDARDIZED OPERATING PROCEDURES (SOP) ALSO FOR POSTOPERATIVE ANALGESIA • WRITTEN BY TEAM ANAESTHESIOLOGISTS • SPECIFICALLY FOR EACH SURGICAL SPECIALITY assoc. prof. Neli Vintar, MD, PhD slide /25 8 Implementation of protocols for acute pain management Acute Pain Management ANALGESIA PROTOCOL : WRITTEN BY ANAESTHESIOLOGIST IN THE OR ON THE „YELLOW PAPER“ DRAFT assoc. prof. Neli Vintar, MD, PhD slide /25 9 Implementation of protocols for acute pain management Acute Pain Management PROTOCOLS FOR SYSTEMIC ANALGESIA DRAFT FIRST POSTOPERATIVE DAY : INTRAVENOUS ANALGESIA MODERATE PAIN: TRAMADOL / METAMIZOL / METOCLOPRAMIDE cont. IV infusion, combined with Paracetamol 1gr/ 8 – 6 hrs, when appropriate Neodolpasse ( diclofenac + orphenadrine)/ 12 hrs SEVERE PAIN: IV PIRITRAMIDE PCA ( 45 mg piritramide + physiol. sol up to 90 ml= 0,5mg/ml), 3-5 ml/hr contin.inf. , bolus 3- 5 ml per 30 min, plus REGULAR treatment Paracetamol 1g/ 8-6 hr, Metamizol 2,5 gr/ 12hrs, when appropriate Neodolpasse ( diclofenac + orphenadrine)/ 12 hrs 2ND/ 3RD POSTOPERATIVE DAY (PATIENT CAN CONSUME FLUIDS OR FOOD): ORAL ANALGESICS: MODERATE PAIN: TRAMADOL / PARACETAMIL / METAMIZOL / NSAIDs SEVERE PAIN: TAPENTADOL OR OXYCODONE PLUS METAMIZOL, PARACETAMOL, NSAIDS assoc. prof. Neli Vintar, MD, PhD slide /25 10 Implementation of protocols for acute pain management Acute Pain Management PROTOCOLS FOR REGIONAL ANALGESIA DRAFT • EPIDURAL ANALGESIA: PCEA , ANALGESIC MIXTURE A or M 3-6 ML/HR, + BOLUS 3-6 ML / 30 MIN ( 3 – 5 days, max 3 weeks) • CONTINUOUS PERIPHERAL NERVE BLOCKS: PCA LA MIXTURE G or C 2- 6 ML/HR + 6-9ML BOLUS/ HR (3 – 7 days, max 3 weeks) • SINGLE SHOT PERIPHERAL NERVE BLOCK: postoperatively Piritramide 5mg / metamizol 1,25gr in 100 ml physiol.sol / 6 hrs REGULARLY! • WOUND CATHETER ANALGESIA: ELASTOMERIC PUMPS LA 2-5 ml/hr, usually 48 hrs • WOUND INFILTRATION: single shot – orthopedics: large volume infiltration (LIA) • LOCAL ANESTHETIC: LEVOBUPIVACAINE, ROPIVACAINE assoc. prof. Neli Vintar, MD, PhD slide /25 11 Implementation of protocols for acute pain management Acute Pain Management STANDARDISED LOCAL ANAESTHETIC MIXTURES PREPARED BY UMC PHARMACY DRAFT Substance Analgesic Analgesic Analgesic Analgesic mixture A mixture M mixture G mixture C Levobupivakainijev 200 ml 200 ml 200 ml 200 ml klorid 0,125% (1,25 mg/ml) Levobupivakainijev - 20 ml 40 ml 20 ml klorid 0,75% (7,5 mg/ml) Morfinijev klorid 4 mg 4 mg - - Klonidinijev klorid 75 mcg - - - Total volume 200 ml 220 ml 240 ml 220 ml assoc. prof. Neli Vintar, MD, PhD slide /25 12 Implementation of protocols for acute pain management Acute Pain Management DRAFT • NUMBER OF CONTINUOUS PERIPHERAL NERVE BLOCKS IS INCREASING • FOR CPNB: LA MIXTURE G AND C assoc. prof. Neli Vintar, MD, PhD slide /25 13 Implementation of protocols for acute pain management Acute Pain Management DRAFT assoc. prof. Neli Vintar, MD, PhD slide /25 14 Implementation of protocols for acute pain management Acute Pain Management MULTIMODAL ANALGESIA combination of different techniques and different drugs DRAFT REGIONAL TECHNIQUE (WOUND INFILTRATION, large volume infiltration) PLUS SYSTEMIC ANALGESIA paracetamol / metamizol / NSAID / opioid AIM: IMPROVE EFFECTIVENESS, MINIMIZE OPIOID REQUIREMENTS assoc. prof. Neli Vintar, MD, PhD slide /25 15 Implementation of protocols for acute pain management Acute Pain Management ADVANTAGES OF REGIONAL ANALGESIA TECHNIQUES DRAFT • regional analgesia with LA avoids opioid side effects: sedation, dizziness, PONV • enables early mobilisation: effective analgesia for physiotherapy assoc. prof. Neli Vintar, MD, PhD slide /25 16 Implementation of protocols for acute pain management Acute Pain Management PATIENT CONTROLLED ANALGESIA (PCA) PUMPS DRAFT • PCA pumps are very accurate and safe, for multiple use • Patient is actively involved • Independent from staff members • Continuous analgesic infusion / no continuous infusion plus boli within programmed safe limits • Record given boli and attempted boli • Daily analgesic consumption is calculated assoc. prof. Neli Vintar, MD, PhD slide /25 17 Implementation of protocols for acute pain management Acute Pain Management ELASTOMERIC PUMPS DRAFT • DISPOSABLE • CONTINUOUS FLOW 2ml/h OR 5 ml/h • FOR PALIATIVE CARE • FOR WOUND CATHETER ANALGESIA assoc. prof. Neli Vintar, MD, PhD slide /25 18 Implementation of protocols for acute pain management Acute Pain Management MONITORING OF PATIENTS WITH PCA / ELASTOMERIC PUMPS DRAFT WARD NURSES: • SEDATION MONITORING EVERY 3 HRS • PAIN ASSESSMENT AND RECORDING EVERY 3 HRS • RECOGNISING SIDE EFFECTS AND POSSIBLE COMPLICATIONS • CHANGING BATTERIES OF PCA PUMPS WHEN NEEDED assoc. prof. Neli Vintar, MD, PhD slide /25 19 Implementation of protocols for acute pain management Acute Pain Management PAIN NURSES TAKE CARE OF ALL PCA PUMPS DRAFT • DAILY VISITS OF ALL PATIENTS WITH PCA PUMPS AND CATHETERS • DAILY CALCULATIONS OF ANALGESIC CONSUMPTIONS, RECORDING ON THE „YELLOW PAPER“ • DAILY ADJUSTMENTS OF PCA PUMPS PROGRAMS - ACCORDING TO EACH PATIENT’S NEEDS • AFTER DISCONNECTION OF PCA PUMP, PAIN NURSE COLLECTS ALL PUMPS AND CLEANS THEM • TAKES CARE OF REPAIR WHEN NECESSARY assoc. prof. Neli Vintar, MD, PhD slide /25 20 Implementation of protocols for acute pain management Acute Pain Management DRAFT EXAMPLE OF AN ANNUAL MEETING ON SURGICAL DEPARTMENT WITH SURGEONS AND WARD NURSES • PRESENTING THE ACHIEVEMENTS • SUGGESTING SOME IMPROVEMENTS ACCORDING TO QUALITY ASSESSMENT STANDARDS assoc. prof. Neli Vintar, MD, PhD slide /25 21 Implementation of protocols for acute pain management Acute Pain Management Effectiveness of postoperative pain management After major urologic procedures in 2016 DRAFT Year 2016 Epidural analgesia IV PCA analgesia Number of patients 39 452 VAS pain scores < 3 92,6% 93,8% assoc. prof. Neli Vintar, MD, PhD slide /25 22 Implementation of protocols for acute pain management Acute Pain Management Postoperative analgesia after urological procedures: DRAFT Side effects analysis 2016 Side effects of Side effects of epidural PCEA IV PCA PONV / 17/ 3,7% hypotension 1/ 2,6% 1/ 0,2% pruritus 1/ 2,6 % Sedation st. 2 1 / 2,6 % 13/ 2,8% assoc. prof. Neli Vintar, MD, PhD slide /25 23 Implementation of protocols for acute pain management Acute Pain Management Side effects / complications of epidural analgesia DRAFT after urological procedures Sensoric block 4 pts/ 10,2 % Motor block 2 pts/ 5,1 % Bleeding at the puncture site of EK 1 pt/ 2,6 % Technical problems 2 pts/ 5,1% assoc. prof. Neli Vintar, MD, PhD slide /25 24 Implementation of protocols for acute pain management Acute Pain Management DRAFT PAIN ASSESSMENT ON SURGICAL WARDS in 2016 Recommendation: 1x / 3hrs = 8x / day Clinical department Average number of Average number of assessments /per pt/ assessments per pt/ day I.V. PCA day PCEA Urology 3,4x = 42,5% 4x = 50% Abdominal surgery 5,6x = 70% 6 x = 75% Thoracic surgery 8x = 100% 10 x = 120% assoc. prof. Neli Vintar, MD, PhD slide /25 25 HEPMP Ljubljana - Day 4 Acute Pain Management Lecture 5.4 Education of healthcare DRAFT providers on acute postoperative pain management at University Medical Center Ljubljana assoc. prof. Neli Vintar, MD, PhD Office of Acute Pain Management, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Vesna Svilenković, RN Head nurse, Acute pain management service, Clinical Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana Lecture 5.4 page 418 - 431 Education of healthcare providers: acute postop pain mgmt Acute Pain Management APS DRAFT PAIN NURSE ROLE IN EDUCATION • Preparing nursing and monitoring standards and protocols • Education programmes for surgical ward nurses, midwives • Education programs for newly employed in anaesthesia department • Preparing Quality assessment protocols assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 1 Education of healthcare providers: acute postop pain mgmt Acute Pain Management POSTOPERATIVE PAIN MANAGEMENT : DRAFT EDUCATION PROGRAMS • Standards for regular education programs for postoperative pain management • Standards for postoperative pain management in adults • Standards for postoperative pain management in children • Bed-side education on surgical wards • Clinical practice for students of health care assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 2 Education of healthcare providers: acute postop pain mgmt Acute Pain Management STANDARDS FOR EDUCATION PROGRAMS DRAFT FOR POSTOPERATIVE PAIN MANAGEMENT • Education programs were confirmed by the Board of head nurses of all surgical departments in UMC • All surgical departments are included (obligatory) • Program: 8hrs of theory and practice for health care providers who take care of surgical patients and treat postoperative pain assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 3 Education of healthcare providers: acute postop pain mgmt Acute Pain Management PROGRAMME FOR HEALTH CARE PROVIDERS 7.00 - 7.15 Registration DRAFT 7.15 – 7.40 Pathophysiology of pain prim.Gorazd Požlep, MD 7.45 - 8.15 Pharmacology of analgesics for postoperative pain management. doc.dr. Neli Vintar, MD 8.15 – 9.00 Regional techniques for acute pain management. Goran Jeglič, MD 9.00 – 9.10 APS organization. Vesna Svilenković, DN 9.10 – 9.30 Acute pain assessment. Vesna Svilenković, DN 9.30 – 10.00 Break 10.00 – 10.20 Monitoring of patient with EA. Mojca Jensterle, DN 10.20 – 10.40 Monitoring of patient with wound catheter analgesia. Sonja Trobec, DN 10.40 – 10.50 Analgesic mixtures for elastomeric pumps. Sonja Trobec, DN 10.50 – 11.10 Monitoring of patients with IV opioid analgesia. Jožica Marolt, DN 11.10 – 11.30 Monitoring of patients with peripheral nerve catheters. Vera Medar,DN 11.30 – 11.50 Ethical aspects of acute pain management. Karmen Zupančič, DN 11.50 – 12.15 Break 12.15 – 14.30 Workshops: 1. Mismatch between subjective pain assessment and physiological signs of pain 2. Monitoring of patients with IV opioid analgesia 3. Monitoring of patients with epidural analgesia 4. Handling with PCA pumps 14.30 – 15.00 TEST ( written ) assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 4 Education of healthcare providers: acute postop pain mgmt Acute Pain Management GOALS OF EDUCATION DRAFT • To inform about ethical principles of acute pain management • To inform about organisation of APS • To understand physiology and pathophysiology of pain • To learn the pharmacology of pain killers • To practice monitoring and assessment of acute pain – different scoring systems • To get theoretical and practical knowledge of different pain management techniques • To learn how to monitor patients with different analgesic techniques • To learn about recognising and treatment of possible side effects and complications assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 5 Education of healthcare providers: acute postop pain mgmt Acute Pain Management STANDARDISED EDUCATION PROGRAMMES FOR ACUTE PAIN MANAGEMENT DRAFT • Started in 2009 • Organised 6x - 10x / year • Participants get licence credit points • Heath care providers come from 10 different clinical departments. • 87.7% of participants successfully passed final exam • Education program got Excellent grade assessment (5) from 85.8% participants. assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 6 Education of healthcare providers: acute postop pain mgmt Acute Pain Management INTERNAL PAIN PROGRAMME FOR ANAESTHESIA AND INTENSIVE CARE DRAFT HEATH CARE PROVIDERS • Pain management and APS organisation • Education programme about pain and APS for the newcomers • (Chronic) wound pain management assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 7 Education of healthcare providers: acute postop pain mgmt Acute Pain Management INFORMATIVE EDUCATION PROGRAM FOR NONSURGICAL HEALTH CARE PROVIDERS DRAFT • ORGANISED REGULARLY 6X PER YEAR • SHORT PROGRAMME : 2 HRS Physiology of acute and chronic pain Presentation of analgesics and analgesic techniques Pain assessment Patient monitoring Recognising of side effects and complications - and their treatment assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 8 Education of healthcare providers: acute postop pain mgmt Acute Pain Management INTERNAL PERIODIC PAIN MEETINGS DRAFT FOR ANAESTHESIOLOGISTS AND ANAESTHESIA NURSES (ALSO INTENSIVE CARE) • New pain management techniques • New PCA pumps • New pain scores • Whenever needed: acute problem…. assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 9 Education of healthcare providers: acute postop pain mgmt Acute Pain Management Operational pain group, on behalf of Slovenian health care provider association for DRAFT anaesthesiology, intensive therapy and transfusiology GUIDELINES AND GOALS: • Pain as 5th vital sign is a standard sine qua non • Pain acknowledgement as important limitation for QOL • Information about pain management for patients and their relatives • Education • Communication with other societies abroad about pain management practice • Research about quality of pain management, patient satisfaction… assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 10 Education of healthcare providers: acute postop pain mgmt Acute Pain Management FUTURE PLANS DRAFT • EDUCATION PROGRAMMES FOR PATIENTS assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 11 Education of healthcare providers: acute postop pain mgmt Acute Pain Management Rawal N. Current issues in postoperative pain management DRAFT Eur J Anaesthesiol 2016; 33:160-171 • Irrespective of the APS model, teaching programmes to upgrade the role of ward nurses, standardised protocols and regular audits are necessary to address the problem • This model is a resource for education and training and promotion of good clinical practice. assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 12 Education of healthcare providers: acute postop pain mgmt Acute Pain Management DRAFT CONCLUSIONS Education improves the quality of postoperative pain management APS plays an important role in education of health care providers involved in postoperative pain management assoc. prof. Neli Vintar, MD, PhD & Vesna Svilenković, RN slide /13 13 HEPMP Ljubljana Pain Management at the Institute of Oncology Lecture 6.1 DRAFT Pain Management at the Institute of Oncology Office of Outpatient Pain Management Ana Pekle Golež, MD Head, Department of Oncological Anesthesiology and Intensive Care, Institute of Oncology Ljubljana Lecture 6.1 page 432 - 449 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Institute of Oncology DRAFT 3 main clinical departments: • Surgery 300 beds • Department of anaesthesiology • Internal medicine • Radio-therapy Ana Pekle Golež, MD slide /17 1 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Department of anaesthesiology DRAFT • Anaesthesiology • ICU • Pain management • Department for CVC Ana Pekle Golež, MD slide /17 2 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Pain management clinic DRAFT 5 days/week, 8 hours/day Acute pain service • hospitalised patients after surgery • Pain nurses Chronic pain management • Outpatient cancer/non-cancer Pain program • Inpatient Cancer Pain program Ana Pekle Golež, MD slide /17 3 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology • pain medicine/ interventional pain management Anaesthesiologist • acupuncture DRAFT Pain nurse Oncologist Cancer Pain Management Team Physiotherapist multidisciplinary Psycologist work Clinical pharmacologist Paliative medicine • Social worker specialist Ana Pekle Golež, MD slide /17 4 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Pharmacological treatment DRAFT Regional anaesthesia/analgesia Pain treatment, US confirmation • Peripheral nerves/ peripheral plexus blocks/ catheters • Paravertebral nerves blocks medicine: • PECS I and PECS II blocks Interventional pain management multimodal • Central nerve blocks/ catheters( tunnelled) • Epidural catheters( epidurography) approach • Subarachnoidal catheters • Neurolytic blocks • Elastomeric pump s.c. / i.v • Palliative sedation Ana Pekle Golež, MD slide /17 5 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Pain nurse role DRAFT Acute pain • At the ward: support, supervision, education • Physician’s support service Patient’s and • Advises how to help theirselves caregiver’s • methods of pain management support • Assistance at interventional procedures Chronic pain • psycho-social support service • administrative Ana Pekle Golež, MD slide /17 6 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Oncologist DRAFT • Deciding about the stage and prognosis of the cancer illness • Use of chemo Th, radio Th , surgery as supportive/symptomatic pain therapy • Admittance of patients in pain to the ward Ana Pekle Golež, MD slide /17 7 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Physiotherapist DRAFT • Rehabilitation after surgery • Prevention of pain behaviour • Laser, magnet, US, TENS- pain revealing Th • Management of patient‘s surrounding Ana Pekle Golež, MD slide /17 8 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Psychologist Psycho-oncology DRAFT group supportive therapy individual • Cognitive- therapy behavioural therapy • Psychotherapy • Attention- diversion strategies: relaxation Ana Pekle Golež, MD slide /17 9 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Pain management Pain assessment: making pain visible DRAFT • VAS score • questionnaires Multimodal approach • mechanism-based strategies • pharmacological and non-pharmacological • regional analgesia • interventional Multidisciplinary team work, bio-psycho-social model Complementary medicine support • acupuncture • cannabinoids Ana Pekle Golež, MD slide /17 10 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology DRAFT Questionnaires for making pain objective DN 4 – for neuropathic pain Ana Pekle Golež, MD slide /17 11 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Palliative care levels at the Institute of Oncology DRAFT Specialist level Basic level • Department for Acute Palliative care (6 beds) • All clinical departments • Early Palliative Care Office (outpatient) Ana Pekle Golež, MD slide /17 12 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology DAPC • 300 admissions/ year • LOS 7 days DRAFT Admissions to DAPC from 0,2 0,37 0,43 D.int.medicine RT surgery Ana Pekle Golež, MD slide /17 13 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Palliative medicine specialist - team DRAFT Symptom Family management support Psychosocial Spiritual care care Ana Pekle Golež, MD slide /17 14 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Acute Palliative Care Department DRAFT •Inpatients •Outpatients •Family meetings •Support at home •Education of patients and caregivers Ana Pekle Golež, MD slide /17 15 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology Patient, family, and group counseling Discharge planning DRAFT Advanced directives (living will/ durable power of attorney) Access community Planning for care resources to support Social worker after hospitalisation functioning. Returning to the workplace Ana Pekle Golež, MD slide /17 16 Office of Outpatient Pain Mgmt Pain Management at the Institute of Oncology DRAFT • Pain management workshops • oncologists, surgeons, residents, nurses, physiotherapists, students • Education for residents • anaesthesiology, • emergency medicine • GP • Oncology • Education for students • Education for patients, care-givers System of internal education Ana Pekle Golež, MD slide /17 17 HEPMP Ljubljana Meeting Report Meeting Report Training of Existing Teaching Staff from DRAFT Partner Countries at Programme Countries assoc. prof. Maja Šoštarič, MD, PhD Head, Department of Anesthesiology and Reanimatology, Faculty of Medicine Ljubljana President, Slovenian Society of Anesthesiology and Intensive Care Introduction University of Ljubljana, Slovenia, organised the meeting as a part of the Erasmus+ programme “Higher Education Pain Medicine Project” (HEPMP). Faculty of Medicine Ljubljana (FML) and University Medical Centre Ljubljana (UMCL) were recognised as partners in this project, able to offer knowledge, quality experience and suggestions for improvement of pain medicine in partner countries from the Western Balkan region, especially in undergraduate education as well as in perioperative and obstetric pain management. Meeting Report pages 450 - 455 report page 1/6 HEPMP Ljubljana Meeting Report The HEPMP Ljubljana programme consisted of both lectures and physical visits to several sites at UMCL and FML. Clinical departments visited were the Office of DRAFT outpatient pain management and Clinical department of Obstetrics at UMCL. As modern medical education methods involve work in simulation centres, visits to two simulation centres (UMCL, FML) were organised during the course of HEPMP. On site, participants further discussed the possibilities of establishing or adapting their own respective education programs for pain management. Curriculum The first day of the meeting was dedicated to the introduction of undergraduate and postgraduate education at FML and to the introduction of the curriculum of the anaesthesiology, reanimatology and intensive care medicine residency in Slovenia. In the discussion, participants agreed that there is still space to improve education on pain medicine, especially in their respective undergraduate programmes. A plan was made to implement pain medicine as an obligatory and an additional optional subject at partners’ universities. assoc. prof. Maja Šoštarič, MD, PhD report page 2/6 HEPMP Ljubljana Meeting Report On the second day, participants visited the Office of Outpatient Pain Management (OOPM), which is a part of the Clinical Department of Anaesthesiology and Surgical Intensive Therapy at UMCL. OOPM has been established as an interdisciplinary DRAFT outpatient management clinic, with cooperation from anaesthesiologists, neurologists, orthopaedists and psychiatrists. It is also the leading institution in the education of specialists from other medical fields who are involved in pain management, such as family medicine practitioners, paediatricians, non-orthopaedic surgeons and others. In the discussion, everyone agreed that the possibilities for the exchange of experts’ opinions will improve with the introduction of a “platform for pain medicine”. The third day focused on obstetric pain management, which at UMCL was fully introduced into everyday clinical practice only a few years ago. With a well-planned education and development of protocols for pain management, a steady progress was achieved. The learned experience and advice on how to improve clinical practice for obstetric pain management was presented by a team of two obstetric anaesthesiologists and an obstetrician. In the discussion session, participants from partners’ universities debated the current practice in their own respective countries. assoc. prof. Maja Šoštarič, MD, PhD report page 3/6 HEPMP Ljubljana Meeting Report Lectures on the fourth day of the meeting were dedicated to the overview of the development of the Acute Pain Management Service (APMS) at UMCL. In contrast DRAFT to obstetric pain management, acute pain service treatment (mainly pain after surgery) has a long-standing tradition in Ljubljana. The APMS was established 20 years ago as the part of the Clinical Department of Anaesthesiology and Surgical Intensive Therapy. The main task of APMS was and still is to develop programs and protocols for postoperative pain management. For this purpose, special fill-out forms and protocols for the evaluation of management of postoperative pain were introduced. Also, education of hospital staff who is included in postoperative patient care was established, and is continuously being carried out by a group of experts in acute pain management. At the day’s discussion session, a plan for the development of partners’ countries acute pain management service was established. It consists of: 1) organisation of courses in partners’ countries for the education of surgical staff and 2) an adoption of programme countries’ protocols for postoperative pain management by partners’ countries healthcare systems. assoc. prof. Maja Šoštarič, MD, PhD report page 4/6 HEPMP Ljubljana Meeting Report Participants came to the conclusion that a lot has been done in partners’ countries already, however postoperative pain management still is not routinely a part of postoperative treatment of surgical patients. To routinely assess the intensity of pain DRAFT postoperatively and record it as the “fifth vital sign” is the first step that should be taken in partners’ countries. All participants decided to organise courses to train teachers who would be able to continue the education and establish acute pain management services as a part of their respective anaesthesiology departments. Experts from programme countries are willing to cooperate and transfer their experience. To conclude: protocols and education programs will be adopted by partners’ countries, modified if necessary and introduced into everyday clinical practice. The last day started out with an overview of the Office of Outpatient Pain Management at the Institute of Oncology Ljubljana, but was mainly dedicated to discussions about research and publication on pain management. In the discussion, all participants agreed that research and publication are also subjects which are important to improve pain management on all levels of healthcare. assoc. prof. Maja Šoštarič, MD, PhD report page 5/6 HEPMP Ljubljana Meeting Report DRAFT Conclusions HEPMP Ljubljana conclusions as agreed by participating members: 1. to organise a “teach the teachers” course for postoperative pain management 2. to introduce pain assessment into every day clinical practice as the fifth vital sign 3. to introduce a subject dedicated specifically to pain medicine into undergraduate education programmes at universities 4. to improve obstetric pain management assoc. prof. Maja Šoštarič, MD, PhD report page 6/6 HEPMP Ljubljana DRAFT March 12-16, 2018