Autopsy in a neonatal intensive care unit: utilization patterns and associations of clinicopathologic discordances

doi:10.1016/S0022-3476(98)70488-3

The Journal of Pediatrics

Volume 132, Issue 1, January 1998, Pages 75-79

https://doi.org/10.1016/S0022-3476(98)70488-3 Get rights and content

Abstract

Objectives: (1) To develop methods to describe autopsy utilization patterns in a neonatal intensive care unit. (2) To identify classes of patients likely to have clinicopathologic concordance or discordance. Methods: Five hundred forty-five consecutive neonatal intensive care unit deaths (338 autopsied, rate 62%) in a regional tertiary/quaternary care neonatal intensive care unit for referred infants (65,000 annual births) were classified in six clinical diagnostic groups (anomalies, cardiac anomalies, hypoxic ischemic encephalopathy, prematurity and its complications, infections, and other) and rated in three levels of certainty of clinical diagnosis as “gold standard” certainty, almost complete certainty, and less certain than the latter. Clinicopathologic discordances were rated in three classes using clinical, pathologic, and multidisciplinary mortality conference records. The proportions of autopsied cases, cases with major discordances, and cases with no discordances were compared and analyzed in relation to diagnostic group and level of certainty. Results: Performance of autopsy was associated with clinical diagnostic uncertainty (p = 0.008). Major discordances with implications for outcome (Class I) were found in 3%, and without implications for outcome (Class II) in 15% of cases; 42% of cases had no discordances. Major discordance rate varied inversely with the degree of diagnostic certainty (p = 0.000) and varied among clinical groups. Conclusions: (1) Autopsy was used most for cases with potential for high yields. (2) Clinicopathologic discordances were more frequent and important in certain clinical diagnostic groups (prematurity, other) and with high levels of diagnostic uncertainty. When the diagnostic “gold standard” is available during life, autopsy will provide little information. (J Pediatr 1998;132:75-9)

Section snippets

Setting and Study Population

The NICU at the Hospital for Sick Children is the only referral center for infants born in level I and II neonatal units (about 55,000 annual births), and the quaternary referral center for infants born in two regional tertiary care perinatal centers (about 10,000 annual births). Infants with rapidly lethal conditions (e.g., extreme asphyxia) who died at referring hospitals were not included. Full-term infants with diaphragmatic hernia were admitted directly to the pediatric intensive care unit

Results

During the 6-year period, 338 of 545 (62%) patients who died had autopsies, 44 were coroners' autopsies, and 19 were limited to pertinent regions by parental request.

Discussion

The major findings of this study were (1) autopsied cases had greater clinical diagnostic uncertainty than nonautopsied cases; and (2) clinicopathologic discordance was associated with clinical diagnostic uncertainty (p < 0.000), and varied between clinical groups. Major discordances with implications for outcome were found in 3% of cases.

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Cited by (28)

Autopsy in a Neonatal Intensive Care Unit: pathological and clinical agreement
2022, Jornal de Pediatria
Citation Excerpt :
Based on the autopsy reports of these patients, management protocols were modified at out NICU; the authors currently recommend echocardiography and a formal fetal cardiology assessment for all patients followed by the fetal medicine service who have major malformations and echocardiography for those with altered cardiovascular examinations or abnormal heart test results. Overall, additional findings have been reported in 22 to 81% of autopsies,9 with 3 to 5% of these having prognostic implications.21,12,13 Costa et al. 17 found that 66% of autopsies revealed additional information.
To evaluate neonatal autopsy rates at a tertiary hospital in southern Brazil ascertain the level of agreement between premortem and postmortem diagnosis.
The authors reviewed all neonatal autopsies performed over a 10-year period and described the percentage of neonates who died and underwent autopsy. The authors tested for agreement between autopsy findings and the cause of death as defined by the neonatologist. Agreement between clinical diagnosis and autopsy findings was classified using the modified Goldman criteria. Additional findings at autopsy were grouped by organ system. Linear regression and multiple comparisons were used for statistical analyses.
During the study period, 382 neonates died at the Neonatal Intensive Care Unit (NICU). Consent to perform an autopsy was obtained for 73 (19.1%). The complete agreement between autopsy findings and the neonatologist's premortem diagnosis was found in 48 patients (65.8%). Additional findings were obtained at autopsy in 25 cases (34.2%). In 5 cases (6.9%), the autopsy findings contributed to subsequent genetic counseling. Seven autopsies (9.6%) revealed a diagnosis that would have changed patient management if established premortem. The autopsy rate increased by an average of 1.87% each year.
Despite a high level of agreement between clinical diagnosis and pathological findings, autopsies provided relevant data regarding the cause of death, providing additional clinical information to neonatologists and allowing genetic counseling of family members.
Supporting bereaved parents: practical steps in providing compassionate perinatal and neonatal end-of-life care - A North American perspective
2008, Seminars in Fetal and Neonatal Medicine
Citation Excerpt :
These may include parental testing, placental tissue for cytogenetics, blood sampling, skin biopsy, radiographs, and a post-mortem exam or autopsy.1,40 Whether autopsy adds new information in a strictly medical sense is disputed41; however, in an estimated 10–40% of occasions it provides further clarification of diagnosis.1 Nonetheless, advantages to families of a post-mortem investigation include the opportunity to support parents' decision for palliation, alleviate guilt, and give closure.32
Providing compassionate bereavement support challenges care-givers in perinatal medicine. A practical and consistent approach tailored to individual families may increase the care-giver's ability to relieve parental grief. This approach includes: (1) clear and consistent communication compassionately delivered; (2) shared decision-making; (3) physical and emotional support; and (4) follow-up medical, psychological and social care. Challenges to providing comprehensive end-of-life care include care-giver comfort, consistency of care, cultural and legal barriers, and lack of adequate training.
Value of autopsy in a neonatal intensive care unit
2008, Anales de Pediatria
Conocer el perfil de los casos sometidos a autopsia, analizar la discrepancia clinicopatológica e investigar los factores predictivos de un rendimiento alto.
Se estudiaron retrospectivamente todas las autopsias practicadas en una unidad de cuidados intensivos neonatológicos de tercer nivel entre enero de 1999 y diciembre de 2005. De manera independiente, dos patólogos y dos neonatólogos establecieron la concordancia clinicopatológica según la clasificación de Goldman modificada. Se compararon los neonatos sometidos a autopsia con los que no lo fueron, y se investigaron los factores predictivos de hallazgos insospechados.
Se practicaron 128 autopsias (41,4 %) en 309 fallecimientos ocurridos durante el período de estudio. Las necropsias se realizaron con más frecuencia en los recién nacidos mayores de 36 semanas de edad gestacional (p < 0,001), peso superior a 1.500 g (p < 0,001) y con malformación (p < 0,007). Sin embargo, la probabilidad de que se concediera la autopsia decreció cuanto mayor era la edad del paciente fallecido (p < 0,016). Se observaron diagnósticos insospechados en el 49,2 % de las necropsias, siendo relevantes en el 21,1 %. En 4 casos (3,1 %) existió una discrepancia clinicopatológica con implicaciones en el pronóstico. No fue posible predecir los hallazgos insospechados relevantes en función del diagnóstico clínico ante mortem, la edad gestacional, el peso al nacer, el sexo y la edad en el momento del fallecimiento.
La autopsia continúa siendo el método de referencia e insustituible para demostrar diagnósticos insospechados y relevantes. La necropsia debe solicitarse de manera sistemática ante toda muerte neonatal. Sin embargo, factores como la edad gestacional, el peso de nacimiento, la presencia de malformaciones y la edad de fallecimiento influyen en la probabilidad de ser concedida.
1) To identify the profile of the cases requested for autopsy; 2) to analyze the clinocopathological discordance; 3) to investigate predictive factors for unsuspected clinically relevant diagnoses.
All autopsies performed between January 1999 and December 2005 in a tertiary neonatal intensive care unit, were retrospectively reviewed.
Clinicopathological concordance was assessed independently by two neonatologists and two pathologists, according to a modification of the Goldman classification. A comparison was made between newborns who had an autopsy performed and those who did not and predictive factors for unsuspected findings were investigated.
During the study period, there were 309 deaths, and autopsies were performed in 128 (41.4 %) of these cases. Autopsies were more common in newborns who had gestational age > 36 weeks (p < 0.001), birthweight > 1500 g (p < 0.001) and congenital defects (p < 0.007). However, the probability that the autopsy was granted decreased with increasing death age (p < 0.016). Unsuspected diagnoses were observed in 49.2 % of the autopsies, being a major finding in 21.1 % of the cases. A clinicopathological discordance involving the prognosis was found in four cases (3.1 %). Relevant unsuspected findings could not be predicted from the ante-mortem clinical diagnosis, gestational age, birthweight, sex, and death age.
The autopsy remains the “gold standard” method to reveal major and unsuspected diagnoses and there is no substitute for it. Postmortem examination should be requested systematically in every neonatal death. However, several factors such as gestational age, birthweight, presence of congenital defects and death age, influence the likelihood of autopsy being granted.
Clinical aspects of neonatal death and autopsy
2004, Seminars in Neonatology
An autopsy carried out by a trained perinatal pathologist can provide parents and professionals with new information about the cause of a baby's death. It is extremely stressful for parents to be asked for autopsy authorisation. The request is also very demanding for the staff. The rates of neonatal autopsy have been declining since 1990 and, almost certainly, the adverse publicity surrounding the Alder Hey enquiry precipitated a further fall in authorisation rates. Only a re-establishment of trust between parents and professionals can reverse this trend. This trust is founded on excellent perinatal communication and clinical care. The child's death must be managed in the most empathetic way, with an understanding of bereavement and the grief support required. If the parents and professionals work together as a team, the parents should sense the commitment of staff to their family. They may then be more likely to understand the importance of autopsy and to provide authorisation.
Postmortem studies in the contemporary pediatric intensive care unit
2011, Pediatric Critical Care Medicine
To describe the implementation of an educational program that achieved high compliance with autopsy requests and consents in a pediatric intensive care unit. To evaluate the concordance between clinical diagnoses and autopsy findings and to identify patient characteristics in which postmortem diagnosis elucidated the primary disease process.
Retrospective, observational study.
A pediatric intensive care unit in a tertiary care teaching hospital.
All pediatric intensive care unit patients with autopsy reports from 2000 to 2005.
An educational program and protocol were initiated in 1995–1996 to raise awareness and formalize the process for autopsy request. From 2000 to 2005, data were collected from medical records and pathology department autopsy reports. Premortem and postmortem diagnoses were compared utilizing the modified Goldman's classification. The associations of Goldman's classification with age of patients and length of stay were explored.
After the educational program was instituted, an autopsy rate of >50% was attained compared to 20%–30% in previous years (p < .05). From 2000 to 2005, 139 autopsies were performed. In 111 patients (79.8%), complete concordance of premortem and postmortem diagnoses was found; in 22 cases (16%), there was no concordance and in six cases the postmortem studies failed to explain the mechanism of death. Autopsies provided new and pertinent findings in 47.5% of all studies, with histologic information accounting for 58% of them. A relationship between short length of stay and the presence of autopsy findings elucidating the main disease process was found (p < .05).
It is feasible to produce a sustainable increase in the rate of postmortem studies within an organization. Autopsy results added new information to almost half of the patients, particularly those who died soon after admission. A pediatric intensive care unit strategy to increase and maintain compliance with autopsy requests is an important practice with favorable clinical and educational repercussions.
Cause of Death in Neonates with Neurological Insults in the Neonatal Intensive Care Unit: Insights from A MITS Pilot Study
2021, Clinical Infectious Diseases

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^☆: From the Division of Neonatology, Department of Paediatrics and the Department of Pathology, Hospital for Sick Children and the University of Toronto, Ontario, Canada.

^☆☆: Reprint requests: Max Perlman, MB, FRCP, Division of Neonatology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8.

^★: 9/21/82213

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Autopsy in a neonatal intensive care unit: utilization patterns and associations of clinicopathologic discordances☆,☆☆,★

Abstract

Section snippets

Setting and Study Population

Results

Discussion

Pediatr Clin North Am

J Pediatr

The clinical utility of the perinatal autopsy

JAMA

Reflections on the postmortem audit

JAMA

Factors influencing discrepancies between premortem and postmortem diagnoses

JAMA