Diagnostic yield from 231 autopsies in a community hospital

A triad algorithm for analysing individual ante- and post-mortem findings to improve the quality of intensive care

Autopsy is an important source of data for education and quality control. The aim of this study was comparison of ante- to post-mortem findings to detect weak points of intensive care unit (ICU) care. Patients who died in our 14-bed university medical ICU care and underwent an autopsy examination over 20 months (September 2007 to May 2009) were included. Modified Goldman's criteria were used to categorise discrepancies between diagnoses and post-mortem findings. A triad algorithm was constructed to analyse individual ante- to post-mortem findings. One hundred and seventy post-mortem examinations were conducted (45.6% autopsy rate). Major diagnostic discrepancies were detected in 20 patients (11.8%); four class I (2.4%) and 16 class II (9.4%). Massive pulmonary embolism with cardiac arrest was the most common class I discrepancy (75%). Triad analysis of major class I discrepancies showed that all patients had a history of chronic disease; the majority (75%) had a short ICU length of stay. In 75% adequate tests were used to detect disorders. There were interpretation problems of bedside data in complex emergency clinical conditions, especially with less experienced ICU physicians. Inappropriate or incorrectly interpreted diagnostic procedures were performed in more than half of cases with class II discrepancies (9/16, 56%). Abdominal ultrasonography was misleading in 31% (5/16) cases with class II discrepancies. In conclusion, triad algorithm analysis revealed problematic interpretation of bedside diagnostics in emergency cases by inexperienced physicians in class I major discrepancies detected at autopsy. No correct test and wrong interpretation of abdominal ultrasonography were major causes of class II discrepancies.

Comparison of clinical and post-mortem findings in intensive care unit patients

The autopsy has long been regarded as an important tool for clinical confrontation, education and quality assurance. The aims of this study were to examine the correlation between the clinical diagnosis and autopsy findings in adult patients who died in an intensive care unit (ICU) and to identify the types of errors in diagnosis to improve quality of care. Autopsies from 289 patients who died in the ICU during a 2-year period were studied. Post-mortem examination revealed unexpected findings in 61 patients (21%) including malignancy, pulmonary embolism, aspergillosis, myocardial or mesenteric infarction and unsuspected bacterial, viral or fungal infection. These unexpected findings were classified as Goldman class I errors in 17 (6%), class II in 38 (13%) and class III in six (2%) cases. Although the incidence of unexpected findings with clinical significance was low, post-mortem examination remains a valuable source of pertinent information that may improve the management of ICU patients.

Post mortem examination in the intensive care unit: still useful?

OBJECTIVE

Post mortem examination rates have decreased worldwide and their usefulness has been challenged. The aim of this study was to compare ante- versus post mortem findings in a multidisciplinary ICU.

DESIGN

Retrospective study.

SETTING

Thirty-one-bed, medico-surgical ICU.

PATIENTS

All patients who died on the ICU and underwent an autopsy examination in 1999.

MEASUREMENTS

Records from autopsies were compared with clinical records. A modified Goldman's criteria was used to categorize the post mortem diagnoses. Unexpected findings were evaluated according to the duration of hospitalization prior to death (fewer than or more than 10 days).

RESULTS

Among 2,984 ICU admissions, there were 489 deaths; 222 autopsies were conducted (45.4% autopsy rate). Post mortem examination revealed unexpected findings in 50 patients (22.5%), including malignancy (22 [9.9%]), fungal infections (9 [4%]), pulmonary embolism (7 [3.2%]), nosocomial infections (3 [1.3%]), Hashimoto's disease (3 [1.3%]), mesenteric infarction (2 [0.9%]), Barrett's esophagus (2 [0.9%]), endocarditis (1 [0.5%]) and myocardial infarction (1 [0.5%]). These unexpected findings were considered as major (Class I/II) in 19 (8.5%), and minor (Class III) in 31 (14%) patients. In patients with a short ICU length of stay (<10 days), there were more major unexpected findings than minor, while after a prolonged stay (>10 days), minor unexpected findings were more common.

CONCLUSIONS

After a short ICU stay (<10 days), autopsy revealed discrepancies primarily related to the cause of death associated with diseases whose diagnosis can be difficult. Following more prolonged ICU stays (>10 days), autopsy was more likely to reveal coexisting diseases unrelated to death.

Clinical recognition of pulmonary embolism: problem of unrecognized and asymptomatic cases

Dyspnea, pleuritic chest pain, and tachypnea are widely appreciated as common initial features of pulmonary embolism (PE). This knowledge is derived primarily from prospective studies evaluating diagnostic tests or therapeutic interventions in which the study patients are suspected to have PE based on their initial symptoms. Autopsy studies, however, continue to show that most cases of fatal PE are unrecognized and undiagnosed. Data from studies screening for PE in patients with deep venous thrombosis and in postoperative patients suggest that many patients with PE are asymptomatic and that PE is unrecognized. We believe that the current concepts regarding the initial clinical features of PE are too narrow and biased toward symptomatic cases. High clinical suspicion may be insufficient in recognizing PE. Herein we summarize the available data and explore the implications for clinical practice.

Thoraxsonography--Part II: Peripheral pulmonary consolidation

In many cases of pulmonary diseases extending up to the pleura, ultrasound (US) helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. Pneumonic infiltration shows a hypoechoic inhomogeneous echo texture, with multiple air inlets and bronchoaerograms. Fluid bronchogram indicates an obstructive pneumonitis. Pulmonary infarctions are visible in different stages as triangular pleural-based lesions in most cases of pulmonary embolism. The diagnostic accuracy of chest sonography in pulmonary embolism was 85%-90%. US-guided transthoracic biopsy shows a diagnostic yield of > 90% in malignancies and 50%-83% of benign lesions. The overall complication rate is very low: 1%-2% hemoptysis, 2%-4% pneumothoraces and 1%-2% requiring chest tube drainage. Color Doppler US can demonstrate the vascular patterns and may help in the understanding of underlying pathophysiology. Sonographic examinations of the upper and central mediastinum provide good results in 90-95% of cases. Some anatomical limitations of transcutaneous US can be circumvented by endoluminal US.