Anesthesia Section

Template ID: 2.16.840.1.113883.10.20.22.2.25 Version: V2 (2014-06-09) Badge: Surgical Section

Overview

The Anesthesia Section records the type of anesthesia (e.g., general, local, regional) and may state the actual anesthetic agents used during a surgical or procedural intervention. This section may be included as a standalone section or as a subsection of the Procedure Description Section. The full details of anesthesia administration are usually found in a separate Anesthesia Note.

Clinical Purpose and Context

The Anesthesia Section documents: - Type of anesthesia used (general, local, regional, sedation) - Specific anesthetic agents and medications administered - Route of administration - Timing of anesthesia (start and end times) - Anesthesia provider information - Clinical notes about anesthesia delivery

This section provides critical information for post-operative care, future anesthetic planning, and documentation of the complete surgical procedure.

When to Include

The Anesthesia Section is typically included in: - Operative Notes (primary use case) - Procedure Notes (for procedures requiring anesthesia) - Surgical Summaries - Discharge Summaries (when documenting surgical procedures)

Note: Detailed anesthesia records are typically maintained in separate Anesthesia Notes; this section provides summary information.

Template Details

Official OID

• Root: 2.16.840.1.113883.10.20.22.2.25
• Extension: 2014-06-09 (V2)

Conformance Level

• Conformance: MAY (Optional)
• Section Code: 59774-0 (LOINC - "Anesthesia")

Cardinality

• Section: 0..1 (Optional)
• Entries: 0..* (Procedure Activity and Medication Activity entries)

Related Templates

• Procedure Activity Procedure (V2): 2.16.840.1.113883.10.20.22.4.14:2014-06-09 (for anesthesia type)
• Medication Activity (V2): 2.16.840.1.113883.10.20.22.4.16:2014-06-09 (for anesthetic agents)

Protocol Requirements

The AnesthesiaProtocol defines the data contract for anesthesia records. Each anesthesia record must provide:

Required Properties

Property	Type	Description
anesthesia_type	str	Type of anesthesia (e.g., "General anesthesia")
anesthesia_code	str	SNOMED CT code for anesthesia type
anesthesia_code_system	str	Code system (typically "SNOMED CT")
status	str	Status: 'completed', 'active', 'aborted'

Optional Properties

Property	Type	Description
start_time	Optional[date\|datetime]	When anesthesia was started
end_time	Optional[date\|datetime]	When anesthesia was stopped
anesthesia_agents	Optional[list[MedicationProtocol]]	Anesthetic medications used
route	Optional[str]	Primary route of administration
performer_name	Optional[str]	Name of anesthesiologist/anesthetist
notes	Optional[str]	Additional clinical notes

Data Types and Constraints

• anesthesia_type: Human-readable description (e.g., "General anesthesia")
• anesthesia_code: SNOMED CT code (e.g., "50697003" for general anesthesia)
• start_time/end_time: Can be date or datetime objects
• anesthesia_agents: List of medications, each implementing MedicationProtocol
• route: Common values: 'Inhalation', 'Intravenous', 'Intramuscular', 'Topical'

Code Example

Here's a complete working example using ccdakit to create an Anesthesia Section:

from datetime import datetime
from ccdakit.builders.sections.anesthesia import AnesthesiaSection
from ccdakit.core.base import CDAVersion

# Define an anesthetic medication class
class AnestheticAgent:
    def __init__(self, name, code, dose, route):
        self._name = name
        self._code = code
        self._dose = dose
        self._route = route

    @property
    def name(self):
        return self._name

    @property
    def code(self):
        return self._code

    @property
    def dose(self):
        return self._dose

    @property
    def route(self):
        return self._route

    @property
    def frequency(self):
        return None

# Define anesthesia records using AnesthesiaProtocol
class AnesthesiaRecord:
    def __init__(self, anesthesia_type, code, agents=None, start_time=None,
                 end_time=None, route=None, performer=None):
        self._anesthesia_type = anesthesia_type
        self._anesthesia_code = code
        self._anesthesia_code_system = "SNOMED CT"
        self._status = "completed"
        self._start_time = start_time
        self._end_time = end_time
        self._anesthesia_agents = agents or []
        self._route = route
        self._performer_name = performer
        self._notes = None

    @property
    def anesthesia_type(self):
        return self._anesthesia_type

    @property
    def anesthesia_code(self):
        return self._anesthesia_code

    @property
    def anesthesia_code_system(self):
        return self._anesthesia_code_system

    @property
    def status(self):
        return self._status

    @property
    def start_time(self):
        return self._start_time

    @property
    def end_time(self):
        return self._end_time

    @property
    def anesthesia_agents(self):
        return self._anesthesia_agents

    @property
    def route(self):
        return self._route

    @property
    def performer_name(self):
        return self._performer_name

    @property
    def notes(self):
        return self._notes

# Create anesthetic agents
agents = [
    AnestheticAgent(
        name="Propofol 10mg/mL injection",
        code="73133000",  # SNOMED CT for Propofol
        dose="200 mg",
        route="Intravenous"
    ),
    AnestheticAgent(
        name="Fentanyl 0.05mg/mL injection",
        code="373492002",  # SNOMED CT for Fentanyl
        dose="100 mcg",
        route="Intravenous"
    ),
    AnestheticAgent(
        name="Sevoflurane inhalation",
        code="386838001",  # SNOMED CT for Sevoflurane
        dose="2% concentration",
        route="Inhalation"
    )
]

# Create anesthesia record
anesthesia_records = [
    AnesthesiaRecord(
        anesthesia_type="General anesthesia",
        code="50697003",  # SNOMED CT for general anesthesia
        agents=agents,
        start_time=datetime(2024, 10, 15, 8, 30),
        end_time=datetime(2024, 10, 15, 11, 45),
        route="Intravenous",
        performer="Dr. Jane Smith, MD (Anesthesiologist)"
    )
]

# Build the Anesthesia Section
section_builder = AnesthesiaSection(
    anesthesia_records=anesthesia_records,
    title="Anesthesia",
    version=CDAVersion.R2_1
)

# Generate XML element
section_element = section_builder.build()

# Convert to XML string (for demonstration)
from lxml import etree
xml_string = etree.tostring(section_element, pretty_print=True, encoding='unicode')
print(xml_string)

Official Reference

For complete specification details, refer to the official HL7 C-CDA R2.1 documentation: - HL7 C-CDA R2.1 Implementation Guide - Section: Anesthesia Section (V2)

Best Practices

Common Patterns

1. Document Complete Anesthesia Information
2. Include both anesthesia type (procedure) and agents (medications)
3. Record timing (start and end times)
4. Document the anesthesia provider

5. Note the primary route of administration

6. Use Standard Anesthesia Codes

7. General anesthesia: 50697003 (SNOMED CT)
8. Local anesthesia: 386761002 (SNOMED CT)
9. Regional anesthesia: 231249005 (SNOMED CT)
10. Spinal anesthesia: 50697003 (SNOMED CT)
11. Epidural anesthesia: 18946005 (SNOMED CT)

12. Conscious sedation: 72641008 (SNOMED CT)

13. Link Agents to Anesthesia Type

14. Each anesthesia record can include multiple agents
15. Agents are represented as Medication Activity entries

16. Group related agents with their anesthesia type

17. Document Timing Accurately

18. Start time: When anesthesia was initiated
19. End time: When patient emerged from anesthesia
20. Use datetime objects for precise timing
21. Important for calculating anesthesia duration

Validation Tips

1. Section Code Validation
2. Ensure section code is 59774-0 (LOINC "Anesthesia")

3. This is automatically set by the builder

4. Entry Structure Validation

5. Procedure Activity entries for anesthesia type
6. Medication Activity entries for anesthetic agents

7. Each entry has typeCode="DRIV"

8. Code System Validation

9. Anesthesia type codes from SNOMED CT
10. Medication codes from SNOMED CT or RxNorm

11. Route codes from NCIT or SNOMED CT

12. Status Validation

13. Use 'completed' for finished procedures
14. Use 'active' for ongoing anesthesia (rare in final documentation)
15. Use 'aborted' if anesthesia was started but discontinued

Common Pitfalls

1. Confusing with Medications Administered
2. Use Anesthesia Section for anesthetic medications
3. Use Medications Administered Section for other medications given during procedure

4. Don't duplicate anesthetic agents in both sections

5. Missing Timing Information

6. While optional, timing is important for anesthesia
7. Include start and end times when available

8. Helps calculate anesthesia duration and recovery time

9. Incomplete Agent Information

10. List all significant anesthetic agents, not just induction agents
11. Include inhalational agents, IV agents, and adjuncts

12. Document doses when known

13. Not Distinguishing Anesthesia Types

14. Clearly identify the type of anesthesia used
15. Don't just list agents without specifying general vs regional

16. Anesthesia type affects post-operative care

17. Missing Provider Information

18. Document who provided the anesthesia
19. Important for accountability and follow-up

20. Include credentials (MD, CRNA, etc.) when known

21. Route Confusion

22. The route property is for the primary anesthesia route
23. Individual agents may have different routes
24. Common for combined techniques (IV + inhalational)

Related Sections

• Medications Administered Section: Non-anesthetic medications given during procedure
• Procedures Section: The surgical procedure requiring anesthesia
• Complications Section: Anesthesia-related complications
• Postoperative Diagnosis: Diagnoses at end of surgery

Code Systems and Terminologies

Anesthesia Type Codes (SNOMED CT)

• 50697003 - General anesthesia
• 386761002 - Local anesthesia
• 231249005 - Regional anesthesia
• 18946005 - Epidural anesthesia
• 231253002 - Spinal anesthesia
• 72641008 - Conscious sedation
• 50697003 - Balanced anesthesia

Anesthetic Agent Codes (SNOMED CT)

• 73133000 - Propofol
• 373492002 - Fentanyl
• 386838001 - Sevoflurane
• 387173000 - Isoflurane
• 387472004 - Desflurane
• 373200000 - Rocuronium
• 387222003 - Lidocaine

Route Codes

• 447694001 - Inhalation (SNOMED CT)
• 47625008 - Intravenous (SNOMED CT)
• 78421000 - Intramuscular (SNOMED CT)
• 6064005 - Topical (SNOMED CT)

Section Codes

• Primary: 59774-0 - "Anesthesia" (LOINC)

Implementation Notes

Dual Entry Pattern

The section uses a dual entry pattern: 1. Procedure Activity entry for anesthesia type/procedure 2. Medication Activity entries for each anesthetic agent

This allows complete documentation of both what type of anesthesia was used and what specific drugs were administered.

Narrative Table Generation

The builder creates a comprehensive table with columns: - Anesthesia Type - Code - Status - Start Time - End Time - Route - Agents (comma-separated list) - Performer

Time Formatting

The builder handles both date and datetime objects: - datetime: Formatted as "YYYY-MM-DD HH:MM" - date: Formatted as "YYYY-MM-DD" - Checks for the presence of hour attribute to determine type

Agent Handling

Anesthetic agents (medications) are: - Passed as a list in the anesthesia_agents property - Each agent must implement MedicationProtocol - Automatically converted to Medication Activity entries - Displayed in the narrative table

Multiple Anesthesia Records

The section supports multiple anesthesia records: - Useful for procedures with multiple anesthesia phases - Each record becomes a separate set of entries - Rare but possible (e.g., regional followed by general)

Integration with Procedure Note

The Anesthesia Section is commonly part of: - Operative Note documents - Procedure Note documents - Surgical Summaries

It provides context alongside: - Preoperative Diagnosis: Why surgery was needed - Procedure Description: What was done - Postoperative Diagnosis: What was found - Complications: Any adverse events

Anesthesia Note vs. Anesthesia Section

Anesthesia Section (this section): - Summary of anesthesia type and agents - Included in operative/procedure notes - Brief documentation for continuity of care

Anesthesia Note (separate document): - Detailed anesthesia record - Pre-anesthetic evaluation - Intraoperative monitoring - Complete medication administration record - Vital signs throughout procedure - Usually maintained separately

Provider Documentation

The performer_name should include: - Full name of anesthesia provider - Credentials (MD, CRNA, CAA) - Role if multiple providers (attending vs resident)

Example formats: - "Dr. John Smith, MD, Anesthesiologist" - "Mary Johnson, CRNA" - "Anesthesia Care Team: Dr. Smith (Attending) and J. Johnson, CRNA"

Route Documentation

The route property represents the primary route: - For general anesthesia: Often "Intravenous" (induction) or "Inhalation" (maintenance) - For regional: "Epidural", "Spinal", "Nerve block" - For local: "Subcutaneous", "Topical"

Individual agents may have different routes from the primary route.