Attendees were welcomed by Andrew Norton and a brief summary of the growth of anaesthetic terminology was given, with specific reference to the work of the Anaesthesia CRG, formerly SIG, in SNOMED/ IHTSDO.

Monica Harry supports the CRG as a terminologist, and briefly introduced her role.

2018-03-27 Anesthesia CRG Call

The minutes of this meeting were reviewed and accepted as a suitable record.

Review of sections of SNOMED CT hierarchy:

• 128258000 Ventilation finding
• 250763003 Anesthetic finding
  
  

Include consideration of relevance of terms under anesthetic finding to other medical specialties

Discussion of terminology relating to Accidental Awareness under GA (AAGA, see the NAP5 audit) was used as an example of the group's work.  Terminology will develop to accommodate AAGA as a search term and definition.

A number of other terms are undergoing revision and have been submitted to the content request system.

The structure of Ventilation Finding and Anaesthetic Finding was considered; "grouper" terms such as "Anesthetic finding" should be removed where they do not add value.  Some groupers may be removed, some should be renamed.

Anesthetic finding

Potentially redundant terms for difficulty with airway management, inc. intubation, were reviewed. Monica Harry and the group will look at these with a view to the consequences should we amalgamate them all.  The group noted that the term "intubation" was previously used to primarily refer to "intubation of the trachea", but wider use is now normal (e.g. placing a gastroscope in the oesophagus).  We may have to modify "intubation" terms to explicitly specify "tracheal intubation".  Classification structure will stay the same at moment.

CICV was not found in the pending release of SNOMED, Monica Harry will review this and see if its inclusion can be expedited.

Distinction between "Anaesthesia Finding" and "Anesthetic Finding" was not clear - changes were not made.

"Ventilation finding" was reviewed.

Terms will be reviewed so that terms properly fit their concepts; so that a continuous measurement (e.g. minute volume, or minute volume) is an Observable Entity, and the diagnosis of Hypoventilation will be a Finding.

SNOMED definition of Observable Entity
SNOMED definition of Finding

Minute volume and Minute ventilation are currently distinct concepts. Consider making them synonyms, with the primary term being an observable entity.

Multiple terms are noted which relate to terms such as Minute Volume; Andrew Norton will review these. Alveolar Ventilation is represented, but a review of ventilatory parameters will be worthwhile. Terminology must: 1) be clearly defined; and 2) use words such as "Volume" and "Capacity" precisely.

4

Current thinking seems to be represented in:

Anaesthesia 2018; doi:10.1111/anae.14247. The Airway App: exploring the role of smartphone technology to capture emergency front-of-neck airway experiences internationally.

The article presents the following terms re cricothyroidotomy:

Cannula Cricothyroidotomy
Wire-guided Cricothyroidotomy
Open Cricothyroidotomy
Scalpel- Introducer procedure:

• Scalpel–bougie Cricothyroidotomy
• Scalpel-Hook Cricothyroidotomy

(may develop to include use of adjunctive tools, e.g. surgical hook)

It also presents these for Tracheostomy:

Open tracheostomy
Percutaneous Tracheostomy

Discussion

Emergency cricothyrotomy is correctly spelt and synonymous with cricothyroidotomy in the current version of SNOMED.  Cricothyroidotomy and cricithyrotomy are now considered synonymous.  Emergency cricothyrotomy has a new FSN 398142004.

Cricothyroidotomy will remain the parent term, with open/ percutaneous/ emergency variants.

Device terminology may need to extend to include terms for specifically designed cricithyroidotomy tubes. We will review the representation of cricothyroidotomy tubes.  Andrew Marchant to review the devices which are available and comment on a suitable classification.

Tracheostomy terms have been reviewed and some ambiguity removed.

Parent of emergency cricothyrotomy was formation of anastomosis - this was incorrect and the parent is now cricothyrotomy.

FONA (Front Of Neck Access) is a recent term which encompss a broad range of techniques designed to access the larynx and trachea for the purposes of ventilation and oxygenation.

BJA: 118: 649 "Critical airways, critical language" uses and defines the term "Emergency front-of neck airway"

AQI terminology noted with respect to this topic area.

Areas of interest:

1. Infection following neuraxial blocks.
2. Infection following peripheral block.

Terms must align with current definitions of systemic sepsis (SIRS, etc.) though, so the AQI definitions are not sufficient in themselves. CQC definitions have been considered.

Superficial infection at neuraxial insertion site was considered to refer to the needle track, superficial to the deep fascia, a synonym which is in keeping with this was suggested. A similar term for infection at site of peripheral nerve block exists.

Deep tissue infection is already represented as "epidural abscess". No further change was proposed.  Deep infection associated with peripheral nerve block was reviewed, AQI/ ASA definition of infection was considered appropriate for use in SNOMED.

Meningitis associated with neuraxial block - was discussed in detail and the favoured wording was "Meningitis following neuraxial block" as this is an established method of expressionand implies no more than temporal association.  We decided that the duration of time should not be specified unless there is a widely accepted value in professional use (e.g. specified by the CDC).

Peripheral Nerve block associated with sepsis

Neuraxial block associated with sepsis

"Epidural infection with associated sepsis" need not be pre-coordinated in this fashion, and this term can be adequately represented with existing terms for "Epidural infection" and "Sepsis".  A similar argument applies to "Peripheral Nerve Blocks with associated sepsis".

Severe Sepsis with organ dysfunction - exists elsewhere and, although precoordinated, should probably be represented in SNOMED.  Must align with current consensus criteria for sepsis - SNOMED definition of sepsis may be ripe for updating. A request/ definition for "severe sepsis" and "sepsis with septic shock" should be formulated to accommodate these terms as currently defined (2018 sepsis consensus criteria). Septicaemic shock is accepted for the moment to continue in use, but sepsis as a parent with hypotension/ hypoperfusion as a child probably reflects current thinking more clearly - may merit a revisit before long.

A number of previous terms have been retired, new terms modelled.

Review new model and parent concepts

CLABSI and CABSI reviewed - these concepts have been superseded although CRBSI is still curent. AN suggests that we adopt the new definitions. "Infection associated with vascular device" seemed an appropriate home for these term, e.g. SCTID: 736152001.

Postoperative confusion is not very well defined; so although we can retain it, it should not be synonymous with POCD. 

POCD has a fairly specific definition.  Note article by Terri Monk - nihms363159, and references to DSM IV - POCD "is distinct from delirium and dementia".  We will request POCD as a new item within "Disorder of nervous system following procedure".

Postoperative delirium is to be requested as a new term, wth children: hyperactive/ htpoactive/ mixed.

Online "Zoom" meeting on 29th May 2018.