1
THE AUTOPSY MANUAL
The Beth Israel Deaconess Medical Center- Department of Pathology
Revised and Adopted:
June 2003 / WCQ
October 2003 / JLH
June 2004 / JLH
June 2006 / JLH
Updated by:
Jonathan L. Hecht MD PhD; Jeffery Joseph MD, PhD; (Original version by Peter Ciano MD; William C. Quist MD
PhD; Melissa Upton MD)
Phone/pager Numbers (75)4-XXXX, (63)2-XXXX, (66)7-XXXX, (outside page) 632-7243:
East Morgue
667-5783
West Morgue
632-9018
Jonathan Hecht, M.D., Ph.D. (Director)
Beeper # 39030
Jeffery Joseph, M.D., Ph.D.(Neuropath.) Beeper # 35290
Autopsy secretary (Chris Sturdivant)
667-5759
Autopsy supervisor (Gail Howe)
Beeper # 31426
Deiner (Emerson Springer)
Beeper # 92588
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Autopsy Check list: Autopsy # : A____-_________
Pt. Name:____________________________________MRN:_________________
The following things must be done prior to beginning an autopsy: Check off every box
after it has been performed and sign below:
  Log in the case into the autopsy log under the next sequential number.

 Speak with an involved clinician and discuss the case. Write down the major
questions for autopsy on the permit. Ask if any additional doctors need a copy of
the report, and list them on your PAD.

 Go over the permission with attending (Is this an ME case? Do the organs
have to be returned to the body? Who needs a copy of the report?)

 Go over the restrictions and major questions with attending

 Consult relevant staff (IS for medical renal, JJ for Neuro issues).

 Make extra copies of the following and take them with you to the autopsy
suite
1. Permission form
2. Certificate of death

 Compare all of the deceased IDs with the permission form and certificate of
death making sure they match before beginning the autopsy

 Return the signed original report of death and permit to Admitting, after you
complete the autopsy.
I have performed the above:
_________________________________________________________
Name (Resident)
date
Return this completed form along with copies of the permission form to Chris
Sturdivant.
Return the chart to medical records when you have finished your review.
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Basics:
1) Follow the above checklist (most items precede the dissection).
2) If you have any questions or complications before during or after the autopsy page your assigned attending, chief
resident or director of autopsy. You should never feel like you’re working on your own.
3) Document findings in detail (the form on the next page may be helpful).
Photograph all abnormalities before they are sectioned/destroyed. Perinatal photographs are required on all cases
(abnormal or not).
4) Start promptly; do not spend more than 30 minutes with the chart and getting hold of clinicians. The Deiner does
not determine the start of the autopsy. If he is not available at the appointed time, report him to his
supervisor (Gail Howe) and begin on your own.
5) Do not take chances with your safety, and call for back-up early if you get confused (there is no such thing as a 5
hr post).
6) Be prompt with your PAD/FAD. These documents must not be vague, but also must address clinical questions
directly- describe what is seen and try to make conclusion in the final summary
Autopsy Service Coverage
1) Every day 8:00am - 3:00pm unless you make special arrangements.
Weekends 8:00am - 3:00pm. The weekend staff member on-call is responsible for any autopsy done on a
weekend. They are responsible for supervising the dissection and signing out the PAD/FAD unless they make
other arrangements. That attending is requested to attend or to send a representative to autopsy conference on
the following Thursday
2) We accept outside cases if the patient has a BIDMC number and a contact clinician either here or at a nursing
facility. Do not accept any other outside cases (i.e. death at home) without involving the autopsy director.
3) The deiner is usually available, but should not be the source of delay – if you need to eviscerate, do so (ask your
chief or senior for help). If possible, arrange the autopsy start time with his supervisor (Gail Howe).
4) Talk to clinicians, not families (get your attending involved if this comes up)
Examination of the Autopsy Permission FormDo not accept a form from Admitting that lacks signature of family/next-of-kin, or the signature of the pronouncing
physician. All cases of a medical-legal nature should be cleared by the Medical Examiner, who may accept or waive
the case.
If you call the medical examiner, document the interaction on the report of death in the appropriate section of the
Report of Death.
Be clear on restrictions. These may be specific and written in the “SPECIFIC RESTRICTIONS OR REQUESTS”
section of the Permit or generic (check-boxes on form) in the “Disposition of organs” section of the Permit.
Division of Labor
1) The resident performs an external exam as the deiner is transferring the body to the table.
2) The deiner usually eviscerates, but the resident must supervise and verify his work (i.e. forgetting to take the
prostate is the resident’s fault). The resident MUST be in the room during the entire autopsy.
3) The deiner cleans the autopsy room each week, but not after each case. You will be cleaning up your
dissection area.
4) For West Campus cases, the deiner is expected to transport the organs to the East morgue within 24 hrs.
Associated conferences (Thursday 11AM Gross and monthly Gross-micro).
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NAME:___________________________________________________ AUTOPSY#______________
Length/Height:
Weight:
Hair (color/length):
Skin:
Eyes (pupils/color):
Ears:
Teeth:
Nose:
Genitals:
Extermities:
Personal Objects:
Brain wt (g)/findings:
NECK & THORAX
Pleural: L(ml):
Type of fluid:
Adhesions:
R (ml):
Thyroid (g):
Breasts:
ABDOMEN
Peritoneal (ml):
Type of fluid:
Adhesions:
GI TRACT
Esophagus:
Adrenals: L(g):
R(g):
Stomach:
(contents):
Gallbladder:
(Contents(ml/stones)):
Liver (g):
(Parenchyma):
Trachea
Lungs: L(g):
Parenchyma:
Bronchi:
Arteries:
Nodes:
Small intestine:
R(g):
Spleen (g):
Pancreas:
Kidneys: L(g):
Cortex:
Medulla:
Ureters/bladder:
Prostate (size):
R(g):
Colon/rectum:
Pericardium (ml):
Adhesions/open:
Diverticula:
Testes: L (g):
Heart (g):
Dominance (L/R):
Walls (cm): LV:
Valves: TV:
PV:
Atherosclerosis:
Systemic:
Coronary(%):
RT:
Lt. Main:
LAD:
Circ:
Lymph nodes:
Muscle/skeletal:
RV:
MV:
AV:
R(g):
Uterus & Cervix:
Tubes:
Ovaries: L:
R:
Appendix:
BABIES (cm)
CR:
Foot:
Head circum:
Cord:
CH:
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TABLE OF CONTENTS
PAGE
1.
Introduction
6
2.
Autopsy Service Coverage
7
3.
Preparation for the Autopsy- Review of Permit and Restrictions
7
4.
Safe Performance of Autopsies and Handling of Tissues and Formalin
10
5.
Infection Control Guidelines
11
6.
Autopsy Room: General Overview and Division of Labor
13
7.
Autopsies on Patients Who Die Outside the Beth Israel Deaconess Medical Center
14
8.
Medical Examiner’s Cases
15
9.
Ancillary Studies
17
10.
Organ Donation
21
11.
The Complete Adult Autopsy- detailed procedure
21
11a. Cardiac Exam
23
12.
Stock Bottle & sections.
29
13.
Autopsy Neuropathology
29
14.
Recording the Cause of Death
32
15.
Reviewing the Case with Staff pathologist, Sectioning, and Photography
33
16.
Preparation of Autopsy Documents
34
17.
Communication of Autopsy Findings
34
18.
Infectious Autopsy
36
19.
Severe Acute Respiratory Syndrome (SARS) Patients
39
20.
Fetal/Neonatal Autopsy
41
20.
Autopsy Conferences
53
21.
Observers
53
22.
Requests for Tissues for Research Purposes
53
23.
Quality assurance
53
24. Templates (adult and fetal)
25. Appendices
46
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Introduction
This manual outlines the procedures and regulations pertaining to the various aspects of the Autopsy Service. While
the manual is not meant to be exhaustive, it addresses most of the specific issues that relate to the autopsy. We have
delineated in detail the entire autopsy process from the reception of the postmortem permission to completion of the
final autopsy report. Questions not specifically answered by this manual may be addressed to the Chief Resident(s),
the Staff pathologist responsible for that case, or the Directors of the Autopsy Service, as indicated by the particular
problem. This manual will be amended or updated as needed. Your suggestions/comments are welcomed.
The Autopsy Service performs ~150 postmortem examinations per year (representing ~20% of the deaths at the
Hospital). The autopsy at this institution ranges from unrestricted cases in which all the internal organs, including
the brain and spinal cord, are examined and removed, to autopsies limited by specific restrictions delineated in the
autopsy permission. The majority of our cases are complete adult examinations. A percentage are fetal/neonatal or
restricted cases.
In addition to their value in epidemiologic studies, detecting or elucidating previously unknown disease processes or
complications of therapy, providing a basis for reassurance or genetic counseling of the patient's family, and
provision of materials for research purposes, the autopsy represents a critical mechanism for assessing the accuracy
of clinical diagnosis and quality of care (reviewed in Cameron et al., Br Med J 281:955, 1980; Goldman et al., N
Engl J Med 308:1000, 1983; Landefeld et al., N Engl J Med 318:1249, 1988). Indeed, a large number of wellperformed studies indicate that 1) roughly 25% (at a minimum) of autopsies reveal important diagnoses not detected
before the patient's death and which, if detected clinically, probably would have resulted in a change in treatment
which might have cured the patient or prolonged his/her survival, and 2) physicians are unable to predict which
autopsies are most likely to reveal clinically unsuspected, important new findings. As a result, it is the position of
both this Department and the Hospital Administration that every attempt should be made to secure autopsies on
every patient dying at the Beth Israel Deaconess Medical Center. Quite clearly, the value of the autopsy is greatest
when it is performed properly and the results of the examination are communicated to the patient's physician
effectively and promptly.
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Autopsy Service Coverage
Postmortem examinations are performed seven days per week between the hours of 8:00am and 3:00pm. Limited
autopsies (brain only) may be started later since. The cases are performed by pathology residents, assisted by a
Deiner (Emerson Springer), under the supervision of a staff pathologist. A pathology resident and staff pathologist
are on-call at all times to deal with questions and problems that relate to autopsy pathology. On rare occasions,
families or physicians will request an autopsy to be done after usual working hours. In virtually all instances, a
postmortem examination can wait until the next morning, but exceptional cases are those in which the funeral home
may need the body the evening of the patient's death or in which prompt dissection is needed for specialized studies
(e.g., viral cultures, electron microscopy). Dr. Hecht or Dr. Connolly must approve delays/after-hour posts. The
resident should contact the autopsy supervisor (Gail Howe) to determine if an autopsy assistant is available;
however, the resident may be required to perform the autopsy without the autopsy assistant.
Preparation for the Autopsy
A. Protocol for Autopsies –
1. EAST and WEST CAMPUS (Resident assignments are to one/either or both)
a)
Admitting should contact the resident regarding autopsies through the AP administrator or directly
(weekends), but it would be prudent for the resident to call or walk to the admitting department to see if
there are any autopsies pending (754-2212)
b) At the Admitting Department:
Pick up the Report of Death Form and expiration worksheet
Pick up the charts, if available, or check with the floor or with medical records
c)
Make sure that the Report of Death Form is properly filled out and that the right hierarchy of consent
was used in giving the permission for the autopsy.
Spouse -> ALL children or designated representative child -> BOTH parents or designated
representative parent -> other relative or caretaker with a statement of their relationship to the
deceased
d) RESTRICTIONS (specified on the permit):
Two sections of the permit pertain to restrictions on pathology.
1) “SPECIFIC RESTRICTIONS OR REQUESTS”: These are specific prohibitions regarding dissection
(i.e. No head, chest only, etc).
2) “DISPOSITION OF ORGANS FOLLOWING AUTOPSY” (section is reproduced below):
These are directions on how the organs are to be treated once they are removed.
a) In section one, if the family chooses the second box (“I do not authorize…”), the organs must be
returned with the body in a bag within the abdominal cavity.
1. The case will not be presented at Gross conference.
2. The brain should be cut in the fresh state with guidance as needed by a neuropathologist.
3. The organs are reviewed in the fresh state by the attending before they are returned to the
body. Histologic sections should be taken liberally (more than the usual 7 cassettes) at the
discretions of the attending.
4. You may keep small chunks of organs if their fixation will add value (i.e. a bowel lesion
may be kept/fixed with an associated short segment, heart values with vegetations may be
detached for fixation and later sectioning), but this privilege should not be abused to
accommodate an attending who wishes to view the organs on the next day. The vast
majority of each organ must be returned.
b) In section one, if the family chooses the first box (“I authorize…”) then a statement of which
organs have been kept for fixation must be included in the PAD/FAD. That line is part of the
proscribed template (included at the end of this manual).
c)
In section 3, if the family chooses the second box (“I do not authorize…”) then organs cannot be
permanently donated to the medical school for teaching. The resident must notify
neuropathology that the brain cannot be donated to Harvard Medical School.
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
This permission covers the removal of internal organs and tissues as may be deemed necessary by
the examining physician for analyzing disease processes and determining the cause of death except
as specified above by the person authorizing the autopsy. It is understood that due care will be
taken to avoid disfiguring the body.

The person authorizing the autopsy has the right to control the final disposition of the organs. Beth
Israel Deaconess Medical Center will return all organs with the body of the decedent at the time the
body is released, except for those organs for which prolonged fixation or complete detailed
examination is required in order to complete the autopsy, unless the authorizing person designates
an alternative disposition below.

The organs retained for detailed examination will be specified in the final autopsy report. The results
of the autopsy will be available from the deceased’s physician in approximately 8 weeks.
1) Disposition of organs (choose one):
I authorize Beth Israel Deaconess Medical Center to retain any organs for further examination to
determine the cause of death or understand the effects of therapy.
I do not authorize Beth Israel Deaconess Medical Center to retain any organs. All organs will be
returned with the body for burial and a limited report of the findings will be issued to the
deceased’s physician. Skip items 2 & 3 below.
2) Disposal of tissue and organs. Tissues and organs taken at autopsy must be disposed of in a
lawful way. The person authorizing the autopsy may arrange for disposal or the Medical Center will
dispose of the organs. (choose one):
The hospital may dispose of retained organs.
I will arrange for the retained organs to be retrieved by a funeral home. I understand that
organs not retrieved within one week of the signing of this permission will be disposed of by
Beth Israel Deaconess Medical Center.
3) Medical research and education (choose one):
I authorize Beth Israel Deaconess Medical Center and/or Harvard Medical School to retain
organs for purposes of medical research and education.
I do not authorize organs being retained for purposes of medical research and
education.
e)
Go to the autopsy log next to the autopsy secretary and obtain an autopsy number.
Be sure to fill ALL the information (brain?, date, Resident, attending, etc).
f)
Review the chart (30-40 min. only), and call the patient’s clinician to discuss the clinical issues and
discuss the case with the autopsy staff pathologist. Make sure that the Medical Examiner has been
called in cases which fulfill the appropriate criteria to be reported
g) During the work week (Monday-Friday), at your request, the autopsy supervisor (Gail Howe) will
page the deiner (Emerson Springer) to inform him of the autopsy and will arrange to have him meet the
resident at a specific time.
h) On weekends, the resident must page the deiner directly (pager #92588)
i)
As soon as possible after the autopsy is completed, the resident will sign the expiration worksheet and
return the original to the Admitting Department so that the body can be released to the funeral home.
The resident will call the patient’s clinician to report the preliminary results.
j)
The patient chart should be returned to Medical records as soon as possible (48 hours max).
B. Examination of the Autopsy Permission Form- The Report of Death Form must be accurately and completely
filled out before the autopsy can begin. Do not accept a form from Admitting that lacks signature of
family/next-of-kin, or the signature of the pronouncing physician. Questions about the validity of the form or its
approval can be addressed to the autopsy staff pathologist and, if additional questions remain, to Dr. Hecht. All
cases of a medical-legal nature (see Appendix 1&3) should be referred to the Medical Examiner, who may
accept or waive the case. Most of the ME cases which are accepted are done by the ME on their premises. If
the ME wishes to accept the case to be done at the BIDMC, the case must be discussed with Drs. Connolly or
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Hecht. It is the responsibility of the pronouncing physician (not the pathology resident) to contact the Medical
Examiner; however, if the resident finds, during the chart review, that the case must be reported, he/she may
make the call to the ME to discuss the circumstances of the case. Document that conversation on the report of
death form in the appropriate section of the Report of Death.
C. Medical Chart Review- The patient's chart must be reviewed prior to performing the postmortem examination.
This should not take more than 30-40 min (read the summary and transfer notes first). On rare instances, a chart
is delayed in transit (outside cases). In order to prevent a significant delay and inconvenience to the family of
the deceased, it is acceptable in such cases to obtain an outline of the patient's history either by telephone or in
person from the patient's physician, in lieu of reviewing the entire chart (Charts must be returned to Medical
Records within two working days after completion of the autopsy- no exceptions.)
D. Consultation with Staff Pathologist- It is mandatory to discuss the case with the staff pathologist prior to
starting the autopsy. The extent of such discussion will depend on many things, such as the level of experience
of the resident, the complexity of the case, etc. Consultation should occur after the examination of the
permission from and review of the chart. During the weekend, the resident may contact the staff pathologist
anatomic pathologist on-call if there are any questions or problems. Residents may contact the staff anatomic
pathologist again if additional questions are raised during the dissection of the case.
Specific questions for autopsy are listed by the pronouncing physician on the permit (in the “SPECIFIC
QUESTIONS FOR AUTOPSY” section on the last page of the Permit. Otherwise, The resident should speak with
the clinical attending physician or surgeon and the patient's house officer prior to beginning. The clinicians
sometimes identify areas of clinical concern that are not mentioned in the chart.
Note: While we encourage clinicians to attend autopsies on their patients, in no case should a physician or
student from another department actually perform the dissection. On rare occasions, and with the permission of
our staff, a clinical physician may assist in a dissection, but in no instance should they be allowed to take over
the case. When clinicians or students from other departments attend autopsies, they must wear the standard
protective equipment and clothing mandatory for all Pathology personnel attending and performing autopsies —
no exceptions (see below).
A pathology resident, who is feeling pressured by a clinician either to perform a specific dissection other than
that initially planned, or to permit the clinician to "assist" in the case, should stop immediately and contact the
staff pathologist, Dr Connolly or Dr. Hecht before the situation gets out of hand. Once a patient has been
transferred to the Pathology Department, we bear ultimate responsibility for how the autopsy is to be performed
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Safe Performance of Autopsies and Handling of Tissues and FormalinWhile some patients coming to autopsy will be known to have infectious diseases, ALL PATIENTS' BLOOD AND
BODY FLUIDS ARE CONSIDERED POTENTIALLY INFECTIOUS; THEREFORE, GUIDELINES/PROCEDURES ARE
STANDARDIZED TO APPLY TO ALL CASES
The following regulations are intended to minimize the risks of contracting an infectious disease during the
performance of an autopsy and to minimize exposure to formalin. In the event of a formalin spill, please refer to
the Department of Pathology, formalin safety manual (SOP) available in all lab areas.
The following are minimum regulations. While these minimum regulations have been determined to be adequate
for all autopsies (including AIDS cases) by Dr. Kenneth Sands of our Infectious Disease Unit, our Department has
decided to use additional measures in certain known infectious cases (see Infectious Autopsy)
A. Attire for the Properly Dressed Prosector (Standard Precautions)
Any personnel dealing with autopsies in progress or with fresh organs (including residents, staff, fellows,
students, pathology assistants/associates and visitors from other departments) must wear gowns, scrubs, plastic
aprons, double sets of gloves (metal mesh gloves are provided in addition), masks, goggles, splash shields,
and shoe covers. Upon completion of the autopsy and presentation of organs to the staff pathologist, the
apron, gloves, masks and shoe covers must be discarded into hazardous waste containers. Scrub suits and
gowns are placed in the soiled laundry area.
B. Demonstration of Organs at Conferences
Fresh organs are not to be shown at Thursday gross conferences. All organs must be formalin-fixed for at
least 24 hours, and then washed before the conference. In order to minimize formalin exposure at Autopsy
Conferences, all organs must be washed thoroughly. See “handling of tissues and formalin” for washing
instructions.
C. Preparation of Blocks for Microscopic Slides
Fixed specimens from autopsies are to be cut into blocks only in the autopsy room. Appropriate attire
includes gloves, gown, mask, eye protection (chemical safety-type glasses or goggles or splash shields), and
apron at a minimum
D. Storage of Fixed Tissues
All fixed or fixing tissue should be kept in heavy-duty plastic containers with lids. These containers can be
stored in vented cabinets. Uncovered fixed tissue of any kind should not be stored in morgue coolers or left
out on counters. No tissue containers should be stored out on the floor at any time
E. Discarding Fixed Specimens
It is the responsibility of staff pathologists and residents to discard tissues promptly; only specimens from ME
or potential medical-legal cases will be saved indefinitely; specimens from other cases will be discarded
quarterly after gross diagnosis is completed, unless the staff pathologist specifically asks that the save period
be extended
F. Autopsy Worksheets are NEVER to Leave the Autopsy Room
All autopsy worksheets are to be transcribed onto clean paper before leaving the autopsy room; the original
worksheets (whether obviously blood-stained or apparently "clean") are not to leave the autopsy room under
any circumstances
G. Autopsy Procedure
1.
The tags on door and on the body are checked for the patient's name to see if they match the autopsy
request. The body is then taken from the cooler; all outside sheets are removed and sent to the Laundry in
designated laundry collection bags. THE RESIDENT WILL DOUBLE-CHECK THE BODY TAG TO
CONFIRM IDENTIFICATION
2.
The body is put onto the autopsy table. At this time, the plastic morgue sheet is removed and put into a
disposable garbage bag; all bandages are removed at this time and are also put into the same garbage bag
3.
A 2% bleach solution is used to wash off visible blood on body surfaces
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4.
During autopsy, interns, residents and pathology assistants wear personal protective equipment: goggles
or splash shields, gloves, masks, and aprons. Complete change of clothing (scrub suit) and morgue shoes
are also worn
5.
After evisceration, the body is washed with an EPA-approved detergent disinfectant (Phenex solution and
bleach), then completely stitched up after a proper amount of cellulose batting is placed in the brain,
thorax and abdominal cavity
6.
The body is then removed from the autopsy table and wrapped in a new morgue sheet; the proper tags are
placed back onto the body, which is then put back into the cooler
7.
Area is washed down with bleach and an EPA-approved detergent disinfectant (Phenex). Instruments are
immersed in the same for 30 minutes. The autopsy assistant will clean his instruments and will clean and
disinfect the autopsy table. He/she will also close and tape-up the biohazard boxes. The resident is
responsible for (i) cleaning the cutting board; (ii) washing all his/her instruments, (iii) cleaning the sinks
and counter areas; (iv) replacing dirty chux, (v) disposing of all blades, including the long blade, from the
knife handle; (vi) cleaning all spills on the floor
H. Washing of organs before conference1.
Formalin is discarded into the waste containers, and the organs are rinsed for 10 minutes in a large bucket
of water.
2.
Two such buckets will be prepared and used/shared for ALL the cases before each conference. This
“first rinse” water (2 buckets/conference) will be discarded as formalin waste after all cases have been
rinsed.
3.
After the initial “bucket rinse”, the organs will be rinsed in running water from the tap.
4.
There is NOT a specific formalin sink, but drain formalin levels should be kept to a minimum by NEVER
dumping formalin directly into the sink and pre-rinsing the organs in the bucket.
Infection Control Guidelines
THE PURPOSE OF THESE GUIDELINES IS TO DETAIL SPECIFIC INFECTION CONTROL PRACTICES FOR AUTOPSY
STAFF TO REDUCE THE RISK OF OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS, TB AND OTHER
INFECTIOUS DISEASES THROUGH A PROGRAM OF INFECTION CONTROL QUALITY ASSESSMENT AND
IMPROVEMENT
STANDARDS ARE BASED ON CURRENT KNOWLEDGE AND INCORPORATE THE CENTERS FOR DISEASE CONTROL
(CDC) "RECOMMENDATIONS FOR PREVENTION OF HIV TRANSMISSION IN HEALTHCARE SETTINGS" AND THE
NATIONAL COMMITTEE FOR CLINICAL LABORATORY STANDARDS "PROTECTION OF LABORATORY WORKERS
FROM INFECTIOUS DISEASE TRANSMITTED BY BLOOD AND TISSUE" AND OCCUPATIONAL HEALTH AND SAFETY
ADMINISTRATION STANDARD "OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS."
Remember that all patient specimens are considered potentially infectiouS, and handwashing is the single most
important factor in the prevention of disease transmission
A. General:
1.
All patients' blood, body fluid, and tissues are considered infectious and must be handled according to the
principles of Standard precautions. Therefore, all autopsy procedures should be performed under the
guidelines of Standard Precautions.
2.
Work practice controls: There will be no hand-to-eye/-nose/-mouth action (i.e., eating, drinking, applying
lipbalm or cosmetics, adjusting retainers or contact lenses) in any autopsy area
3.
Thorough handwashing with soap is an important method of preventing infection. A sink should be
designated for handwashing. Soap (not bar soap) and paper towels dispensers must be at this sink
4.
Handwashing must be done:
12
a) Immediately if hands are soiled with blood, body fluids, or tissues
b) Immediately after removing gloves
c)
Before leaving the autopsy area, and at the end of each day
B. Personal Protective Equipment: Personal protective equipment, gloves, clothing, facewear, should be located
in a designated area readily accessible to all staff.
1.
Skin integrity — Autopsy staff with hand cuts, abrasions, areas of dermatitis, etc., should report to
employee/occupational health services for evaluation of the appropriateness to work and to determine the
need for other protective measures (e.g., cotton gloves, skin cream barriers). All skin defects should be
covered with a water-impermeable occlusive bandage
2.
All autopsies shall be performed while wearing cap, mask, gown, scrub suit, morgue shoes, goggles or
splash shields and gloves (see Procedure: Autopsy)
3.
Contaminated personal protective equipment should be discarded in the appropriate biohazard receptacle
C. Specimen Handling:
1.
Care will be taken to avoid glove tears, puncture wounds and cuts by sharp bone edges, scalpel and
needles from all autopsy cases.
2.
Splashing of any body wash fluids shall be avoided
3.
Fresh tissues should be immediately placed in a suitable fixative
4.
All specimens are either received in or placed in formaldehyde or other fixative
5.
All tissue specimens are disposed of in the appropriate biohazard incinerator receptacle (see procedure:
Disposal of surgical tissue/biological waste)
6.
Specimen storage refrigerators/cold rooms must be clearly labeled for that purpose and must not contain
any food items
D. Equipment:
1.
Contaminated disposables are discarded either into infectious waste receptacles or are disposed of along
with tissue in special incinerator boxes.
2.
Reusable equipment (i.e., specimen-testing equipment) must be disinfected by a 1:10 dilution of bleach
prepared daily, or by a phenolic-Phenex
3.
Equipment that has been contaminated with blood or other fluids should be disinfected before being
repaired in the department or transported to maintenance or the manufacturer
E. Needles, Syringes and Other Sharps: Needles must not be recapped, purposely bent or broken by hand; rather,
after use, needles, syringes, and other sharps should be placed directly into puncture-resistant receptacles
specified for this purpose for disposal
F. Environmental:
1.
Detergents/disinfectants- A detergent solution should be available for cleaning and a disinfectant, such as
a 1:10 dilution of bleach, should be prepared daily (or a phenolic-Phenex).
2.
Accidental spillage of specimens should be cleaned up with a 1:10 dilution of bleach prepared daily (or a
phenolic-Phenex). The appropriate protective equipment should be utilized for the clean-up (e.g., utility
gloves, especially in the case of broken glass)
3.
The autopsy table, all instruments, sinks, floors and any other involved surfaces shall be thoroughly
cleaned immediately following each autopsy with an EPA-approved detergent disinfectant and a 1:10
dilution of bleach or a phenolic-Phenex
4.
Environmental Services will perform a through cleaning of the autopsy spaces weekly
G. Employee Occupational Health and Safety:
1.
Autopsy staff should take care to minimize the formation of droplets, spatters, splashes and spills of blood
13
and body fluids through work practice controls
2.
Autopsy staff should take precautions to prevent accidental injuries caused by needles, scalpels, and other
sharp instruments or devices during procedures when cleaning used instruments, during disposal of used
needles, and when handling sharp instruments after procedures.
3.
Autopsy staff should report IMMEDIATELY all blood and body fluid exposures defined as percutaneous
inoculation of blood and body fluids via a needle puncture, open cuts on hands, or splashing into the eyes,
nose or mouth. All exposures should be reported to the supervisor and the employee should report to
employee/occupational health services (Emergency/Walk-In Units off shift) for appropriate follow-up.
4.
Exposed area should be washed immediately, if a needle or sharps puncture occurs; bleeding should be
forced.
5.
The hepatitis B vaccine is available free of charge through Employee/Occupational Health Services. It is
recommended that all personnel working with human blood, body fluids and tissues be vaccinated.
6.
Semi-annual TB skin testing is performed in Employee/Occupational Health Services. It is important for
all employees
7.
Autopsy supervisors will monitor adherence to the use of personal protective equipment, and work practice
controls in the autopsy area. When monitoring reveals a failure to use personal protective equipment and
work practice controls, counseling, education and/or retraining will be provided
H. Training and Education: (Infection Control, HIV, HBV, and TB): New staff receive an infection control lecture
as part of hospital orientation. Initial education regarding the risk of occupational exposure to bloodborne
pathogens takes place during the Pathology Department Orientation Program. There is an annual review of
the risks of bloodborne exposure and other infectious diseases. Other infection control information is
disseminated through infection control bulletins, updates, and reports
I.
Quality Assessment and Improvement: Collaboration with the management and staff of the unit for the purpose
of quality assessment and improvement for patient care and employee health and safety is on-going.
AUTOPSY ROOM: General Overview and Division of Labor
A. At the end of the autopsy, the resident is responsible for spot cleaning:
1. cleaning the cutting board w/disinfectant;
2. washing all instruments w/disinfectant;
3. cleaning the sinks and counter tops w/disinfectant;
4. disposing dirty chux;
5. disposing of all blades, including the long blade, from the knife handle;
6. cleaning all spills on the floor
C. The autopsy assistant will get the body out of the cooler and into the morgue. If the patient is obese, the autopsy
assistant will ask the resident to help move the body onto and off of the table. Security needs to be called to
open the cooler door when the pathology assistant is not available
D. The resident is responsible for doing the gross examination
E. The resident is responsible for any cultures or sampling that needs to be done and should tell the autopsy
assistant beforehand that these samples will be obtained prior to the evisceration
F.
The autopsy assistant will do the evisceration and bring the organs over to the sink for the resident, but the
resident is expected to be present at the table during the evisceration and to perform at least two (2)
eviscerations during the first year
G. The autopsy assistant will fix the brain and spinal cord in a brain bucket for the resident. The resident should
make sure that the weight is taken before placing the brain into fixative and double-check that the brain is
correctly labeled with the autopsy number. The resident will perform two (2) brain removals during the first
year
H. The autopsy assistant will close and clean the body w/ disinfectant. He may ask the resident for help with
14
moving the body from the table back onto the cart
I.
The autopsy assistant will clean his instruments and will clean and disinfect the autopsy table. He will also close
and tape-up the biohazard boxes
J.
After the resident has completed the autopsy and cleaned up his/her area, the resident needs to complete the
expiration worksheet of the Report of Death Form and return all paperwork (Report of Death Form and
completed expiration worksheet) to Admitting.
Autopsies on Patients Who Die Outside Beth Israel Deaconess Medical Center
A. There are four categories of potential autopsy cases from patients dying outside the hospital:
1. BIDMC patients dying elsewhere
2. Non-BIDMC patients dying at an institution which has a contract to have autopsies performed at BIDMC
3. ME cases transferred to BIDMC for autopsy
4. Non-BIDMC patients for whom the managing physician or family members want to have an autopsy done
at BIDMC
B. Charges:
1.
If the patient has ever been a Beth Israel Deaconess Medical Center or Joslin Clinic patient, there is no
hospital charge to the family for performing the autopsy at Beth Israel Deaconess Medical Center. Outside
institutions which have contracts with BIDMC (Hebrew Rehabilitation Institute, New England Sinai,
Emerson Hospital, BI Glover/Needham) are generally known to Admitting.
2.
ME cases are accepted at the discretion of the BIDMC Medical Examiner, Dr. James Connolly or Dr.
Jonathan Hecht. In any questionable or uncertain cases of this nature, please contact Dr. Hecht or Dr.
Connolly. Additionally, in any case in which there is any concern regarding possible medical malpractice
or allegations, neglect or criminal circumstances, the case must be discussed with Dr. Hecht or Dr. Connolly
before proceeding with the autopsy.
3.
If the patient has never been seen at BIDMC or in a BIDMC-affiliated practice, the case must be accepted
by either, Dr. Jonathan Hecht (Director of Anatomic Pathology,) or Dr. James Connolly before the autopsy
can be done at BIDMC. There is a charge for performing such a case at Beth Israel Deaconess Medical
Center, and the referring physician, institution, or family must be informed of and agree to be responsible
for the charges before we accept the transfer or the patient, and before we begin the autopsy. Dr. Hecht, or
Dr. Connolly will discuss these charges with the referring physician or family member. The cost for a
complete autopsy with neuropathological exam is $2,500; for a brain-only case, the charge is $700.00; for a
limited case, the charge is ~$1,000, depending on the extent permitted.
C. Report of Death-The referring clinician is responsible for completing the entire Report of Death form. The
BIDMC Admitting Office can fax a copy of the Report of Death form to this physician if there is none available
at the outside institution or practice. The referring physician is responsible for contacting the Medical
Examiner's Office at 617-267-6767 in any case fulfilling the criteria as outlined on the BIDMC Report of Death
form.
D. Notification of the Pathologist- The funeral home must notify Admitting upon the arrival of the body at Beth
Israel Deaconess Medical Center. The body must arrive properly identified, preferably with a toe tag or
wrist/ankle identification band, in order for the autopsy to proceed. Admitting should notify the pathologist of
the arrival of the body. The Admitting Coordinator must enter the name of the patient into the Death Log
(outside the morgue) with the other pertinent information
E. Expiration Worksheet and Death Certificate- The expiration worksheet is filled out by the pathologist after the
autopsy has been completed and the cause of death determined. The Death Certificate will be typed in
Admitting, and the BIDMC clinician will sign the Death Certificate. It is the responsibility of the funeral home
to obtain the referring physician's signature when the patient comes from outside the Beth Israel Deaconess
Medical Center
15
Medical Examiner's Cases (Cases reportable to the ME are listed in Appendix 3)
A. Permit- All patients autopsied at Beth Israel Deaconess Medical Center must have a properly filled-out death
report form signed and received from Admitting. In the event that the case is Medical Examiner's case, the
physician caring for the patient must notify the Medical Examiner's Office (at 617-267-6767) to report the case.
If the Medical Examiner accepts the case, the autopsy may be performed either at the 720 Albany Street facility
or here at Beth Israel Deaconess Medical Center under the direction of the Medical Examiners or BIDMC staff.
If the Medical Examiner has accepted the case, no permit is necessary from the family, and in fact, the legal
requirements of the Commonwealth override the family's wishes in these cases, although where strong
objections exist, they may be considered and weighed in performing the case
B. Logbook- The name of the patient should be entered chronologically in the main Autopsy Log Books, where the
case receives a BIDMC autopsy number. All ME cases will be performed at the East Campus morgue. In the
space where clinical diagnoses are usually entered, there should be recorded "Medical Examiner's Case" with
the CME number corresponding to the Medical Examiner's Office autopsy number for the case. No data
regarding autopsy findings should be reported in our logbook. Any information released regarding the autopsy
must be at the discretion of the supervising ME, as some cases may have legally sensitive issues that should not
be released from the Medical Examiner's Office
C. Autopsy Notes and Paperwork- Notes, measurements, weights and all records of observations should be
recorded on forms provided by the ME office and available in the morgue. All provisional or final diagnosis
information should be collated by the supervising Deputy Medical Examiner, who will forward these data to the
ME office for transcription and final reporting. None of these data are given to our secretary at the BIDMC.
There should be only one folder per case with all the relevant forms, section key and clinical data, and this
folder should be locked in the office of the Attending ME. Once the final report has been generated and signed
at the ME Office, all other notes and records must be destroyed, as they can be subpoenaed and may, on
occasion, become the source of troublesome errors or conflicts, as, for instance, where an impression from the
gross is recorded without subsequent modification after reviewing the microscopy
D. Performing the Autopsy and Special Procedures for ME cases
1.
External Examination- As in all autopsies, careful examination of the body should include records of height
and weight, all scars, marks and evidence of treatment, violence or trauma. Records should be in
centimeters (cm). Careful and extensive gross photos are particularly important to record evidence of
trauma, burns or medical treatment, in order to resolve issues of size and extent, and to provide a visual
record useful for court testimony. All jewelry should be removed, identified and put in the hospital safe,
with the ME notified.
2.
Internal Examination- It is essential to examine internal organs prior to evisceration to establish possible
evidence of trauma or violence while the organs are in their natural anatomic position. This permits
correlation of contusion sites on the skin with areas of hemorrhage or other injury involving internal organs
or correlation of the track of a wound with organs underlying the wound. If radiologic studies have not
been performed prior to death, a complete set of full-body x-rays should be considered to look for fractures,
bullet or knife fragments. Careful examination of the pulmonary and coronary arteries in situ may permit
observation of air emboli.
3.
Bloodwork and Special Studies- Prior to evisceration, samples should be obtained for toxicology or other
laboratory studies where necessary. The forms must be completely filled out, carefully specifying the type
of sample and the source and type of blood drawn (location on body, i.e., femoral, heart, subdural, etc.,
affixing appropriately labeled stickers onto the specimen jars. Such samples must be handled using strict
Chain of Custody principles and, thus, must be kept in the presence of or on the person of the pathologist or
pathology assistant until they are picked up by a detective to be taken to the Massachusetts Police
Laboratory. In the morgue, there are special vials and forms for the ME cases; these vials are NOT to be
sent to our clinical laboratory. (In non-ME cases where drug levels are to be ascertained, call the Clinical
Laboratory to determine the appropriate type of sample and container.) Notify the ME office at the time the
samples are taken to expedite the notification of a detective to pick up the samples.
4.
All Medical Examiner's cases dying within 48 hours of admission to a hospital should be considered as
possible candidates for toxicology screening. In cases of motor vehicle accidents, blood and urine samples
16
for ethanol and other recreational drugs should be taken. In certain instances, gastric contents and/or
bile samples should also be taken; these decisions are made on a case-by-case basis after discussion with the
attending ME. In patients with coma of uncertain origin, vitreous humor should also be taken for glucose
and ketone levels. In the case of patients who were on therapeutic drugs, drug levels may be considered in
selected instances, such as to check the phenobarbitol level in a seizure patient involved in a motor vehicle
accident
5.
Microbiologic cultures should be obtained in all fetal autopsies, but only in those rare adult cases where
infection is a major consideration as the cause of death and in which pre-mortem cultures were not obtained.
The decision to culture is made with the attending pathologist.
6.
Autopsy Dissection and Evisceration- The autopsy may be performed in the standard Rokitansky fashion or
by using the modified Virchow approach. The latter is the method commonly used in ME cases in which
the organs are not eviscerated en bloc; instead, they are removed organ by organ. The latter method is less
familiar to most residents in the program and should only be used if the resident is able to dissect carefully,
without damaging the carotid and femoral arteries, and only if he/she is able to maintain the dissection in
context — i.e., looking carefully for trauma or disease involving contiguous structures and organs
7.
All organs must be weighed, with standard measurements (e.g., ventricular thickness, heart valve
circumferences) obtained. After breadloafing the organs, organs should be placed in a plastic bag to be
returned to the body cavity and sent with the body to the funeral home. A representative slice or section of
each organ shall be retained in your stock bottle for histology or examination post-fixation
i)
In any case where a cardiac abnormality is considered, the entire heart is retained for perfusion fixation
ii) In any case where neurologic disease is considered, the entire brain is fixed for later sectioning. Brains
in ME cases only are otherwise cut in the fresh state. In all ME cases, the dura should be removed
from the bones of the cranial vault to look for subtle skull fractures. In all cases, the pituitary should be
identified
iii) If organs cannot be presented to the staff pathologist in a timely manner (ie. Infectious cases), entire
organs may be maintained and discarded later as medical waste or transferred (on request) to the
funeral home for burial. The decision and responsibility of choosing to retain organs will be that of the
staff pathologist
8.
Submission of Blocks — The number of blocks taken in ME cases should be limited to those organ
systems immediately relevant to the cause of the patient's death. In rare exceptions, other organs may be
sampled, after discussion with the attending ME. Other tissues may be retained in your stock pot. All
blocks should be labeled with the CME autopsy number, with the section key given to the attending ME.
Each slide reviewed must be signed in permanent ink by the reviewing ME. After completion of the
microscopic review, all slides and paraffin blocks, along with the tissue stock bottles, are transferred to the
ME Central Office on Albany Street for permanent storage.
9.
Dictation — The clinical, gross, and microscopic summaries are dictated utilizing a standard format
available from the ME staff pathologist. Tapes are mailed or hand-carried to the ME Office, where all
transcriptions are done. The final report is signed at the Albany Street Office and stored there. No copies
of the report may be released to us. Residents should make a note for their own records of the age and sex
of the patient, and the major diagnoses to serve as information for applying for Board Examination, as they
will not have a copy of the final report
E. Death Certificate-In all ME cases, it is the Medical Examiner who composes and signs the Death Certificate. In
ME cases done at BIDMC, the medical examiner or Drs. Hecht or Connolly fill out and sign the Death
Certificate. The certificate must be signed in black ink. The address for Drs. Hecht or Connolly, when acting in
the capacity as Deputy Medical Examiner, must be the 720 Albany Street office. Thus, we do not merely check
and agree with the clinical causes of death. We must determine the manner of death: Natural, Accidental,
Homicide, Suicide or Undetermined. If the patient has died of pneumonia after a fractured hip from a fall
downstairs, the cause of death is NOT natural; it is Accidental, as none of the complications would have ensued
if not for the accident. The certificate might read "acute pneumonia complicating a femoral fracture," the
manner of death being Accidental. A man who dies of a myocardial infarct after being startled by a burglar in
his home is a homicide victim. Writing up the Death Certificate is an art and science perfected by experience,
but the guidelines are: (i) keep it simple and (ii) think carefully about the events leading up to the death.
17
(End of Medical examiner section)
Ancillary Studies
A. EXCEPT AS NOTED, ALL ANCILLARY TESTS MUST INCLUDE A REQUISITION STATING THE
TEST NEEDED AND, "AUTOPSY - NO CHARGE." SUCH STUDIES ARE NOT TO BE BILLED TO THE
PATIENT'S FAMILY
B. Heart Blood Protocol:
a)
Heart blood should be taken in selected cases where serum might not be available in the clinical laboratory
(ie. Non-inpatients), and can be used for biochemical testing/drug screen. In certain instances serological
studies may be valuable in helping to establish an infectious diagnosis. These cases should be tailored
according to discussion with the microbiology lab director on-call.
b) Collect two (2) red-top (empty) tubes of blood from a vessel or heart (scooping spilled blood from a body
cavity is unacceptable) spin it for 15 minutes in the clinical lab (call the CP resident on-call if you get lost),
pour the supernatant into a second tube, then place the tube in the cutting room freezer. After the spindown/pour off, the tube must properly labeled with the date and the autopsy number.
c)
The tubes will be kept until the Autopsy Conference. After the conference, the resident is responsible for
throwing out the tubes from the freezer for their cases. If there is a West Campus autopsy, the resident is
responsible for bringing over the tube of heart blood and spinning it down, labeling it, and placing it in the
cutting room freezer.
C. Postmortem Microbiological Studies: Postmortem microbiological examination (including gram stain) may be
useful in selected situations, but it should not be utilized in all autopsy cases. Blood cultures in general are
highly sensitive and specific in living patients, but have limited utility as a routine procedure in postmortem
evaluations. If a blood culture has been obtained prior to death there is usually no need to re-culture the patient,
unless you are looking for unusual organisms (e.g., Brucella). In this case, contact the CP resident on-call for
instructions. Tissues (lung/spleen) for culture are the more typical specimen.
One should consider performing postmortem cultures in the following clinical situations. It is also a good idea to
consult the staff pathologist, a microbiology staff member, or the CP resident-on-call. Remember to fill out a
requisition in Microbiology (specify that this is an autopsy specimen under under MRN#01238374, Do Not
bill; fetal cases should be entered into the mother's record).
1.
Continuing clinical evidence of pneumonia and/or cavitary lesions. If an open lung biopsy has been done
and appropriate cultures have been obtained prior to death, call the laboratory director, because lung culture
and/or blood culture with special techniques for unusual organisms maybe indicated. The appropriate
approach requires the consultation of a microbiology specialist.
2.
Immunocompromised patients, unless there has been a recent respiratory culture. One would consider reculture of lung in patients in whom a new pneumonia or a new clinical infection has developed without an
intervening opportunity for appropriate pre-mortem culture (such as bronchioalveolar lavage or open lung
biopsy and culture). Blood cultures should be considered if no recent pre-mortem blood culture has been
done.
3.
Patients in whom there is a clinical concern of sepsis, in whom there have been no pre-mortem blood
cultures, or in the instance of an unusual organism which would not usually be detected by blood culture.
Blood culture and lung culture should be considered.
4.
Neonatal deaths or stillbirths (ALL CASES), especially in those where there is a history of:
a)
Possible chorioamnionitis (culture the placenta: peel up the chorionic surface membranes and take a
sterile chunk of tissue)
b) Premature delivery (culture the placenta as well as the fetus)
18
c)
Known infection of the mother, without opportunity for appropriate pre-mortem cultures.
(1) In these instances it is necessary to review the microbiologic data available on the computer and to
discuss the case with the laboratory director, as special tests for Chlamydia trachomatis, and/or
Mycoplasma hominis may be indicated in infants who have evidence of pneumonia.
(2) Take lung and spleen for culture. Specify Ureaplasma, mycoplasma and group B strep.
Remember: In the neonatal intensive care unit many ill and tiny babies are housed in close proximity to
each other. Therefore, documentation of infections in deceased neonates has important epidemiologic
implications for managing other babies.
5.
Cases where the initial gross examination discloses an unsuspected and uncultured abscess cavity,
endocarditis, tuberculosis, or fungal lesion. The lesion should be cultured directly.
6.
Dialysis patients who present with septicemia - specifically, examine and culture the A/V fistula if it had not
been done ante-mortem
7.
Patients in whom autopsy discloses any unexplained or unusual findings in any tissues or organs, for which
the differential diagnosis includes infection and in whom appropriate pre-mortem cultures were not
available. In the event of such a finding (ie. Cardiac valve vegetation), the dissection should be halted, the
appropriate autopsy staff member should be contacted, and the issue should be discussed with the autopsy
staff person and/or the director on-call of the microbiology laboratory.
8.
Specimen collection for microbiologya)
For procedural questions please refer to the clinical laboratory test menu. For questions call
microbiology 7-2306. specimens should arrive in the laboratory within 2 hours after collection in
appropriate closed containers
b) Order of sampling and collection: Samples of the lung and/or blood should be obtained prior to
manipulating the bowel, to minimize the risk of contamination by enteric organisms. Generally
speaking, bacterial invasion and overgrowth become considerations only if a culture is taken about
eighteen hours or more after death. For this reason the interval between the time of death and autopsy
should be recorded
c)
Labeling: Successful microbiological isolation depends on appropriate labeling of the specimen.
Please include the suspected diagnosis, the patient's name, and specific suspected diagnosis. The
patient's name is particularly useful as the technologist may already be familiar with ante-mortem
isolates from the same case. The autopsy number alone will not provide this essential information to
the laboratory. Please fill out appropriate requisitions for all samples submitted. Correct labeling is the
responsibility of the pathologist. Specimens must be submitted as soon as possible to avoid
deterioration and/or overgrowth, and it is worth interrupting the remainder of the dissection in order to
get specimens to the laboratory promptly
d) Blood cultures: Blood specimens for culture can be obtained from the heart (right atrium, pulmonary
artery trunk, or inferior vena cava) and/or the splenic pulp (much less satisfactory). There are two ways
of taking blood from the heart. One requires a V-shaped opening of the pericardium without touching
the heart itself and then aspiration of blood from the atrium or pulmonary trunk. If this cannot be done
(adhesions or excessive effusion) or if contamination of epicardium occurs, the selected area of
epicardium should be seared to dryness with a hot spatula, and then the needle inserted through the
seared area. As blood cultures will be obtained only in unusual instances after discussion with the
laboratory director, the appropriate medium and/or broth for culturing should be tailored to the
individual autopsy. The lab slip should indicate the clinical suspicions, including appropriate
information of possible such as:
(1) Suspected fungemia
(2) History of antibiotics and specific antibiotics utilized
(3) History of possible salmonella
e)
Lung and other viscera: The heat sterilization method must be used for obtaining specimens from all
other organs. When fluid, for example, lung exudate, is needed, a sterile scalpel blade can be used to
19
make an incision through the seared surface of the lung, and swab collections made for aerobic and
anaerobic culture. Fragments of tissue for viral, fungal, and mycobacterial cultures can be obtained at
the same time. Specimens for anaerobic culture must be collected as quickly as possible and promptly
transferred to an oxygen-free transport tube (see below for transport collection systems)
f)
It is essential to label the specimen as to the source of tissue and the suspected organisms, so that the
appropriate inoculation procedure can be selected in the microbiology laboratory. Tissue sampled
should be at least 3 mm cubes, preferably at least two tissue pieces, as multiple small pieces are more
likely to yield positive growth than a single large fragment.
g) Imprints and smears of selected organs: During any autopsy, it is always possible to make fresh
imprints or smears of suspected infectious cases for routine gram, PAS, and Methenamine silver stains.
In addition, scrape smears or touch preps should be obtained from cavitary lesions which have a
differential diagnosis of tumor versus infection, and if a necrotizing tumor is discovered on the
cytologic evaluation, the expensive and detailed microbiological workup of tissue samples can be
halted. Always take imprints and smears after cultures have been taken to minimize the possibility of
contamination. Also do not overlook the value of Papanicolaou stains of imprints and smears in a
diagnosis of viral diseases
9.
Specimen Collection and Transport Systems
a)
Anaerobic Transport Swabs or Syringes (capped w/needle removed) - They are available throughout
the hospital and should be used for transport of aspirated fluids such as pleural, peritoneal, and joint
fluids. as well as abscesses. Tissues should be placed in a sterile cup and transported to the lab as soon
as possible after collection
b) Stool transport systems- Stool for enteric culture and O & P may be transported in CLEAN,
TIGHTLY CAPPED CONTAINERS which aren't sterile
c)
Swabs- The use of swabs to collect material for Microbiological testing is adequate for skin, mucous
membranes, genital sites and anal crypts only
(1) Most testing for Chlamydia, mycoplasma, and viruses require DNA and can be sampled by
standard sterile aerobic swabs (available on the floors and in the autopsy suites).
(2) To ensure adequate amounts of material for inoculation, ONE swab should be submitted FOR
EACH TYPE of culture requested.
d) Urine transport - For clean catch urines a CVS kit with a gray-top tube and collection cup should be
used. If a UA and other tests are needed at the same time, send a solid red-top tube wthout a serum
separator filled with urine
ANCILLARY STUDIES, OTHER TRANSPORT DEVICES
Hematopathological Studies: In cases of lymphoma/leukemia or other hematopathological processes, it is important
to sample the following organs: liver, spleen, lymph nodes, thymus (if it can be identified), and bone marrow from
multiple sites (at a minimum, sample ribs and vertebrae)
1. In cases of marrow failure or pancytopenia, a wedge of femoral marrow should be obtained.
2. Most tissues may be formalin fixed (do this early in the autopsy dissection). In cases of a lymphoma either
first discovered at autopsy or not phenotyped prior to death, tumor tissue might be frozen in “oct” gel for
later marker and molecular studies (in consultation with Hematopathology Staff and/or fellows)
3. Touch imprints of suspicious lymph nodes or vsiceral tumor nodules are also useful. For Giemsa stains,
these can be air-dried. For Diff-Quik® stains, they should be air dried
B. Quantitative Studies of Aluminum, Copper, Iron, Asbestos, etc.: Occasionally it may be necessary to do
quantitative chemical studies of tissue specimens to investigate a specific disease process. For example, a
quantitative iron determination on liver may be helpful in differentiating primary iron overload from other iron
storage diseases. The Director or the GI team should be consulted before a quantitative chemical study is
ordered. Such postmortem analyses are not generally reimbursable, and therefore will not be sent except in the
case of unusual circumstances or if the family agrees to pay for such studies. Asbestos fiber determination can
be of great value, especially in workman's compensation cases likely to come to trial. Save extra lung tissue (in
20
stock bottle) in cases of possible occupational lung disease. Lawyers will generally request such tissue and
arrange for studies on their own. Bone for metabolic work-up can be fixed in buffered formalin or 70% ethyl
alcohol
C. Cytogenetics: Prior to beginning a fetal or neonatal autopsy, it is important to decide whether or not
Cytogenetics studies should be performed. In deciding whether or not to submit Cytogenetics tissues, one
should also consult the autopsy staff pathologist or the clinical attending to determine if such studies are
indicated. A long post mortem interval (greater than 10-15 hours) may diminish the value of these studies, and
the post mortem interval, if known, should be written on the requisition accompanying tissue to the Cytogenetics
laboratory.
In addition, if previous antemortem amniocentesis and chromosome studies have already been performed, it is
not necessary to submit additional tissue at the time of autopsy unless requested by the clinician (as in the need
for more detailed banding or enzyme studies).
1.
The following are the clinical indications for which to consider the study:
a)
Unexplained fetal death associated with congenital anomalies
b) A history of three or more spontaneous abortions or fetal losses
c)
Severe intrauterine growth retardation unexplained by other circumstances
d) Ambiguous genitalia after thirteen weeks of gestation
e)
Any major malformations, for example cleft lip with fetal death, club foot with fetal death. (The two
conditions which would not fall into this category would be neural tube defect or renal
agenesis/dysgenesis
f)
Familial history of genetic diseases or syndromes
g) History of previous chromosomal abnormality or genetic abnormalities associated with previous births
2.
Tissues should be submitted as rapidly as possible after completion of the autopsy to the Cytogenetics
laboratory at Beth Israel Deaconess Medical Center. Transport medium or saline is available in the
Surgical Pathology cutting room refrigerator, from the Cytogenetics section during normal working hours or
from Laboratory Control in shifts other than weekday "day" shifts. If you take the last container of
transport medium, please obtain additional medium at the laboratory at the time of submission of
specimens. Appropriate specimens to submit include a piece of skin, a piece of deep fascia (as above the
groin), fetal placenta and membranes, and pieces of fetal viscera, such as lung and spleen. The more tissues
submitted, the greater the opportunity to obtain reasonable cell growth. Fetal placenta and/or membranes
may grow better than others given a long post mortem interval. Please put the different specimens in
different containers, as this also increases the likelihood of obtaining a sterile sample. Specimens should be
obtained by sterile technique, swabbing the skin with iodine and cutting with a sterile blade.
D. Electron Microscopy: Due to autolysis, autopsy material generally is not adequate for electron microscopic
examination. On occasion (e.g., tumor of unknown primary), autopsy tissue taken shortly after death may be
studied. The decision about whether to process such tissues will be made, on a case-by-case basis, in
consultation with Dr I Stillman and the EM Department. In potential cases, small (1 mm) tissue fragments
(avoid obviously necrotic areas) should be fixed in K2 for 2 hours, at room temperature, and then transferred to
cacodylate buffer for storage at 4°C. The tissue will be held in the EM lab, and the decision as to whether the
case will be processed will be taken after evaluation of the light microscopy.
Isaac Stillman should be paged prior to beginning cases of intrinsic medical renal disease and renal allograft. In
such cases, a portion of renal tissue / allograft should be frozen (in cryostat) for potential IF studies.
F.
Toxicological and Ocular Fluid Studies: Occasionally it may be necessary to obtain tissue and body fluids for
toxicological or electrolyte analysis (e.g., ME cases). In a suspected case of drug overdose or toxicity, obtain (at
a minimum) liver (300 grams), bile (10 ml), blood (50 ml in sodium fluoride) and urine (50 ml); keep all of
these specimens at 4°C. Gastric or small bowel contents may be useful in evaluating potential oral drug
overdose. Ocular fluid analysis may be useful in evaluating electrolyte and certain drug levels prior to death.
(In some instances, levels of electrolytes and drugs in the ocular fluid are more stable in the postmortem period
21
than are blood levels.) Instruction on the proper procedure for obtaining ocular fluid will be provided. Any
questions regarding these tests and which test is most appropriate should be directed to Dr. Bruce Beckwith or
Dr. Gary Horowitz
Organ Donation
A. Eyes- Residents will be notified by the Admitting Office that eyes will be removed by the Organ Bank on
certain cases scheduled for autopsy. Eye Bank technicians will remove the eyes either in the evening or morning
before the autopsy is performed. In the event of an afternoon autopsy, the Eye Bank should be called (5733325) to arrange a mutually convenient time for removal of eyes. Eyes can be removed in the cooler; the
procedure does not require the presence or assistance of either Pathology Assistants or residents.
B. Skin and Bone- These will be taken at 8:30 a.m. on weekdays before the autopsy begins. Removal is done by
Organ Bank technicians. Pathology residents may be called in the evening to be informed that skin and bone
will be harvested on a case to be autopsied in the morning. In the case of skin and bone harvesting on a
weekend (on a body not being autopsied), only the Pathology Assistant will need to be present. During a
weekday, the harvesting of skin and bone from non-autopsied patients will be done at a mutually convenient
time for both the Organ Bank and Pathology Associates and Assistants.
The Complete Adult Autopsy (see also Appendix 4)
A. Confirm patient identity by checking the "toe tag" or body label. In cases where such identification is missing,
the staff physician, funeral director or nurse must identify the patient before the case can be started.
B. General: The complete autopsy includes (but need not be restricted to) a careful external examination,
examination and removal of all internal organs (neck, thoracic, abdominal, pelvic organs, and brain), and
examination and sampling of ribs, vertebral column, skin and muscle. The spinal cord should be removed in all
cases. Testes should be removed in all unrestricted adult male autopsies and should be removed if there is any
clinical suspicion of a testicular problem, or in cases of cancer of unknown primary. In addition to the routine
dissection in unrestricted autopsies, one can examine and sample most anatomical regions, providing that the
dissection of that region will not deform or disfigure the body. A resident should never undertake a difficult
dissection in the region of the head and face or distal extremities without first discussing the issue with the staff
pathologist
Examples of additional dissections which can be done in unrestricted autopsies include the following:
examination and sampling of musculoskeletal system in all areas except hands and face; dissection of deep veins
of leg in cases of pulmonary emboli (dissection of deep veins of the arm may also be performed, but should first
be discussed with the staff pathologist); arterial dissection of legs; temporal artery biopsy; removal of tongue.
As already mentioned, examination of a-v fistula may be required in certain dialysis patients presenting with
septicemia. It is important that the funeral home be notified, in most instances before beginning the procedure,
in cases which will require unusual or complex dissections. Such communication is both a simple courtesy and
also promotes a good working relationship with the local funeral homes.
A. Dissection- NOTE: The following guidelines refer to the typical unrestricted adult autopsy. These steps may
require modification in individual cases, particularly in those patients who have had extensive thoracic or
abdominal surgery. If restrictions include “return organs to the body”, you will need to photograph all
findings in the fresh state and take microscopic sections at the time of the autopsy and return all the
organs to the body cavity in a plastic bag at the end of your dissection. The brain will be cut fresh by the
neuropathologist.
1.
Before beginning dissection, it is important to perform a thorough external examination (don't forget to
examine the back) and to document findings. Photographs and drawings may be used when appropriate. A
note as to how the body was identified should be included. The presence of scars, open wounds,
tubes/drains, intravenous catheters, endotracheal tubes should be noted. Take care to note the presence of
personal objects on the deceased (such as rings, watches, bracelets); the presence of these objects at the
time of autopsy should be noted in the case book — e.g., "yellow metallic ring noted on left ring finger."
2.
Occasionally it may be necessary to investigate the possibility of PNEUMOTHORACES, AIR OR FAT
22
EMBOLIZATION. These investigations should be done early in the autopsy, generally before cultures are
obtained. The pneumothorax test is done before the chest plate is removed. The skin and subcutaneous
tissue flaps of the chest wall are used as a sac to which water is added, such that the water level is higher
than the mid-axillary line. A puncture is made below the water line and just superior to a rib, and the
puncture is extended into the pleural cavity. Simultaneously, the water within the chest tissue sac is
carefully examined, looking for the exit of air bubbles. A similar approach can be used to search for air in
the heart, using the pericardium as a sac. If you are uncertain as to how this is done, please call your staff
pathologist.
3.
In order to detect FAT EMBOLIZATION, it is best to obtain a fresh sample of either blood clot, generally
venous, or lung tissue. A frozen section can then be done on tissue or clot, followed by an oil red 0 stain,
which detects neutral fat. Oil red 0 stain may also be done on formalin-fixed tissue which has not been
processed in alcohol.
4.
In routine cases, the body is opened via a Y-shaped incision. After the Y-shaped incision is made, proceed
as follows:
i)
ii)
iii)
5.
Measure abdominal panniculus.
Remove chest plate and a sample of blood via needle puncture of the inferior vena cava (after
appropriate heat sterilization). If clot in the IVC prevents blood collection, one may incise the
ventricles and use the pericardium as a sac to collect a blood sample. If the heart is devoid of blood, as
in a case of exsanguination, one can often collect blood by needle puncture of the pulmonary arteries.
Cultures of lung (submit tissue, not a swab), effusions (pleural, pericardial, peritoneal), abscess
cavities, or other sites of suspected infection can be obtained at this time as well. Palpate the accessible
part of the pulmonary artery and its major branches, then make incisions into these structures to check
for large emboli (these may become dislodged upon evisceration of the thoraco-abdominal block).
The retroperitoneum and other body cavities should be inspected in situ.
iv)
The small and large intestines are next removed by tying-off the bowel at the ligament of Treitz
and at the recto-sigmoid junction. In routine cases (i.e., bowel appears unremarkable), the intestines
can be removed by cutting along the mesenteric surface. In cases of suspected bowel infarction or
other instances when it may be useful to examine the intestine with its vasculature intact, one should
leave the intestines attached to the abdominal block and dissect them later, maintaining the relationship
of the intestine to its vascular supply. The intestines should also be retained, attached to the abdominal
block in cases where these cannot be easily separated, such as in peritoneal carcinomatosis or when
there are multiple, dense, fibrous adhesions
v)
The main arteries of the neck and upper extremities are isolated and tied-off (subclavian, common
carotid), and the common iliac arteries are isolated and tied-off. This makes it easier for the funeral
home to identify major arteries and to perfuse the extremities and head after autopsy.
vi)
The iliac veins should be inspected, palpated and then transected. The lower extremities should
then be "milked" to assess the patency of the deep venous system. NOTE: Flow of blood from the
transected iliac veins does not entirely exclude a thrombosis of deep leg veins, and additional
dissection (e.g., of popliteal vessels) may be needed in individual cases.
vii)
The organs are then eviscerated en bloc from the level of the larynx, caudal to the prostatic urethra
or upper vagina via the Rokitansky method. NOTE: Eviscerations, including brain removals, are
generally performed by Pathology Associates or Assistants; however, residents will be required to learn
how to perform such procedures and will be given enough practice in such to become proficient.
Residents will be expected to perform at least two complete eviscerations by the end of their first year
viii)
If the intestines have been removed separately, they should be inspected externally (note the
presence, position, and condition of appendix) and then opened along the antemesenteric surface. The
mucosa should be examined throughout, with care taken not to rub the mucosal surface too vigorously.
The bowel should then be placed in formalin, pending review by the staff pathologist. Staff pathologist
residents may not need to show the staff pathologist the entire bowel if it is unremarkable, but need
only save representative segments for the stock bottle.
The individual blocks are next separated, as follows:
23
i)
From a posterior approach, transect the thoracic aorta at the level of the diaphragm, and free-up the
esophagus and reflect it inferiorly. After cutting the inferior vena cava at its entrance into the right
atrium, one has divided the thoraco-abdominal block into two blocks, the first (#1) consisting of the
cardiopulmonary system, mediastinal tissues and neck organs, and the other (#2) consisting of
peritoneal, retroperitoneal and pelvic organs and structures.
ii)
Examine the main pulmonary arteries and its branches; if pulmonary thromboemboli are found,
one must search for a venous source. This includes examining the IVC, hepatic vein and iliac veins,
which are located in block #2, and the lower extremity veins. The deep veins of the lower extremity
are dissected via a posterior approach. (Residents will receive instruction in performing this
dissection.) It is rarely necessary to dissect the deep veins of the arms; if it does appear necessary,
consult your staff pathologist
6.
Remove adrenal glands; weigh, measure, and serial-section; then place in formaldehyde
7.
The next block can be dissected by opening the larynx and trachea longitudinally via a posterior approach.
If necessary, the parathyroid glands (usually four are present) can be identified at this time. Most will be
found posterior to the thyroid gland along a line connecting the inferior and superior thyroid arteries.
(Sample parathyroids in patients with calcium abnormalities and/or chronic renal failure.) The thyroid
gland should be removed intact, weighed, and serially sectioned.
8.
Block #2 can now be dissected. By a posterior approach, the descending aorta can be opened longitudinally
down to its bifurcation. The iliac arteries should then be opened in a similar fashion. Identify the renal
arteries and make cross-sections to assess their degree of luminal narrowing. Occasionally, in cases of
bowel infarction, it is necessary to identify and remove the arterial supply of the bowel. This is done by
keeping the aorta, its branches, the mesentery and bowel together as one piece. The celiac artery, SMA and
IMA are identified. The vessels are then serially sectioned in the intact specimen to assess the extent of
luminal narrowing and to evaluate the presence of clot and/or atherosclerosis. Occasionally it is necessary
to fix and decalcify heavily calcified vessels. The portal venous system can be examined in a similar way
by dissecting inferiorly from the portal vein to its various branches.
9.
The aorta, its bifurcation, the kidneys, ureters and pelvic organs can then be dissected away from the
anterior structures by transecting the anterior branches of the aorta and separating the tissue planes. The
kidney capsules are removed, the cortical surfaces examined. As in a surgical specimen, the most proximal
ureter is opened, probes are inserted in the kidney pelvis to each of the poles to guide a cut (using a long
knife) through the collecting system to bivalve the kidneys. Kidney weights and cortical thickness
measurements are made. The calyces are opened. The ureters are then opened longitudinally to their
entrance into the bladder. The bladder is opened, and the urethra is opened longitudinally as well. In
males, the prostate should be serially sectioned in 5-mm sections. Special attention should be paid to pelvic
venous structures (prostatic plexus in males) to look for possible thrombi, especially in cases of pulmonary
emboli. In females, the pelvic organs (if present) should be measured, and the endocervical and uterine
cavity opened, then the myometrium and ovaries sectioned. At the infero-posterior portion of this block
will be a segment of rectum which can be opened longitudinally.
10. The remaining block consists of esophagus, stomach, duodenum, extra-hepatic biliary tree, liver, pancreas,
and spleen. The initial approach to this specimen is to open the esophagus, stomach and duodenum
longitudinally and examine the mucosa. In suspected cases of varices, the stomach and esophagus can be
turned inside-out to best visualize the varices. Contact the staff pathologist for instruction in this technique.
The ampulla of Vater is identified, and the common bile duct is opened. The cystic duct is opened into the
gallbladder, and then the hepatic ducts are opened. Any stones present within the gallbladder or common
bile duct should be characterized, documented, and (if indicated) retained at 4°C for possible chemical
analysis; contact Gary Horowitz for further instructions. (This is especially important in potential medicallegal post-surgical cases.) The liver is weighed and serially sectioned into 1.5-cm sections. The pancreatic
duct and splenic artery are opened, and the pancreas is serially sectioned (if stones are present, these should
be characterized and, in some cases, saved for chemical analysis). The spleen is weighed and serially
sectioned as well
Adult Cardiac Examination:
24
Dissection strategies are based on underlying disease states and optimal methods for visualization and
demonstration of specific cardiac pathology. In general, residents should discuss planned strategies with the
staff pathologist prior to evisceration
The cardiac pathology service at Brigham & Women’s hospital is available for consultatoin. Contact Robert
Padera, E-mail: rpadera@partners.org Beeper 732-5700 #37451 or the BIDMC staff member may call the
BWH “on-service” carciac pathologist
Non-Cardiac Deaths (Assumes cause of death is known)
A. After the breast plate has been removed, the pericardium is incised its full length to expose the heart.
Observation of the amount and quality of any pericardial contents (serous, serosanguinous, frank blood, etc.)
should be documented. The main pulmonary artery should be opened in-situ and the presence of thrombus
assessed. The heart is lifted at the apex and blood cultures (if warranted) taken from the inferior vena cava. The
heart is then excised by cutting across the inferior vena cava, reflecting the heart superiorly. From the backside
of the heart, the insertion of pulmonary veins into the left atrium is identified. Transection of the pulmonary
veins, pulmonary trunk and aorta is performed circumferentially.
B. The heart is weighed and the coronary arteries palpated. If significant coronary artery disease is found
(calcification along major tracts of coronaries), it is best to perfusion-fix the heart and dissect the coronaries free
after fixation (see Fig. 1). Fresh heart dissection can be performed if appreciable coronary artery calcification is
not found. The coronaries should be incised in-situ every 2-3 mm to document absence of disease. Cuts should
be superficial so as not to enter the myocardium. An understanding of coronary anatomy is necessary to
complete this task. Once the coronaries have been evaluated, the heart is serially sectioned from apex to base at
0.5-cm intervals. Myocardial cuts should stop 1.0 cm below the tricuspid and mitral valves. Attention is then
directed to the base of the heart.
C. The right atrium is opened with the incision extending to the right atrial appendage. A cut is made in the lateral
right ventricular wall, opening atrium and ventricle. The right ventricular outflow tract is identified and a knife
inserted to open the pulmonary outflow tract. Attention is then directed to the left side of the heart. The left
atrium is opened through the pulmonary veins and carried out to open the left atrial appendage. A knife is
passed through the mitral valve, and the lateral free wall of the left ventricle is incised. The final cut places the
knife through the aortic valve with the incision passing through the anterior left ventricular wall. These cuts are
referred to as cutting the heart “along blood flow lines” and are standard cuts
D. The benefit of this method is that it is quick, allows immediate examination of the coronaries, myocardium,
valves and any congenital abnormalities such as ventricular septal or atrial septal deficits. The downside is that
unsuspected coronary artery disease can be missed, unsuspected infarction can be missed, and, finally,
presentation points will be lost in a poorly performed fresh dissection
Cardiac Deaths
A. Cardiac deaths requiring special imaging and/or dissection techniques are as follows
1. All sudden cardiac deaths (death for unknown cause) in people aged 18 years or older
2. All deaths within 30 days of a coronary intervention such as:
a) angioplasty/stent/arteriography
b) bypass surgery
3.
4.
All deaths following valve replacement
All in-hospital deaths with known myocardial infarction
B. General Comments
1.
In general, when removing the heart, it is best to transect the aorta at the level of the brachiocephalic artery.
This allows enough room for a perfusion cannula. It is my opinion that a well-fixed heart is easier to
dissect, preserves cardiac chamber morphology, and provides more information than many of the highly
specialized techniques outlined in further sections (2-7). To that end, I prefer a large-bore cannula inserted
retrograde into the aorta and the heart perfused through the coronary system (either native coronaries or
those with grafts) at ~80-100 mm/Hg (Fig. 1). Perfusion fixation by this method will take anywhere from
10 to 30 minutes, depending on the patency of the coronary tree. Perfusion fixation should continue as long
as needed to achieve the standard 10 to 1 volume ratio for tissue fixation. The heart is suspended with
string to complete overnight fixation. This fixation is the method of choice when the cause of death is
25
uncertain and preservation of coronary anatomy and myocardium is essential. It should be evident that, in
cases of uncertainty, pressure perfusion fixation is the best method.
2.
Sudden cardiac deaths; possibly cardiac or suspected infarcts less than 6-12 hours-old
a)
Myocardial infarcts less than 6-12-hours-old have limited findings on H&E staining. If a new
(acute)myocardial infarct is suspected as a cause of death, vital staining may be required to prove such
an event. The heart is removed as previously described and the coronary vessels dissected fresh from
the heart following known anatomic landmarks. The heart is cut in standard 0.5-cm coronal cuts, apex
to base, and the central myocardial slice is placed into 37° succinate/tetrazolium solution.
b) Viable myocardium has functional dehydrogenases which will reduce the clear tetrazolium solution to a
purple-stained myocardium. In the case of an acute myocardial infarct, the myocytes do not have intact
dehydrogenases, and, therefore, the myocardium cannot reduce the tetrazolium and remains pale-brown
in the infarct area. The remaining myocardium should turn purple (internal control). Notify Dr. Hecht
if there is a question of acute myocardial infarction less than 12-hours-old.
3.
Cardiac deaths following angioplasty and/or coronary stents
a)
Successes and failures following coronary angioplasty have definite morphologic correlates which can
only be diagnosed with appropriate post-mortem investigational techniques. The clinical scenario of
death will dictate the method of evaluation. If possible, residents should review and discuss the
angiographic findings of the case with the cardiologist prior to addressing the heart. These discussions
are critical and often dictate the appropriate mode of investigation
b) The default evaluation for acute death (<30 days) following coronary stenting consists of retrograde
aortic perfusion, coronary dissection after 24 hours’ fixation, and x-ray of the coronaries to evaluate the
stent position and status of the stent. The coronary artery involved with the stent, including proximal
and distal, should be submitted for histologic evaluation. DO NOT attempt to cut across the stent. It is
metal and will only crush and deform with your attempts. Early stents (< 30 days) can be gently
removed from the distal coronary cuts. Later stents (> 30 days) require epoxy embedment and are not
routine. Some cases will require clearing to see through the vessel wall. Segments are dehydrated
through graded ethanols and are placed in methyl salicylate for 2 to 6 hours. The vessel will become
translucent. This will not affect subsequent histology
4.
Cardiac deaths following coronary artery bypass grafting (CABG) — Specialized Technique
a)
In-hospital deaths following CABG or death within 30 days of CABG should be evaluated with
coronary artery and graft injection with radiopaque material. Caution is required while removing the
breast plate, as internal mammary artery grafts will be adherent. Grafts and native coronaries are
cannulated followed by infusion with 5% neutral buffered formalin. Ideally, diastolic pressure (80-90
mmHg) should be used. Hand injection with 50-cc syringes will be adequate to perfuse the heart prior
to barium injection. Injection is followed with a barium/gelatin mixture using 20-cc syringes.
Approximately 10 to 15 cc is all that is required. DO NOT FORCE THE INJECTION. If the
formalin or injectate does not flow freely, it’s best to stop. If more than 10-15 cc is injected, you are
over-injecting the heart, forcing injectate to the venous side, making the study useless. Extravasation of
contrast material onto the epicardial surface will obscure arterial anatomy. Therefore, rinse off any
extravasated material with warm water prior to x-ray.
b) Following the barium/gelatin injection, the heart is immersed in 10% neutral buffered formalin for
overnight fixation
c)
After fixation, the heart is radiographed prior to coronary dissection. The coronaries and grafts are
dissected free from the myocardium, and the heart is cut in cross-sections from apex to base in 0.5-cm
intervals. The base is opened along blood flow lines (see Section I, above).
d) The dissected coronaries and grafts are x-rayed as are the myocardial cross-sections. Occlusion in
grafts as well as in collaterals within the myocardium will be readily visualized. Coronaries and
anastomoses should be decalcified before serial cross-sectioning. Anastomotic sites should be
submitted entirely as serial cross-sections (Fig. 2).
5.
Cardiac deaths following valve replacement and/or native valvular disease
26
Hearts should be retrograde-perfused via the aorta and immersion-fixed prior to dissection. Coronaries are
dissected free, decalcified and serially sectioned in 2- to 3-mm intervals. The heart proper should be cut in
a 4-chamber cut to demonstrate valvular pathology
6.
Cardiac deaths in dilated or hypertrophic cardiomyopathy
Since, by definition, cardiomyopathy is muscle disease in the absence of identified coronary artery disease
or other primary cardiac muscle process, most cardiomyopathies have normal or insignificant coronary
artery disease. I recommend retrograde perfusion via the aorta with overnight fixation. After fixation, the
coronaries can be cut on the heart surface. A 4-chamber cut should be performed to demonstrate ventricular
volumes.
7.
Cardiac deaths to demonstrate infiltrative processes (amyloidosis, sarcoid, myocarditis, glycogen storage
diseases, tumor, and hemochromatosis)
Since coronary artery disease is usually NOT an issue, retrograde aortic perfusion is recommended with
overnight fixation. Coronaries can be either cut on the heart surface or dissected free and cut after
decalcification, if necessary. The heart proper should be cut in a 4-chamber cut configuration.
8.
Cardiac - Final Anatomic Diagnoses (sample FAD)
a)
In general, for coronary artery disease cases, the FAD should reflect native coronary disease, any
interventional procedures and pertinent negatives. For example:
A.
Atherosclerotic cardiovascular disease
1.
Native coronary arteries (right dominant)
a.
Left main; 30% stenosis
b.
Left anterior descending; total occlusion with recent plaque rupture and
overlying thrombus
•
status-post angioplasty (date)
c.
Circumflex; 70% stenosis
d.
Right coronary artery; 80% stenosis with sequential stenoses
2.
Status-post coronary artery bypass (date) emergent
a.
Left internal mammary artery to left anterior descending; patent
b.
Saphenous vein graft to obtuse marginal one; patent
c.
Saphenous vein graft to posterior descending artery; patent
d.
Cannulation sites; intact
e.
Post-pericardiotomy pericarditis
B.
Myocardium, cardiomegaly 830 grams
1.
Acute myocardial infarct. Anterior and septal left ventricular wall. Age ~3-5
days with reperfusion injury
2.
Old myocardial infarct; posterior left ventricular wall with extension to right
3.
Myocyte hypertrophy with dropout and interstitial fibrosis
a.
History of hypertension, clinical
C.
No significant valvular pathology
27
FIGURE 1
Formalin Perfusion
28
FIGURE 2
Coronary Artery and Bypass Graft Dissection and Block Submission (A-D)
29
Stock Bottle (retaining of organs for prolonged period) & Sections.
A. Routine sections required on all cases are one cassette of lung, one cassette of heart, one cassette of liver and
kidney, one cassette of bone marrow. Additional sections documenting findings should be guided by the
attending. In addition, sections may also be requested at Gross conference.
B. The following specimens should be placed in a “stock bottle” (one 2 pint white container) in all unrestricted
autopsies; even those with “return all organs to the body”. Whole organs should not generally be kept beyond
the autopsy conference in any case.
1.
2.
3.
4.
5.
6.
7.
Section/slice of heart (LV and RV), and any tissue with pathologic findings (not the whole heart with valves
and aorta)
Sections (2-3 cm cubes) of lungs (from each lobe), thyroid, prostate, uterus with endometrium, ovaries,
adrenal glands, breast, skin (e.g., from chest wall at Y incision), skeletal muscle (e.g., from psoas), bone
(vertebral column), testis
Sections (2-3 cm cubes) of liver and spleen, pancreas
Sections (2-3 cm cubes) of each kidney (cortex & medulla). Do not save entire kidneys.
Bone marrow –thin slice of spine or segment of rib.
Short segments of small intestine (10 cm each of duodenum, distal ileum with cecum/appendix), large
intestine (sigmoid), stomach and esophagus (5cm on either side of the GE junction).
Small piece of any other organ not already mentioned or submitted for histology.
B. Also save:
Cardiac valves in cases with valvular disease (e.g., a stenotic aortic valve), lymph nodes in lymphoma cases
C. In unrestricted cases, the entire brain is fixed for later sectioning. Brains can be cut in the fresh state in cases
with no suspected neurologic findings, case that requires fresh tissue (ie. Metabolic disease), when the family
requests that all organs be returned for burial WITH THE BODY, or in ME cases. In all ME cases, the dura
should be removed from the bones of the cranial vault to look for subtle skull fractures. In all cases, the
pituitary should be identified
D. Autopsy conference
1.
More tissue is saved for conference than will be stored in the stock bottle. The tissues not reserved for stock
bottle and histology will be discarded as medical waste following conference or after 1 week of issuing a
PAD.
2.
Although families reasonably expect that organs will be returned for burial, they understand and sign a
consent allowing us to retain tissues necessary for diagnosis. These fixed tissues are available for return
until the time of discard (3 months following signout - CAP guidelines)
3.
If organs cannot be presented to the staff pathologist in a timely manner (i.e. Infectious cases), entire organs
may be maintained and discarded later as medical waste or transferred (on request) to the funeral home for
burial. The decision and responsibility of choosing to retain whole organs will be that of the staff
pathologist
Autopsy Neuropathology
The final part of the complete autopsy involves removal of the brain, pituitary gland, and spinal cord. This is usually
done after the other organs have been removed. All of these tissues should be removed for neuropathological
examination in all unrestricted autopsy cases. In patients with any neurodegenerative disease, or other major
neurologic disease, the entire spinal cord should be removed, including the difficult-to-reach sections of the cervical
spinal cord. In patients with a history of a neuromuscular disease, several muscles, including the quadriceps, should
be snap-frozen and also sampled in formalin, and several nerves, including one sural nerve, should be preserved
30
separately. The pituitary should be placed into a labeled cassette and held. The following are minimum requirements
and steps for fixing and evaluating brains (see Infectious Autopsy section for CJD brains):
A. Brain at the time of autopsy (see I. below if organs are to be returned to the body)
1.
Record fresh weight of brain in work book
2.
Record in work book any gross abnormalities appreciated prior to sectioning, i.e., hemorrhage, cystic
infarction, severe atherosclerosis, meningitis, severe autolysis, or indicate "grossly normal"
3.
Properly label outside of brain crock and place label on basilar artery with the autopsy number, patient's
name, and prosector's name
4.
In cases in which the entire spinal cord is removed, the dura should be opened and pinned, so that the cord
can be maintained in a straight configuration during fixation
B. Fixation:
1.
The brain crock is filled with formalin as follows: 1 to 1.5 Mason jars of concentrated formalin, followed by
water until the crock is 2/3 full
2.
The brain is then hung in the crock by suspending it via a string passed underneath the basilar artery.
Suspend it in the formalin first, otherwise the basilar will break. Place the brain in a vented cabinet, and
allowed to fix for one week; brains should be washed under continuous running water for at least 24-48
hours
C. Brains may be donated to Harvard Medical School for medical student teaching, providing that the family has
not specifically requested that tissues not be used for research or teaching outside of the Department of
Pathology. In general, brains from individuals without neurological abnormalities, systemic disease, potentially
infectious disease processes (HIV, HBV, TB) or metastatic tumor may be donated. The attending
neuropathologist (e.g. Drs. Jeffrey Joseph or Matt Anderson) will decide which cases are most appropriate for
donation. Needless to say, only uncut and properly fixed and washed brains should be donated. The fact that a
brain was donated to HMS should be noted in the Autopsy Case Book. Donated brains still need to be
examined! Any suggestion of pathology in the exterior requires a full dissection.
D. Brain cutting (specific instructions on the proper way to cut a brain will be provided by the attending
neuropathologist, e.g. Drs. J. Joseph or M. Anderson).
1.
It is the resident's responsibility to check the brain cutting list and be prepared to cut the brains on the day
they are scheduled. Occasionally a resident may need to be scheduled at a time when they are signing out
surgical specimens or are covering the operating room. It is nevertheless his/her responsibility to have the
brain cut ahead of time, or find appropriate coverage if necessary.
2.
Record the weight of the formalin-fixed brain in the work book.
3.
The prosector is responsible for bringing a copy of the patient's clinical summary and autopsy findings to
the brain cutting.
E. Gross photographs should be taken of any pathology that has potential teaching value, that will be used in
conference, or that may come up at time of sign-out. The neuropathology attending should be consulted if one is
unsure as to whether photos are necessary
F.
Notes must be taken and recorded in the autopsy case work book, even if findings are essentially normal.
Important negative findings include: clear leptomeninges, vessels without atherosclerosis, absence of masses,
hemorrhages, infarcts, or significant atrophy.
G. Pink Cassettes must be properly labeled with the autopsy number and letter designation as follows: A02-098 A.
Keep a key to match slide with anatomical site, list the stains you will need, and give a copy to histology with
the cassettes.
H. Brain sign-out:
1.
Neuropathology final report should be issued within 12 weeks of the autopsy. This deadline may be
extended in cases with many tissue blocks since they require special processing, but extensions must be
31
noted in writing in the patient’s folder in the autopsy office.
I.
2.
It is the resident's responsibility to arrange brain sign-out with the neuropathologist.
3.
At the time of sign-out, residents should bring information regarding the clinical history, gross CNS
findings and general autopsy findings.
Cases of “return organs to the body”:
1. Call the neuropathologist to check if they want to participate and document their response in your notes (name,
time, yes/no). If the brain is known to have significant pathology, all attempts should be made to change the
permission and fix the entire brain.
2. Weigh the brain.
3. TAKE EXTERNAL PHOTOS OF THE INTACT BRAIN (TOP AND BOTTOM) with brain stem still
attached.
4. Examine brain (cortex and white matter) and cord for focal lesions; infarcts, necrosis, tumor. Be sure to check
for herniation (subfalcine, uncal, tonsilar). Cut off the brainstem then dissect the cerebrum coronally and the
brainstem transversely. Examine ventricles for widening or granularity. Inspect caudate and basal ganglia for
atrophy or asymmetry. Search for hemorrhages, lacunes, larger infarcts, masses, or vascular. Check the
midbrain and pons for Duret hemorrhages. Look at the pigmented areas, including the locus ceruleus (upper
pons) and substantia nigra (midbrain). Examine mammillary bodies for old/new hemorrhage and pons for
central myelinolysis. The cerebellum may show abnormalities of the folia if the patient had been on a
respirator, or vermal atrophy in alcoholics. Examine cerebellar white matter for atrophy. Record findings
carefully, including clear notations on pertinent negative observations (as) relevant to the case.
5.
Save the required slices in a small flat square containers. These will be fixed for 2-3 days and then
transferred to the stock jar. However, no sections should be taken unless a lesion is found.
6. what to write:
_____________________________________________________
A. Brain (XXXX g):
1. Hemispheres: convexities symmetric with a well-developed gyral pattern with clear leptomeninges. No
localized external softening, hemorrhages, infarcts, masses, herniation (subfalcine or cingulate, uncal,
or tonsilar), or contusions.
2. Coronal sections show intact cortical ribbon of appropriate thickness. Internal architecture has the usual
pattern, without focal lesions or hemorrhages. The ventricular system is unremarkable, symmetric and
of appropriate configuration and size.
3. Brain stem and cerebellum: Typical external configuration. Transverse sections of the brain stem show
a well pigmented substantia nigra and locus ceruleus. The pons and olivary nuclei are unremarkable.
Cerebellar hemispheres have usual foliar pattern and dentate nucleus
B. Dura: unremarkable and sinuses are patent
C. Circle of Willis/basal vasculature: normally formed and patent. No/minimal/non-occlusive atherosclerosis
present in carotid arteries, main branches from circle of Willis, and basilar artery.
D. Spinal cord: Dura intact and unremarkable. Leptomeninges are translucent. The anterior and posterior roots are
comparable in size and bilaterally symmetric. Transverse sections of cord show no abnormalities.
______________________________________________________
32
Slices to be saved:
33
IC
SN
H
Love S, Histopathology 44;2004:309-317
Recording the Cause of Death
A "cause of death" must be entered on the report of death and taken to the Admitting Office as soon as possible so
that the body of the deceased may be released to the funeral home. Generally, the anatomical "cause of death" can
be determined within 2-3 hours of the start of an autopsy. We should strive to keep to this time period. The staff
pathologist should be consulted if possible on determining the cause of death, unless the cause is obvious - such as a
ruptured aneurysm, large myocardial infarction, etc. Remember that one must list an anatomical cause of death (only
one). Congestive heart failure, respiratory failure, or sepsis are clinical diagnoses and are not to be listed on the
"cause of death" sheet (see Appendix 1)
Reviewing the Case with the Staff pathologist; Sectioning, and Photography
A. Following completion of the autopsy, the resident should contact the staff pathologist to review the fresh organs
on the same day as the autopsy. Staff should discard most of the organs. These can be returned with the body to
the funeral home in a doubled, closed biohazard bag. This is required by law if the family has indicated this as
their preference on the Permit. When staff pathologists do not view cases on the same day, residents must fix
the tissues in formalin-filled containers, sometimes up to three, drain the formalin, and wash the tissues the next
morning for presentation (see section on “handling of tissues and formalin”), and after review, the tissues to be
presented at conference must once again be placed in formalin for thorough fixation prior to presentation at
Gross Conference. This is clearly a waste of formalin and time; additionally, it exposes personnel to greater
34
amounts of formalin than needed for a given case
B. Residents should receive guidance with regard to examination of the small intestine and colon. Staff
pathologists must make clear to residents how they prefer to handle bowel which appears normal to the resident.
For example, some staff pathologists may want to be shown only bowel which appears abnormal, while other
staff pathologists prefer to review the entire bowel. It is the Autopsy Directors' opinion that when fresh organs
are examined by the staff pathologist that the bowel should be given the same review as any other organ. We
will, however, leave the handling of this matter up to the individual staff pathologist's discretion and only ask
that they make their wishes clear to residents
C. Staff pathologists should provide guidance in deciding which organs should be saved for Gross Conference and
which should be sampled for microscopy. (During the first two months of the academic year, it is appropriate to
show all organs, both normal and abnormal, so that residents just beginning the program will develop a solid
frame of reference. After this period, the Gross Conference should focus on abnormal findings.) This issue is of
importance, since we have very limited space to store tissues
D. Cases done late in the day or on weekends ordinarily are reviewed the next day or on the following Monday,
respectively. In the latter instances, the organs should be fixed in formalin and placed in the vented cabinets
(use plastic containers). To ensure uniform fixation, it is important to make slices in organs, use paper towels
between tissue slices to allow good formalin permeation between slices, and line the bottom of the pan with
paper towels to lessen "pan change." In particular, the cardiac chambers should be filled with paper towels or
rubber gloves so that the fixed heart approximates its pre-fixation shape. Fresh tissues exposed to room
temperature for 3 or more hours will show autolytic changes. It is therefore good practice to take small samples
of the major organs for fixation early during the course of the autopsy
E. A digital camera and camera-stand are available in the autopsy room for gross photography. A label with case
number and ruler should be included adjacent to all organs photographed. Consult with your staff pathologist
before discarding organs with important findings, as photographs may be indicated. Photographs should be
taken after conference for all cases to be presented at the monthly Gross/Micro Conference.
NOTE: Under no circumstances are fresh organs or any other potentially infectious materials to leave the
autopsy room without the knowledge of the Director of the Autopsy Service
F.
Following completion of the autopsy case, the resident should do a basic cleaning of the work area (the major
cleaning will be done by the Pathology Assistant). (Tissue to be discarded should be left in a pan with a sign
stating "discard," and the Pathology Assistant should be notified of this in person. Do not leave fresh tissue on
the counter without informing someone of its status, as such tissue may wind up staying out overnight or over
the weekend.) The resident puts tissue in a plastic bag and freezes it. The tissue is discarded from the freezer
on Wednesdays
G. Autopsy cases should be sectioned after review with the staff pathologist, but no later than 2 working days after
the autopsy. Additional sections might be requested following Gross Conference if additional findings are
discovered. Tissue sections should be placed in green cassettes labeled with the autopsy case and cassette
number. The resident should keep a key to match cassettes with a specific organ or pathological site. Two
copies of the slide key are to be made. One is given to the Histology Lab with any tissue blocks submitted. The
second is given to the autopsy secretary to be kept with the case folder.
1.
Routine sections required are one section of: lung, heart, liver, kidney, bone marrow
2.
Most cases can be adequately blocked in under 10 cassettes. Those requiring 15 or more are required to
have the staff pathologist's signature on the log sheet.
Preparation of Autopsy Documents (PAD/FAD)
Note:
The Autopsy Case folder must remain in the Department file at all times. Take copies of gross diagnoses or
clinical summaries that are in the folder, but not the last copy.
A. Gross Diagnosis- Provisional Anatomic Diagnosis (PAD) The resident should work closely with the staff
pathologist in preparation of the Gross Diagnosis forms and other documents. A JCAHO regulation states that
the preliminary or gross diagnosis must be in Medical Records within three working days of the day of the
35
autopsy. We should meet this requirement in every case.
Each PAD/FAD MUST include a statement of the organs that were retained for prolonged fixation (not
returned to the body cavity). “Organs retained for further study: Liver, spleen, heart, lungs,
kidneys, adrenals, pancreas, brain…”. This statement is included in the templates.
Note that while we strive for accuracy in the Gross Diagnosis, these documents are not expected to include the
results of microscopic examination. Organ weights are included with expected values (Appendix 2). Thus, we
should not delay submitting the Gross Diagnosis form in order to examine "rush" autopsy slides. Similarly, do
not delay submitting the Gross Diagnosis simply because the case is potentially infectious and cannot be
thoroughly dissected until after a 6-week period of fixative. State in the "Gross Diagnosis": "Body As-AWhole: Active hepatitis B infection (based on clinical data): organs will be fixed for 2 weeks before further
gross and microscopic examination." This informs the clinicians about the status of the case, and tells them that
the final sign-out will be delayed. It also satisfies the JCAHO request that the Gross Diagnosis form be
submitted to Medical Records within 3 working days of the autopsy.
If a brain is taken, the Gross Diagnosis form should state (if there are no grossly discernible lesions): "CNS:
Brain, X-grams; complete examination will be performed and submitted in a supplemental report.
B. Clinical Summary- The clinical summary should be prepared and reviewed with the pathology attending prior to
issuing a PAD, however, the Summary is not part of the PAD and will not be sent out. The secretary will
not keep a copy of the Clinical summary; Residents should save a copy of this summary and incorporate it
into the final autopsy note in the FAD, or may attach a copy to the patient’s autopsy file.
The clinical summary should be concise and summarize the hospital course. Completely restating physical
examination findings, especially normal ones, or all laboratory data is not necessary. Be selective. One should
strive to fit the summary onto one typed page. This summary should be objective and should avoid
interpretation or extrapolation from data in the medical record.
C. Final Diagnosis and Final Note- This part of the autopsy report must be completed within 4 weeks in the usual
autopsy case. In infectious cases and those in which there are major CNS findings, the case should be
completed within 12 weeks. (Place interesting or challenging microscopic slides from your cases on the
Surgical Slide Conference tray for everyone's review.)
D. Autopsy reports, including both the Gross and Final Diagnosis, should be distributed to all concerned clinicians.
At a minimum, the list for distribution of reports should include the resident most involved with the patient's
case and the staff physician responsible for the case (this is usually the physician whose name is on the patient's
card, bracelet, etc.). Also list significant consultants (surgeons, angiographers, etc.). We are still working on
establishing an "Autopsy Mailbox" in the Hospital computer system. This system, if established, would be
another means of communicating autopsy findings. Any requests by family members for copies of an autopsy
report should be referred to the Correspondence Office (667-3715). The Pathology Department does not handle
the processing of such requests.
E. Addendum: In cases in which the clinical data, and the gross examination of the brain, indicate that CNS
findings are unlikely to have contributed to the patient's death, the results of the CNS examination can be
reported in an addendum. This ordinarily permits a more rapid distribution of the Final Diagnosis form. In such
cases, the Final Diagnosis should read, "CNS: Brain, X-grams, the results of a detailed gross and microscopic
examination will be reported in an addendum." Such addenda should be distributed even if the examination
discloses no findings, thus "closing" the case. If important or potentially important findings are disclosed, it is
appropriate to send a short, additional "Final Note" with the addendum.
Addenda may also be used to report results of other potentially time-consuming studies (chemical analyses
performed outside the Hospital, external review of slides from the case by outside "experts," etc.). It is clearly
preferable, however, to have these studies done rapidly enough to include the results in the original Final
Diagnosis and Final Notes.
In infectious cases (in which all organs are fixed before dissection), or in cases in which the CNS findings
clearly are critical, the Final Diagnosis and Final Notes should be prepared only after both the general autopsy
and neuropathological examinations are completed.
36
Communication of Autopsy Findings
One of the important aims of the autopsy is to provide accurate information regarding the autopsy findings in a
timely fashion to the clinicians and family of the deceased. It is especially important to maintain a system whereby
major unexpected findings, especially those that may have public health implications, are reported promptly. Prompt
follow-up is also indicated in deaths of patients on experimental drug and radiotherapy protocols or bone marrow
transplantation protocols, so that modifications in these procedures can be considered. The following protocol
should be followed in disseminating the information derived from postmortem examination.
F.
Even in the most routine cases, please contact either the patient's attending physician or major house staff
physician immediately after completion of an autopsy to provide them with the major gross findings. While this
is not mandatory, it takes little time and clearly can strengthen the clinician-pathologist relationship. It can be
done by telephone or e-mail.
G. Major new findings disclosed at autopsy, such as death due to an undiagnosed ruptured AAA, should be
communicated as soon as possible.
H. If the prosector/attending pathologist identifies or seriously suspects a major infectious disease (such as
TB, HBV, HIV) at any point during the evaluation of an autopsy case, the attending clinician should be
notified promptly either by telephone or by letter. Appropriate documentation of this communication
should be retained in the Autopsy Case folder. An example of such an interaction is as follows:
1.
"Dear Dr. 'X': Gross examination of the lungs of your patient, John Doe, revealed a caseous nodule in the
upper lobe, strongly suggestive of tuberculosis. Histological sections including special microorganism
stains will be processed promptly. In addition, tissue will be submitted for culture. Results of these studies
will be communicated when they become available."
2.
The pathologist/pathology resident should not wait until the final diagnosis/final note is completed to
communicate such information.
I.
The prosector should perform directed biopsies and culture in cases where a major infectious process is noted
incidentally at autopsy or in cases where there is a strong suspicion of a major infectious disease (such as viral
hepatitis, TB) not previously diagnosed. The tissue specimens should be processed immediately, and the
attending clinician notified promptly regarding the results of this examination.
J.
In autopsy cases being treated with extra precautions because of known HIV disease, HBV, TB, C-J, directed
biopsies should be performed carefully on tissues or organs of major clinical concern or those that appear clearly
abnormal at the time of evisceration. These tissue biopsies should be fixed overnight in formalin (except for C-J
disease, where the fixation protocol in the manual should be followed) and then processed immediately so that a
provisional microscopic diagnosis can be rendered.
Infectious Autopsy
General Procedures ( “STANDARD OPERATION PROCEDURE – Infectious autopsy” approved by Dr. JL Hecht on
10/10/03, 4/19/05 and reviewed by Infection Control nursing and Dr. Sharon Wright-Brodie of infectious disease in 1/06):
(‘STANDARD OPERATING PROCEDURE - Handling Cases of CJD, Creutzfeld-Jakob Disease, or Prion Diseases’ adopted
11/8/01 by William C. Quist, M.D., PhD; Jo-Ann Rosol-Donoghue (MASCP) SLS and approved by Jeff Joseph, M.D., Ph.D.
11/01; 6/02; 5/06)
A.
1.
Autopsy pathologists and infectious disease clinicians are not in precise agreement as to what the minimum
standard for performing an infectious autopsy should be. There is much inter-institutional variation in how
such cases are performed. As noted above, our procedures for routine autopsies have been reviewed by the
Hospital's Infectious Disease Department and Infection Control Nursing, who feel that the routine
procedures adequately protect residents and pathology staff from pathogens such as hepatitis B, HIV, and
tuberculosis.
2.
In cases of known or suspected hepatitis (either non-A, non-B, or B), HIV, we follow the following
procedures (Creutzfeldt-Jakob disease and SARS are special cases and is described below)
37
a)
Personnel in the autopsy room at the time the case is performed should be limited to the deiner who
performs the evisceration, and the Pathology resident. The same autopsy room dress used in noninfectious cases applies for infectious cases as well.
Cut resistant gloves or long gloves are available (not just for known infectious cases), please ask the
autopsy supevisor (Gail Howe).
b) The case will not be presented at autopsy conference.
c)
Tissue blocks for histology (that is tissue in a cassette) should be fixed for 24 hrs before submitting.
d) Otherwise, these cases are dissected like every other case. They should be dissected fresh. DO NOT
just put the organ block intact in a bucket
3.
In cases of known or suspected active tuberculosis, the situation is different since the worry is related to
airosolization and duration of exposure, and there is a literature about the validity of precautions.
a)
Limit personnel to a Deiner and 1 resident. Wear an approved TB mask in addition to the usual
personal protective equipment.
b) A limited fresh dissection is necessary. DO NOT just put the organ block intact in a bucket
c)
The organ block is separated into the usual 3 organ blocks: heart/lungs, kidneys/pelvis, GI tract
including large and small bowel) and each part is serially sliced and fixed for 2 weeks in a large
formalin bucket before dissection.
d) Prior to large bucket fixation, small chunks of each organ (slice of heart, liver, kidney, bowel…)
are put in a stock jar to ensure that something will be well fixed for histology.
4.
Additional tips:
a) Inflate the lungs through the trachea (DO NOT detach the lungs); this will limit splashing during
inflation. Weigh the lungs by tipping them into the pan balance.
b) Since the fixed gross organs from known infectious cases are not shown at conference, liberal use of
gross photography should be made in these cases.
B. Brain Removal and Fixation in Infectious Cases1.
AIDS: Regardless of the clinical history, in addition to the brain, remove a small section of cervical spinal
cord (removed through the foramen magnum) and segment of lumbar spinal cord, including cauda equina.
Also remove a piece of skeletal muscle (pectoralis or psoas) and a piece of peripheral nerve (femoral
nerve). If there is a clinical history of myopathy in an AIDS patient, also remove a piece of muscle such as
quadriceps or gastrocnemius. All tissues should be fixed in 10% formalin for 1 week.
2.
Creutzfeldt-Jakob disease (CJD), Subacute Spongiform Encephalopathy, or Prion Disease Cases: The
purpose of this procedure is to address the current protocols to be followed when handling possible cases of
CJD, Creutzfeld-Jakob disease, or prion diseases during autopsy.
General rules:
a)
Use disposable, absorbent “chux” beneath all work being done
b) Whenever possible, use disposable instruments (e.g. scalpel blades, forceps, wooden sticks, etc.) when
handling the tissue,
c)
Note: Disposable instrument kits will be available in each morgue
d) Discard all disposable instruments in the proper containers (sharps containers or red bag lined boxes
for biohazardous waste)
e)
If you need to use regular instruments (scissors, hacksaw), soak the instruments in full strength bleach
for 1.5 hours after finishing the procedure. Set a timer!
f)
Label all specimen containers and vials with “CJD” Precautions”.
Performing autopsy:
38
a)
Notify the attending neuropathologist (e.g. Dr. Jeff Joseph #35290 or Matt Anderson #31766).
b) Unless there is an overwhelming clinical question, limit the autopsy to the brain.
c)
Use a hacksaw to open the skull. Do not use the electric saw (may aerosolize the tissue).
d) Remove the brain in the usual manner. Save a sample of the cerebral cortex in a specimen container at
–80C. Label appropriately.
e)
Fix the remainder of the brain in formalin until dissection.
f)
Dissect the brain in the standard manner. Block as in any dementia. Take three extra “scout” blocks,
two of cortex and one of basal ganglia.
g) Keep scout blocks in fixation at least overnight to complete the fixation.
h) Using disposable forceps remove the tissue from the original formalin, wash briefly in water, and place
the three scout blocks for one hour in concentrated (95%) formic acid. Use a timer! No more than
one hour!
i)
Wash copiously in tap water and return to abundant, fresh buffered formalin overnight, to reestablish
the correct pH. It is no longer “infectious”.
Discard of the formalin in the original container as follows:
a)
On the “chux” place a Tissue-Tek Neutra-Pad (4295)
b) Position the colored side of the pad facing up
c)
Formalin from the tissue will be absorbed and neutralized resulting in lower vapor emissions
d) The used formalin from the container should be absorbed onto this pad or pads and absorbed
e)
Then wrap the chux around these pads and dispose of all in the biohazardous box
Process the tissue:
a)
Process the formic-acid scout sections routinely, getting the more rapid H&E stains (i.e. not the usual
LFB stains). You no longer need to indicate CJD precautions.
b) Examine the H&E scout sections for spongiform encephalopathy. If the cortex or basal ganglia display
significant vacuolization of the neuropil, especially in deeper cortical layers, then treat the remaining
blocks similarly in formic acid. In the absence of spongiform changes, process the remaining blocks as
any other brain autopsy specimens.
Significant notes:
a)
Although the brain tissue is infectious, no data have demonstrated aerosolized transmission. The only
documented routes of transmission are by direct implantation of infectious materials into the brain (e.g.
with surgical instruments, dural grafts, corneal transplants), by administration of human-derived growth
hormone, and probably by large oral inoculation of brain or spinal cord (Kuru, nvCJD or Mad Cow
Disease). Nevertheless, you want to minimize aerosol exposure.
b) The best tool to use to prevent infection is your brain!
c)
Follow all safety rules/precautions
d) Wear all appropriate PPE (personal protective equipment) as outlined in the autopsy manual including
“TB mask”.
e)
Dispose of all tissues properly.
f)
Label all potentially infectious containers.
g) Wash hands thoroughly after any autopsy procedures.
39
C. Safe Handling of Human Remains of Severe Acute Respiratory Syndrome (SARS) Patients (Interim CDC
Guidelines – May 3, 2005). We conform to these guidelines.
Severe acute respiratory syndrome (SARS) is a respiratory illness caused by a coronavirus, called SARS-associated
coronavirus (SARS-CoV). All postmortem procedures require adherence to standard precautions with the use of
personal protective equipment (PPE) and facilities with appropriate safety features. Mechanical devices used during
autopsies can efficiently generate fine aerosols that may contain infectious organisms. Thus, PPE should include
both protective garments and respiratory protection as outlined below
Objective: Safely handle human remains during autopsy procedures to prevent
transmission of SARS-CoV.
Activities
In general, safety procedures for human remains infected with SARS-CoV should be
consistent with those used for any autopsy procedure. However, additional respiratory
protection is needed during an autopsy procedure that generates aerosols (e.g., use of
oscillating saws).
Personal protective equipment (PPE)
Wear standard autopsy PPE, including a scrub suit worn under an impervious gown
or apron, eye protection (i.e., goggle, face shield), double surgical gloves with an
interposed layer of cut-proof synthetic mesh gloves, surgical mask or respirator, and
shoe covers.
Add respiratory protection if aerosols might be generated. This includes N-95 or N100 disposable particulate respirators or PAPR. Autopsy personnel who cannot wear
a disposable particulate respirator because of facial hair or other fit limitations
should wear a loose-fitting (i.e., helmeted or hooded) PAPR.
Remove PPE before leaving the autopsy suite and disposed in accordance with
facility policies and procedures.
Engineering controls
Whenever possible, perform autopsies on human remains infected with SARS-CoV in
autopsy settings that have adequate air-handling system. This includes a minimum
of 6 (old construction) to 12 (new construction) ACH, negative pressure relative to
adjacent areas as per recommendations for AIIRs, and direct exhaust of air to the
outside or passed through a HEPA filter if air is recirculated. Exhaust systems
around the autopsy table should direct air (and aerosols) away from healthcare
workers performing the procedure (e.g., exhaust downward).
Use containment devices whenever possible. Use biosafety cabinets for the handling
and examination of smaller specimens. When available, use vacuum shrouds for
oscillating saws to contain aerosols and reduce the volume released into the
ambient air environment.
Prevention of percutaneous injuries
Follow standard safety procedures for preventing percutaneous injuries during autopsy.
40
Fetal/Neonatal Autopsy
Policy: Fetal autopsies are performed on involuntarily terminated pregnancies in which the fetus is either greater than
or equal to 20 weeks' gestation (determined by dates and/or ultrasound) and/or greater than 350 grams in weight. It is
required by law (MGL c.111, section 202) that the death be registered with the department of public health. an
autopsy permission form must be completed which should include signatures of both parents, assuming both are
known and actively involved.
All fetal deaths below these cutoffs should be handled as surgical specimens. Voluntarily terminated pregnancies
(Fragmented fetus or POC), irrespective of gestation or weight, are handled as surgical specimens. (Exceptions are
therapeutic procedures designed to deliver an intra-uterine fetal demise [IUFD] or impending IUFD. Such cases are
considered fetal deaths if they fall within the established weight and/or gestation.).
It is a responsibility of the after-care team to arrange for photography of the deceased fetus. Pathology is not
responsible for this activity. The autopsy should not be delayed any longer than 1-2 hours because photographic
services are not available.
The general autopsy attending will be responsible for all cases except those that involve known anomalies or genetic
aberrations. Cases with congenital abnormalities (by ultrasound or by external exam) will be referred to Dr.
Jonathan Hecht.
Fetal/neonatal cases are occasionally referred to the Children's Hospital Department of Pathology for autopsy. The
decision for referral should be made by Dr. Hecht or (if he is not available) the autopsy staff pathologist. The
indications for referral are as follows:
1.
multiple congenital anomalies;
2.
prior amniocentesis documenting a genetic abnormality;
3.
parents and/or clinicians wish that a case be referred.
A case referred to the Children's Hospital will still be given a BIDMC autopsy number. The Beth Israel Deaconess
Medical Center Pathology resident who gets credit for the case is responsible for seeing to it that the fetus arrives at
Children's and is returned to Beth Israel Deaconess Medical Center upon completion of the autopsy, and that the
cause of death is submitted promptly. The resident is encouraged to view the autopsy at the Children's Hospital
Department of Pathology.
AUTOPSY PROCEDURE
A. Verify that we have the placenta in pathology
B. Read the mother (and baby) charts
1.
Maternal/gestational ages
2.
History of fetal loss (SAB), therapeutic abortions (TAB), siblings
3.
Social history (drug use, toxin exposure)
4.
Prenatal care, screening (infections, Diabetes, cytogenetics/AFP), and risk factors (smoking, prior fetal
losses, incompetent cervix or anatomic defect)
5.
Complications (Preecclampsia, hypertension, placenta previa, twins)
6.
Prenatal ultrasound (fetal anomalies, small for dates, oligohydramnios)
C. Look at the baby/fetus with a senior before cutting anything!
D. Take photographs – face (front AND side view), full body (front/back), hands (palms)/feet (profile). The
hand/feet photos are not necessary if the appropriate views (see example below) are represented in the body
shots. Remember what you need to see: Genitals, neck, palms, side view of the feet, front and side view of
the face, abdomen.
41
If the hands are folded on the abdomen or hands are palm side down, or the cord is covering the
genitalia or the feet are flopped to the side rather than frog-legged, you are WRONG!
E. Weight the fetus
F.
Take an AP X-ray if indicated (external limb anomalies, ultrasound abnormalities, or internal findings on
dissection – TE fistula, renal anomalies)
G. Take cytogenetics (Skin down to fascia, and liver) if there are 2 or more structural anomalies (1 anomaly in a
fragmented fetus), or requested by the clinician
H. Open chest/abdomen using the standard Y-shaped incision (REMEMBER THAT YOU WILL BE SEWING
UP THE SKIN LATER as in an adult autopsy) noting any abnormalities of organ position (situs inversus,
diaphragmatic hernia (trisomy 18), congenital renal tumors)
I.
Cultures of the lungs and spleen may be taken now if there is a question of infection/sepsis
J.
Remove/weigh the thymus.
K. Remove the gonads – they will otherwise be lost
L. Take out the block intact including the tongue
M. Remove brain using the biparietal incision (REMEMBER THAT YOU WILL BE SEWING UP THE SKIN
LATER) (and spinal cord), weigh and fix for later exam
N. Open the esophagus in-situ to look for tracheoesophageal (TE) fistulas
O. Continue examining through the stomach and duodenum to look for duodenal atresia
42
P. Detach all the organs, weigh them and note any abnormalities (important weights are thymus, liver, heart,
combined lungs)
1.
Lungs – combined weight, look for abnormal lobation, petechiae
2.
Heart (ventricles should be about equal in size, aorta should be anterior) If there was any question of
cardiac disease, leave the heart/lung block undissected in a small formalin container for consultation.
Otherwise, open the atria (snip off the tip)
i)
Cut the lateral right free wall to the apex. Probe the pulmonary outflow tract to see if there is an overriding aorta, and the cut out the outflow on the anterior wall along the septum. Note the foramen ovale
in the posterior atrial septum (there should be a flap covering it, but a probe can get through), and the
tricuspid and pulmonic valves.
ii) The ductus arteriosus is the extension of the pulmonary trunk beyond the branches to the lungs. There
should be a sharp transition to gray endothelium. If you see it, then the DA is patent.
iii) Open the left ventricle by cutting along the anterior and posterior septum to create a free wall flap. This
exposes the ventricular septum. Note the mitral valve then cut along the outflow tract (through the
septal leaflet of the mitral valve) to reveal the membranous septum and aortic outflow. This is the most
common site of VSD.
3.
Kidneys – combine weight, look for hydronephrosis, misplacement, horseshoe fusion
Q. Submit sections (mixed cassettes , but bowel and gonads should have their own cassettes):
1.
2.
3.
4.
5.
6.
Thymus
Lung (part of each lobe – not specifically identified)
GI (from all segments – do not open the bowel)
Gonads (with uterus and tubes in a female)
Kidneys, adrenals (both sides)
Skeletal muscle (diaphragm or tongue)
R. It is the resident's responsibility to pack the fetal body cavities, sew the skin back together, and wrap the fetus
upon completion of the autopsy. Use the straight needle-silk sutures in the morgue.
43
Perinatal Checklist:
External exam (DO NOT DICTATE ALL THESE ELEMENTS, JUST LOOK FOR THEM)
3) General body habitus:
1. Macrosomia (diabetes, Beckwith-Weidemann syndrome). Is it symmetric? (head and body are both big)
2. Edematous (hydropic)
3. Macerated with skin slippage
B. Head:
1. Epicanthal folds (Down’s)
2. Excessive wrinkles under eyes / flat nose (potters)
3. Cleft lip or Palate (LOOK IN THE MOUTH) (trisomy 13)
4. Protuberant tongue
5. Nose pressed down (Potters)
6. Flattened nasal brigde (Down’s)
7. Low set ears (top should be at the level of the outer canthus of the eye)
8. Overfolded/misshapen ears (potters)
9. Scalp defects (trisomy 13)
10. Short neck (trisomies)
C. Thorax:
1. Short sternum (should be half way from internipple line to umbilicus), tri18
2. Nuchal (back of the neck) thickening or hygroma (swelling of the neck)
3. Spinal fusion defects/spina bifida
S. Abdomen: defects in wall
T. External genitalia:
1. Male- fused scrotum, testes descended or abdominal, ?hypospadias
2. Female- patent vagina
3. Ambiguous (vs. not identified.)
4. Anus: Patent (VATER syndrome)
F. Extremieties:
1. # fingers on each hand/foot
2. Syndactyly/polydactyly- specify if extra is near the thumb or pinky, or which fingers are fused (triploidy or
tri 13)
3. Arthrogriposis/clenching/contractures (cns malformations)
4. Overfolded fingers (tri 18)
5. Short great toe (tri 18)
6. Joint webbing
7. Abnormal palm creases (simean crease or single flexure of 5 th finger)
8. Skeletal dysplasia on X-ray
Measurements:
A. Body weight:
1. Crown-rump length:
2. Crown-heel length:
3. Foot length:
4. Head circumference (at nipples):
5. Chest circumference (at nipples):
B. Organ weights:
1. Thymus
2. Lungs (Combined)
3. Heart
4. Liver
5. Kidneys (combined)
6. Brain
P/FAD format:
– Liveborn/stillborn (macerated) female/male fetus (__wks by foot length, __wks by crown-rump length,
__wks by clinical/US at __wks)
44
–
–
–
Probabale CAUSE OF DEATH: (multiple congential anomalies, placental abruption, chorioamnionitis,
prematurity, indeterminate)
•Fetal pathology
•Placental pathology
•Ancillary studies (cultures, cytogenetics)
Major findings not associated with the cause of death (review of systems)
Placental pathology (S02-XXXX)
AUTOPSY SUMMARY:
• Summarize the clinical scenario (1-2 sentences)
• External findings (Grossly normal, well developed female fetus; Markedly macerated male fetus;
Fragmented fetus of indeterminate sex) (1-2 sentences)
• Describe findings listed above (b)
• Synthesize the data
What went wrong (cause of death)
Likelihood of recurrent loss
USE YOUR RESOURCES (genetic counselors, gynecologists, children’s pathologists, etc. Call them
without hesitation). This is your chance to learn
45
ADULT TEMPLATE:
BETH ISRAEL DEACONESS MEDICAL CENTER
330 BROOKLINE AVENUE
BOSTON, MASSACHUSETTS 02215
AUTOPSY REPORT #A04-010
Name: Smith, John
Age: 65
Hospital #: 1234567
Sex:
Race: Caucasian
Restrictions: None
Date of death: 9/6/04
Hour of death: 8:58 AM
Date of autopsy: 9/6/04
Date of PAD: 9/8/04
Date of FAD:
Prosector: J.Smith
J. Jones
Male
Clinical Service: Medicine
Report to Dr(s): Dr. J. Simpson
Staff Pathologist: J. Partridge, M.D.
_________________________________
Provisional/Final Anatomic Diagnosis
For PAD only (remove from FAD): PLEASE NOTE: THIS IS A PRELIMINARY (GROSS)
REPORT AND IS PENDING MICROSCOPIC EXAMINATION. FINAL ANATOMIC DIAGNOSIS
TO FOLLOW.
II.
External Examination
A. Body Habitus: Height = _’__”, weight: ___ lbs (from chart).
B. Eyes: COLOR, pupils (A)SYMMETRIC.
C. Mouth: (i.e. poor dentition, upper and lower dentures).
D. Skin/Scars:
1. COLOR (i.e. Jaundice with scleral icterus).
2. LESIONS (i.e. Petechial rash, both legs).
3. SCARS (i.e. s/p appendectomy, RLQ, 6 cm healed scar).
E. Lines/devices: (i.e A-line, right antercubital, tracheostomy).
F. Chest: (i.e. unremarkable, barrel chested).
G. Abdomen: (i.e. mildly distended. prominent veins around the umbilicus/caput medusa)
H. Extremities: (i.e. tattoos, edema, nail clubbing, hematoma).
III.
Cardiovascular System:
A. Pericardium: (i.e. adherent, fibrinous pericarditis, effusion, tamponade).
B. Heart (___ g):
1. Left ventricular hypertrophy (_cm, mid lateral ventricle).
2. (No) acute or remote infarcts.
3. Valves: (i.e. Mitral leaflets with myxoid degeneration, calcification of
the mitral annulus, aortic cusps with calcification and stenosis).
C. Coronary arteries (Left/right dominant):
1. LAD: __% stenosis (cross sectional area).
2. RCA:
46
3. Circumflex:
D. Aorta: (i.e. moderate atherosclerosis, focally severe in the abdomen with stenosis
of the renal arteries).
IV.
Respiratory system:
A. Pleura: (i.e. fibrous plaques, effusions, 50 cc, adherence of parietal and visceral)
B. Right lung (____ g):
1. MEDICAL (i.e. collapse, consolidation, hemorrhage, mild
emphysematous changes, upper>lower lobes).
2. ).
3. NEOPLASTIC (i.e. tumor obstructing right main stem bronchus.
Microscopic: squamous cell carcinoma).
4. INFECTIOUS (i.e. Targetoid lesions, necrotizing granulomas.
Microscopic: aspergilloma. Cultures: positive for fungus).
C. Left lung (____ g):
1. MEDICAL (i.e. collapse, consolidation, hemorrhage, mild
emphysematous changes, upper>lower lobes).
2. NEOPLASTIC (i.e. tumor obstructing right main stem bronchus.
Microscopic: squamous cell carcinoma).
3. INFECTIOUS (i.e. Targetoid lesions, necrotizing granulomas.
Microscopic: aspergilloma. Cultures: positive for fungus).
D. Trachea
1. (i.e. Erythematous mucosa adjacent to tracheostomy site, thick mucous
secretions, trachea and bilateral bronchi, diffuse mucosal necrosis c/w
prolonged intubation).
IV:
Gastrointestinal system:
A. Esophagus: (i.e. unremarkable, intestinal metaplasia- 3 cm above the G-E
junction, fibrosis c/w history of radiation, enlarged peritracheal lymph nodes).
B. Stomach: (i.e. normal fold/no focal lesions, punctate superficial erosions/stess
ulcers, diffuse thickening or mass. Microscopic: no evidence of viral inclusions.
Gastric tube site remnant within stomach wall).
C. Duodenum/small bowel: (i.e. unremarkable, mucosal flattening or ulceration.
Microscopic: c/w peptic ulcer disease).
D. Colon/rectum: (i.e. unremarkable. multiple adenomatous polyps, no carcinoma. 3
cm tumor mass in the cecum. Microscopic: andeocarcinoma, grade 3, stage 2
involving 10/10 region lymph nodes).
E. Liver: (____ g): (i.e. mild vascular congestion, multiple white nodules, < 0.7 cm.
Microscopic: metastatic small cell carcinoma.).
F. Gallbladder: (i.e. distended with green bile. Single mixed-type gallstone.).
G. Pancreas: (i.e. unremarkable. Fat necrosis c/w acute pancreatitis).
H. Peritoneum: (i..e. serosanguinous effusion, 100 cc).
V: Hematopoietic system:
A. Spleen (___ g): (i.e. unremarkable).
B. Lymphadenopathy: (tracheal, hilar, diaphragmatic, and peri-aortic).
VI: Endocrine:
A. Thyroid (__ g): (i.e. unremarkable, multinodular hyperplasia).
B. Adrenals (right = _._ g, left = _._ g): unremarkable.
47
VII. Genitourinary system:
A. Right kidney (___ g): (i.e. unremarkable, focal glomerulosclerosis).
B. Left kidney (___ g): (i.e. unremarkable, focal glomerulosclerosis).
C. Prostate: Nodular hyperplasia.
D. Testes (L = __ g, R = __ g): unremarkable.
E. Uterus, tubes and ovaries: unremarkable.
VIII.
Central Nervous System:
A. Brain (___ g): See separate neuropathology report.
B. Meninges: Unremarkable.
In cases of “put back the organs” where neuropathology is uninvolved include:
A. Brain (____ g):
1. Hemispheres-dorsal convexities: symmetric with a well-developed gyral
pattern. No localized external softening of contusion. No displacement
of the cingulated gyrus, medial temporal lobe or cerebellar tonsils
2. Coronal sections show intact cortical ribbon of appropriate thickness.
Internal architecture has the usual pattern without focal lesions or
hemorrhage. The ventricular system is unremarkable, symmetric and of
appropriate configuration and size.
3. Brain stem and cerebellum: Typical external configuration. Transverse
sections of the brain stem show a well pigmented substantia nigra and
locus ceruleus. The pons and olivary nuclei are unremarkable. Cerebellar
hemispheres have usual foliar pattern and dentate nucleus
B. Dura: unremarkable and sinuses are patent
C. Leptomeninges: transparent without subarachnoid hemorrhage or exudates
D. Circle of Willis/basal vasculature: normally formed and patent. Minimal
atherosclerosis is seen in carotid arteries without stenosis.
E. Spinal cord: Dura intact and unremarkable. Leptomeninges are translucent. The
anterior and posterior roots are comparable in size and bilaterally symmetric.
Transverse sections of cord show no abnormalities.
Organs retained for further study: Liver, spleen, heart, lungs, kidneys, adrenals, pancreas,
brain.
48
Cassette Identification Key
A= lung, left (upper lobe inked red, lower black)
B= lung, right (upper lobe inked red, lower black, middle blue)
C= heart (septum, left and right free wall)
D= liver
E= kidney
F= bone marrow
G= Sections corresponding to specific findings.
Organ
Heart
Male
Female
RV
Weight (g)
Expected Organ Weights
Change p/fixation
Measurement (cm)
-5.8%
300(270-360)
250 (200-280)
0.2-0.4 (measured 2cm proximal to
pulmonic valve)
1.5 (measured 2cm distal to mitral
valve)
(circumference)
8.5
4.5-7.0
3.5-4.5
LV
Aorta
Ascending
Thoracic
Abdominal
Lungs
Right
Left
Liver
Kidneys
Male (combined)
Female
Cortex
Medulla
Adrenals (each)
Male
Female
Parathyroids
Thyroid
Spleen
Brain
Male
Female
Cord
450 (350-570)
375 (325-480)
1650 (1500-1800)
-4%
+2%
313 (230-440)
288 (240-350)
0.6-0.7
1.3-1.7
9.7
8.3
0.12-0.18 (comb)
40 (30-70)
<250
+15%
+2%
+9%
1400
1275
45
49
Final Note
(Clinical summary)
(Synthesis)
(Cause of death)
Note: Dr. _____ reviewed slide __ in consultation.
Special tests performed:
50
Fetal Template:
BETH ISRAEL DEACONESS MEDICAL CENTER
330 BROOKLINE AVENUE
BOSTON, MASSACHUSETTS 02215
AUTOPSY REPORT #A04-087
Name: Harris, Twin B
Age: 0
Hospital #: Baby (Mother)
Sex: Female
Race: Caucasian
Restrictions: None
Date of death: 8/18/04
Hour of death: 1:03AM
Date of autopsy: 8/18/04
Date of PAD: 8/19/04
Date of FAD:
Prosector: J.Smith
J. Jones
Clinical Service: OB/GYN
Report to: Dr. J. Simpson
Staff Pathologist: Jonathan Hecht, M.D., Ph.D.
_____________________________________________
Provisional/Final Anatomic Diagnosis
For PAD: PLEASE NOTE: THIS IS A PRELIMINARY (GROSS) REPORT AND IS
PENDING MICROSCOPIC EXAMINATION. FINAL ANATOMIC DIAGNOSIS TO
FOLLOW.
I. External examination (expected values for gestational age):
A. Phenotypically (i.e. male/female) fetus, __ weeks based on obstetrical ultrasounds.
B. Skin:
1. Maceration with skin slippage over __% of surface.
2. (Skin defect in left leg, presumed cytogenetics sample).
C. Measurements
1. Weight: _____ grams (____+___ g).
2. Crown-rump length: __ cm (___+_ cm).
3. Crown-heel length: ______ cm (____+___ cm).
4. Foot length: left ___ cm, right ___ cm (___ +___ cm).
5. Head circumference: ___ _cm.
6. Inner/Outer canthal distances: ___/___ .
7. (x-rays show___).
D. Head and neck:
1. Hair: COLOR, DISTRIBUTION (single whorl, none).
2. Neck: (i.e. unremarkable, nuchal thickening or lateral neck webbing).
3. Ears: (i.e. normally formed, flattened, ear pits, patent canals).
4. Mouth/palate: (unremarkable, cleft hard palate/lip, hyperglossia, teeth).
5. Eyes: (i.e. symmetric, closed).
E. Chest: (i.e. unremarkable, narrowed, widely spaced nipples).
F. Abdomen/back
51
1. (i.e. Unremarkable, omphalocele, gastroschesis, distension, meningo-myelocele,
sacral teratoma, lumbar midline defect).
2. Umbilical cord remnant: 7 cm long, 1 cm diameter, 3 vessels.
G. Pelvis:
1. (i.e. male external genitalia, fusion in midline, descended tested; unremarkable
ovaries, tubes and uterus).
2. Patent anus.
H. Extremities:
1. Apparently proportional to torso without palpable fractures.
2. Feet: Five toes. No webbing, abnormal spaces between toes.
3. Hands: Five fingers. No webbing or abnormal palmar creases.
II. Respiratory System:
A. Patent trachea with no stenosis or atresia. No tracheoesophogeal fistula present.
B. Lungs with normal lobation. Combined weight = _____ grams (__ g, expected).
III. Cardiovascular System:
A. Heart ___ grams (__ g, expected).
B. Patent foramen ovale and ductus arteriousus.
C. Cardiac chambers, AV valves and semi lunar valves grossly unremarkable.
IV. Gastrointestinal System:
A. No malrotation present.
B. No atresia or stenosis present.
C. Liver: ____ grams (__ g, expected), unremarkable with gallbladder.
D. Pancreas: unremarkable.
V. Genitourinary System:
A. Left and right kidneys combined ___ grams (_ g, expected). No cysts.
B. Ureters not dilated, bladder: unremarkable with urine.
C. Two ovaries, one uterus: unremarkable.
VI. Lymphohematopoietic System:
A. Spleen: ___ grams: (i.e. unremarkable, accessory spleen).
B. Thymus: ____ gram (__ g, expected): involution.
VII. Endocrine System:
A. Adrenals, combined weight ____ grams (___ g, expected): unremarkable
VIII. Musculoskeletal System: Unremarkable
IX. Cranium:
A. Brain: __ grams (__ g, expected). See separate neuropathology report.
B. Skull, small subgaleal hemorrhage and subcutaneous petechiae on surface of the cranium
(non-specific)
X. Placenta: (S0_-_______)
A. PATHOLOGY REPORT.
B. (summary of findings)
52
Organs retained for further study: Liver, spleen, heart, lungs, kidneys, adrenals, pancreas,
brain.
53
Cassette Identification
A= lungs,thymus, liver
B= kidneys, adrenal, spleen
C= gonads/uterus/tubes (wrapped on lens paper)
D= GI tract, brain (if not taken for brain cutting)
E= Heart
FINAL NOTE
(Clinical summary, ultrasound, genetics)
(Synthesis)
(Cause of death)
Note: Dr. _____ reviewed slide __ in consultation.
Special tests performed:
54
Autopsy Conferences
The times and places of the Autopsy Conferences are as follows:
The weekly Gross Pathology Conference will be held in the East Campus Autopsy Room every Thursday
afternoon (11-12 p.m.)
A monthly subspecialty autopsy Gross/Micro Conference is held on the last Wednesday of each month in the
department conference room. Staff pathologist staff will request specific microscopic sections be shown to correlate
with gross findings. This conference is coordinated with the chief resident. The conference is part of Quality
Assurance/Quality Control, and a record of the findings is kept on file.
The Pathology Department also participates in the weekly Surgical Morbidity and Mortality Rounds, and
periodically in Medical Morbidity and Mortality Rounds. The surgical or medical coordinator will notify the
Pathology Chief Resident(s) at least 5 working days in advance of autopsies to be presented at this conference. We
should adhere strictly to this rule in order to allow sufficient time to prepare cases and to obtain Kodachromes, if
needed. (Residents already should have photographed the significant gross findings.) The resident should organize
their presentation and discuss the case with the Pathology staff member ahead of time. Generally, if microscopic
sections are not available in time for this conference, microscopic follow-up can be given at a later date. On
occasion, microscopic sections are crucial for the understanding and evaluation of a case. In such cases, one or two
microscopic sections can be rushed so that information is available prior to the Surgical Conference. If this cannot
be accomplished due to time limitations, the Chief Resident should request that the case be rescheduled.
Observers
A. Medical students and others (i.e. Pastoral care, researchers, residents from other departments) may observe
autopsies, and may participate if directly supervised by the prosector or pathology staff. They must have
permission from the director of autopsy or Dr. Connolly.
B. All visitors must wear personal protective gear as described for residents. Their presence must be noted in the
residents autopsy notes.
C. They must understand that they are obliged to maintain patient privacy. Autopsy findings may be shared with
the medicine teams who cared for the decedent, but only after the information is verified with pathology staff.
Requests for Tissues for Research Purposes
The Department of Pathology collaborates with several researchers from BIDMC and elsewhere in projects that
utilize autopsy material. All collaborations must be approved in advance by the Director of the Autopsy Service, and
requests for collaboration need to be made in writing and directed to Dr. Hecht.
Quality assurance consists of microscopic correlation (GM conference), and reviews of 10% of
adult PAD/FAD/NP on a quarterly basis by Dr. J. Hecht.
55
BETH ISRAEL DEACONESS MEDICAL CENTER
Department of Pathology
Autopsy Pathology Quality Assurance Monitoring Form
Autopsy Effectiveness Report
Pathologist Reviewer (ID Number)___________
Autopsy Number__________________
Autopsy Date_____________________
Date of Review________________
Patient Number_____________________________
Clinical Service_____________________________
Major Disease(s):
Cause of Death:
1. Did this autopsy uncover a major disagreement in diagnosis? Yes______ No_________
If YES, check the following applicable categories:
______ Discrepant primary diagnosis with adverse impact on survival
______ Discrepant primary diagnosis with equivocal impact on survival
______ Discrepant secondary disease not directly related to cause of death, but was either
symptomatic and should have been treated or could have eventually affected prognosis
______ Discrepant non-diagnosable (occult) secondary disease
2. Did this autopsy establish an unexpected or additional diagnosis? Yes______ No________
If YES, was this a ____ Neoplasm;____ Myocardial infarction;____ Infection;____ Other, specify:
Would the clinical outcome been affected if this diagnosis had been known?
3. DID THIS AUTOPSY:
(A) provide clarification of the clinical differential diagnosis?
(B) confirm or verify the major clinical diagnosis?
(C) provide information on any diagnostic procedures?
Yes_____ No_____
Yes______ No_______
Yes______ No_______
Yes______ No_______
(radiologic?_____ endoscopic?______ other?____________________________)
(D) provide information about any of the following areas? ____surgical pathology; _____cytopathology;
_____hematopathology; ______ clinical laboratory; ____other_________
4. Is there need to provide additional follow-up on this autopsy?
If YES, please describe (USE BACK OF PAGE IF NEEDED)
Yes______ No_______