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Univ.Prof. Dr. Rudolf Likar Pain Clinic, General Hospital Klagenfurt Klagenfurt, Austria

ZISOP The concept of the Centre for interdisciplinary pain therapy, oncology and palliative medicine. Univ.Prof. Dr. Rudolf Likar Pain Clinic, General Hospital Klagenfurt Klagenfurt, Austria. IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL.

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Univ.Prof. Dr. Rudolf Likar Pain Clinic, General Hospital Klagenfurt Klagenfurt, Austria

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  1. ZISOP The concept of theCentre for interdisciplinary pain therapy, oncology and palliative medicine Univ.Prof. Dr. Rudolf Likar Pain Clinic, General Hospital Klagenfurt Klagenfurt, Austria IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL

  2. 1992 Establishment of interdisciplinary Outpatient Pain Department (anaesthesiology, neurosurgery, neurology, orthopaedics, radiology) at Klagenfurt General Hospital 1992 Introduction of postoperative pain service and regional anaesthesiological procedures 1993 – 2005 Organisation (planning, concept, implementation) of the international pain congresses in Carinthia 1999, 2002, 2003 Co-Organisation of the Austrian Pain Congress 1996 Introduction of and cooperation in establishing the Outpatient Pain Department at Graz University Clinic for Anaesthesiology and Intensive Medicine Development and implementation IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL

  3. Purpose interdisciplinary cooperation for optimal management of inpatients and outpatientsat Klagenfurt General Hospital Pain: Symptom of many different diseases, interdisciplinary approach essential Interdisciplinary Outpatient Pain Department IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL

  4. Fields of activity:  chronic pain therapy and palliative medical management of outpatients and inpatients postoperative pain therapy  preoperative regional anaesthesia techniques  postoperative pain therapy in recovery room (evaluation – patient survey 2000 in Austria) concept “painless hospital”

  5. Pain on rest/on movement VAS/NRS/VRS/KUSS and SMILEY Twice daily Documented on a chart Pain Measurement

  6. Postoperative pain Cancer pain Chronic forms of headache and facial pain (migraine, tension headache, cluster headache etc.) Neuropathic pain (trigeminal neuralgia, post-zoster neuralgia, phantom pain, central pain syndromes etc.) ischemic pain (DST [Dynamic Sequential Thermography] III bis IV) CRPS (Complex Regional Pain Syndrome = sympathetic reflex dystrophy and causalgia) Chronic spinal pain syndromes Spasticity associated pain Pain due to central nervous disorders Psychogenic pain Treatment of the following diseases/symptoms

  7. Oral and transdermal pharmacological treatments with analgesics and other agents used for chronic pain syndromes (anticonvulsants, psychotropics etc.) Nerve blocks: a) reversible blocks (CT-guided, under fluoroscopic control) b) neurolytic blocks (chemical and thermal) Radiofrequency cryotherapy (in cooperation with neurosurgery department): gasserian ganglion, peripheral nerves, facet joint denervation Subcutaneous and intravenous administration of opioids with pain pumps Use of the following forms of therapy

  8. Spinal opioid analgesia (in cooperation with neurosurgery department) a) Trial use with bolus injections, catheter with a port b) Implantation of medication pumps (volume flow controlled gas-pressure pumps, electronically programmable pumps) Spinal cord stimulation (in cooperation with Neurosurgery Department) a) Implantation of epidural test electrodes in the screening phase b) Implantation of pulse generators Implantation of medication pumps for intrathecal baclofen administration in spasticity (in cooperation with neurosurgery department) TENS Acupuncture Provision of psychotherapeutic support (pain-coping training, behavioural therapy) and learning of relaxation methods (biofeedback, Jacobson)

  9. Pain Therapy Symptomatic Treatment Options Pharmacological pain treatment Physiotherapy Physical therapy Psychological therapy TENS Acupuncture Invasive procedures

  10. Year 1998 2001 2004 2007 Outpatients 587 804 1.750 2.150 Follow-up examination of an outpatient 2.386 4.047 5.927 6.630 Consultation activities for inpatients: 5.529 6.490 7.019 9.190 2001: total 19.074 services 2002: total 21.895 services2004: total 21.562 services2007: total 22.323 services

  11. CT-guided blocks:424 / 2001 964 / 2004 982 / 2007 Invasive procedures: 1,284 / 2001 1,950 / 2004 2.037 / 2007 (One-day surgical interventions). 25 to 30 SCS*(114.000 performance-oriented hospital financing points).* Spinal cord stimulations 10 to 15 pain pumps (220,000 performance-oriented hospital financing points). (hospital admission – Neurosurgery, Neurology, Orthopaedics and other wards).

  12. CT-guided blockade epidurale blockade

  13. CT-guided nerve-blockade

  14. CT-gezielte Blockadebehandlung

  15. Ultrasonographic cross-axis view with the needle at the groove of the transverse process adjacent to the superior articular process. SP, spinous process; TP,trans-verse process; AP, articular process; Lat,lateral; Med, medial Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and Pain Medicine 2006; Vol. 31 No. 5 September – October 2006

  16. Ultrasonographic longitudinal paravertebral view with the needle at the cephalad margin of the transverse process. TP, transverse process. Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and Pain Medicine 2006; Vol. 31 No. 5 September – October 2006

  17. CONSULTING ACTIVITIES Chronic - 80 % cancer pain patients pain - 20 % chronic non-cancer pain syndromes OUTPATIENT - 30 % cancer pain patients - 70 % chronic non-cancer pain syndromes Acute pain postoperative pain therapy 2 rounds daily Outpatients Referred by GP Referred from other general hospital outpatient department former inpatients Interdisciplinary OUTPATIENT PAIN DEPARTMENT

  18. INTERDISCIPLINARY OUTPATIENT PAIN DEPARTMENT PATIENT GENERAL PRACTITIONER HOME CARE PAIN CONFERENCES (intramural and district advanced training for physicians and nursing personnel) TRAINING OF NURSING PERSONNEL AND PHYSICIANS International and national CONGRESSES Interdisciplinary OUTPATIENT PAIN DEPARTMENT

  19. Anesthesia and intensive medicine Neurosurgery Neurology Orthopaedics Radiology Physical medicine, clinical psychology, oncology, surgery, radiotherapy, nuclear medicine Outpatient department times: MO – FR 7 a.m. – 2 p.m. Tel. ++43 463 538 23720 Fax. ++43 463 538 23722 Interdisciplinary centre for pain therapy and palliative medicine (ZISOP) Centre of Excellence (Austrian Pain Society) Klagenfurt General Hospital IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL

  20. Out-patients Out-patient home - care Family physician Out-patients Out-patients Palliative ward „local competence Team“ (14 Beds) Hospice Service Daytime hospice Palliative Team Out-patients

  21. PALLIATIVE CARE DEFINITIONS Palliative care is the active, holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments.

  22. Palliative Care cannot only be defined by the stage of disease but by the actual needs of the patient and his family Change of paradigm in palliative care

  23. Number of Patients – palliative care unit 295 322 410

  24. Diagnosis (in %)

  25. Reason for admittance (in %)

  26. Average hospital stay in days

  27. Type of discharge (in %)

  28. 3 mobile palliative care teams Interprofessional (physician, nurse, psychologist) Support of general practicioners and nurses, when palliative patients are at home or in nursing-home „bridge“ between palliative care unit and home care Project of Carinthian government, free of charge

  29. Institutions of Palliative Medicine in Carinthia

  30. The terminal patient may stay at home in the last weeks of life Palliative care is available around the clock He may die without pain in the family circle

  31. Course: Decompressive laminectomy Th 7 and placing of fixateur interne complete transection at Th 7 weakness of the upper extremities following possibly old injury Patient, male, 62 years old

  32. Intensive care 10.09.04 – 10.03.05 Reason for hospitalization: The patient felt tingling in both legs for several hours and increasing pain in the mid thoracic vertebral region. Diagnoses: compression fracture Th6 and Th7 with severe compression on vertebra Th7 and compression of the myelon, slightly less compression on Th6 marked COPD osteoporosis associated with long-term cortisone therapy Patient, male, 62 years old

  33. Admittance with acute respiratory insufficiency Local infection at the operative site - removal and reimplantation of material Difficulties in mobilization - Decubitus sacralis (attempt at plastic coveringonly moderately successful) Difficulties in establishing feeding - PEG tube implantation Delay in withdrawal of artificial ventilation, repeated episodes of pneumonia and atelectasis - tracheostomy, weaning up to adjustment to home respirator

  34. Admittance to palliative ward 10.3. – 25-03. 2005 stabilization of general condition induction of future care organization of home help for the patient and organization of antidecubitus mattress organization of home respirator and oxygen supply service introduction of the management by mobile palliative team

  35. 10 inpatient beds: partially implemented for two patients with back pain,two patients with headache,two patients with neuropathic pain,two patients with articular or myofacial pain,two patients with lower abdominal pain (networking with obstetrics and gynecology) 5 part-time inpatient treatment places (interdisciplinary pain day-clinic) 14 beds for palliative ward (networking with interdisciplinary pain centre / oncology) Night duty up to 10 p.m. Area of responsibility: chronic pain therapy, palliative, acute postoperative pain therapy

  36. We are a multiprofessional interdisciplinary team located in Klagenfurt General Hospital – specialists under one roof. We offer our patients individualised holistic care with curative and palliative intention with the aim of maintaining / improving quality of life. We care for people with acute /chronic pain, malignant diseases and neurological illnesses. Our research and teaching focus on improving people’s quality of life. We are a team characterised by medical and human competence, openness, reliability, flexibility, tolerance and willingness to continuously learn and develop. We aim at achieving high efficiency combined with the careful use of available resources. Mission statement – ZISOP

  37. THANK YOU FOR YOUR ATTENTION! If you have any questions to this presentation please contact me per e-mail: tamara.kreuter@kabeg.at

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