Discussions - Anesthesia Clinical Reference Group

I was doing some mapping and discovered that some commonly used iv fluids in North America were not in SNOMED. D5, 0.2 NS D5 RL Note 1197547008 | Product containing precisely calcium chloride dihydrate 270 microgram and potassium chloride 400 microgram and sodium chloride 6 milligram and sodium lactate 3.2 milligram/1 milliliter conventional release solution for infusion (clinical drug) | and  782106007 | Product containing precisely anhydrous glucose 50 milligram/1 milliliter and potassium chloride 1.5 milligram/1 milliliter and sodium chloride 4.5 milligram/1 milliliter conventional release solution for infusion (clinical drug) | There are a large number of these clinical drug combinations that are iv fluids.  It would also be nicw if they had sysnonyms with their more commonly known names  if not trademarked and concentration units in mEq/L Example  1197547008 | Product containing precisely calcium chloride dihydrate 270 microgram and potassium chloride 400 microgram and sodium chloride 6 milligram and sodium lactate 3.2 milligram/1 milliliter conventional release solution for infusion (clinical drug) | Synonym: 1197547008 | Product containing precisely sodium (Na+), 130 mEq, potassium (K+) 4 mEq, calcium (Ca++) 3 mEq, chloride (Cl−) 109 mEq and lactate [CH3CH(OH) COO−] 28 mEq per litre conventional release solution for infusion (clinical drug) |

Caudal doesn't have an insertion/approach "level" as such, so the record would likely be "Sacral Epidural Block", Caudal is a synonym: https://browser.ihtsdotools.org/?perspective=full&conceptId1=110533007&edition=MAIN&release=&languages=en https://browser.ihtsdotools.org/?perspective=full&conceptId1=110533007&edition=MAIN&release=&languages=en

I agree with Steven's comments. The grouping of Anesthesia AND/OR Sedation only makes sense if there is a use case for a procedure where we don't know in advance what the requirements are or what plan has been made with the patient. So it could (in theory) be used as part of a pre-assessment plan, with the expectation that agreement will be reached with the patient on whether the procedure can be done under an anesthetic (of any type) and if regional/topical/local, is sedation given. In the case where a procedure begins under local or regional and subsequently requires conversion to GA, this would be recorded in a sequential manner. Patrick also mentioned that there is a use case in the US where the conflation of Anesthesia and Sedation has implications for billing but I can't remember the details. Also, see: Anesthesia, sedation and analgesia procedures classification

There is a tracker on this topic as well. It is here:   https://confluence.ihtsdotools.org/display/IHTSDO1/Content+Project+Tracker+Documents?preview=%2F18777631%2F18777817%2FProject+1_Artf221500-RestructuringofLocalanesthesia_Inception_20141202.docx https://confluence.ihtsdotools.org/display/IHTSDO1/Content+Project+Tracker+Documents?preview=%2F18777631%2F18777817%2FProject+1_Artf221500-RestructuringofLocalanesthesia_Inception_20141202.docx 

Hi sdain and gforrest The International Release includes sufficiently defined Clinical drug concepts with >1 active ingredient (e.g. 408035004 |Product containing precisely bupivacaine hydrochloride 2.5 milligram/1 milliliter and epinephrine (as epinephrine bitartrate) 5 microgram/1 milliliter conventional release solution for injection (clinical drug)|). More specific concepts, such as those that would indicate the solution is available in a 5 mL vial, a box of 10 x 5 mL vials, or concepts with a specific brand/trade name, would be modeled in a national extension or local medicinal product dictionary. If the bupivacaine-glucose product you are discussing is manufactured as a premixed solution, I expect it could be modeled similarly to the bupivacaine-epi example above, reflecting whatever strengths are available. If it is a product that is provided as separate components (e.g. an ampule of bupivicaine and an ampule of glucose) to mixed by the clinician, then the individual components could be included in the International Release but the package containing both components would be in a national extension or local medicinal product dictionary. We do not currently describe medicinal products based on baracity as was not a use case or requirement identified for consideration when we developed the Medicinal product concept model and editorial guidelines several years ago. I hope this helps answer your questions; please let me know if you need any further information. Toni cc: mharry

Hi Monica, just to reiterate my comments from Monday - the patient-ventilator interaction can be thought of as a feedback loop. Settings/actions/prescriptions are made and adjusted in real time and the outcome of those settings and adjustments are measured and monitored as observations, both clinical (e.g. effort, skin changes) and from the ventilator itself and associated sensors. From a record-keeping perspective, the data is usually presented as a time-axis chart. Adjustments to therapy in the form of changes to settings, position (e.g. prone) and other airway interventions are accompanied by some form of assessment - did the change in settings/therapy achieve the desired effect, was there no change, or did the condition worsen. I hope that helps.

A couple of other scores in common use that do not have clinical findings in SNOMED.  The score itself exists 445520006 | Visual infusion phlebitis score (observable entity) | and the assessment exists 445577007 | Assessment using visual infusion phlebitis scale (procedure) | image2020-11-10_14-39-20.png

Regarding the Glasgow Coma scale, I would propose using the concepts that are used in the Netherlands copied below.  The concept names, in my opinion are very well done as they can easily be used in postcoordinated terms for reasons other than the GCS.  I propose that SNOMED include all the Conceptnames in the tables below as clinical findings. One then for the motor functions postcoordinate with bodysite and laterality from:  GlasgowComaScale-v3.2(2020EN) - Zorginformatiebouwstenen (zibs.nl) https://zibs.nl/wiki/GlasgowComaScale-v3.2(2020EN) Valuesets 1           ConditionsDuringMeasurementCodelist Valueset Binding: Extensible Conceptname Codesystem name Description Sedated SNOMED CT sedated Paralysis caused by skeletal muscle relaxant SNOMED CT muscle relaxants Aphasia SNOMED CT Aphasia Endotracheal tube present SNOMED CT tube present Tracheostomy present SNOMED CT tracheostoma present other NullFlavor Else   2           GCS_EyesCodelist Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Spontaneous 4 GCS_Eyes Spontaneous [Eyes are opened without exhortation To sound 3 GCS_Eyes When addressing or calling [The eyes are only opened at the patient's address] To stimuli 2 GCS_Eyes In case of an incentive [The eyes are only opened after giving a physical stimulus] No response 1 GCS_Eyes No response [Eyes remain closed under any circumstance] Not applicable 0 NullFlavor Not testable by a local limiting factor    GCS_MotorCodelist Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Obeys 6 GCS_Motor Executes Command [A Simple Command Is Executed] Localises pain 5 GCS_Motor Locating [Being able to clearly locate the pain] Withdrawal response 4 GCS_Motor Retreat [Able to make a repellent or retreating motion on a pain stimulus] Flexor response 3 GCS_Motor Bending reaction [Arms and hands folded in spasmodic way. Usually legs stretched.] Extensor response 2 GCS_Motor Stretching reaction [Arms and hands folded in a convulsive way with hand turned outwards. Possibly all muscles of the body tense] No response[DEPRECATED] 1 GCS_Motor No response to pain stimuli [No physical reaction movement to a pain stimulus] [DEPRECATED] No response 1 GCS_Motor No movement on stimulus [No movement on a stimulus] Not applicable 0 NullFlavor Not applicable   GCS_MotorCodelistBaby Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Moves spontaneously and purposefully 6 GCS_Motor Normal [moves as expected] Localizing 5 GCS_Motor Retreat on touch [Pulls back on touch] Normal flexion 4 GCS_Motor Retreat in response to pain [Makes repellent or receding movement in case of a pain stimulus] Abnormal flexion 3 GCS_Motor Bending response [Slow, bending of arms and/or legs] Abnormal extension 2 GCS_Motor Decerebral stretching response [stretching of arms and/or legs] No response 1 GCS_Motor No movement on stimulus [No movement on a stimulus] Not applicable 0 NullFlavor Not applicable   3           GCS_MotorCodelistToddler Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Obeys commands 6 GCS_Motor Executes order to move [A simple request for movement is performed] Localising 5 GCS_Motor Retreat on touch [Pulls back on touch] Normal flexion 4 GCS_Motor Retreat in response to pain [Makes repellent or receding movement in case of a pain stimulus] Abnormal flexion 3 GCS_Motor Bending response [Slow, bending of arms and/or legs] Abnormal extension 2 GCS_Motor Decerebral stretching response [stretching of arms and/or legs] No response 1 GCS_Motor No movement on stimulus [No movement on a stimulus] Not applicable 0 NullFlavor Not applicable   4           GCS_VerbalCodelist Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Oriented 5 GCS_Verbal Oriented [Clearly and clearly aware of the situation] Confused [DEPRECATED] 4 GCS_Verbal Confused [Confused conversation but able to answer the questions] [DEPRECATED] Confused 4 GCS_Verbal Confused [confused but communicates coherently] Inappropriate speech 3 GCS_Verbal Inadequate [Words are understood but do not form sentences] Incomprehensible sounds [DEPRECATED] 2 GCS_Verbal Unintelligible [Speech is not understood] [DEPRECATED] Moaning 2 CGS_Verbal Moaning [no speech, just moaning] No response 1 GCS_Verbal No response [No verbal response] Not applicable 0 NullFlavor Not applicable   5           GCS_VerbalCodelistBaby Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Oriented [DEPRECATED] 5 GCS_Verbal Laughing and crying [Laughs or Cries Softly] [DEPRECATED] Coos/babbles 5 GCS_Verbal Kirt/babble Confused 4 GCS_Verbal Crying [Cries and Is Impassable] [DEPRECATED] Irritable cries 4 GCS_Verbal Cries irritable Inappropriate speech [DEPRECATED] 3 GCS_Verbal Not adequate crying [Persistent crying or screeching] [DEPRECATED] Cries to pain 3 GCS_Verbal Cries of pain Incomprehensible sounds [DEPRECATED] 2 GCS_Verbal Moaning [Moaning and Restless/Restless] [DEPRECATED] Moans 2 GCS_Verbal Wails/groans No response 1 GCS_Verbal No response [No verbal response] Not applicable 0 NullFlavor Not applicable           6           GCS_VerbalCodelistToddler Valueset OID: Binding: Required Conceptname Concept value Codesystem name Description Orientated 5 GCS_Verbal Oriented [Clearly and clearly aware of the situation] Confused 4 GCS_Verbal Confused [confused but communicates coherently] Inappropriate speech [DEPRECATED] 3 GCS_Verbal Crying [Persistent crying or screeching] [DEPRECATED] Words 3 GCS_Verbal Inadequate [Words are understood but do not form sentences] Incomprehensible sounds [DEPRECATED] 2 GCS_Verbal Moaning [Moaning Only] [DEPRECATED] Sounds 2 GCS_Verbal Incorrect words [incorrect words or sounds like moaning] No response 1 GCS_Verbal No response [No verbal response] Not applicable 0 NullFlavor Not applicable

Jeremy, Zac I've been through this again and added more comments, also suggested a few more inclusions SNOMED codes for COVID ICU 20200406 AnesCRG comments v2.xlsx