Guidelines for Collection of Peri and Post-Mortem tissue samples on
PICU
Tissue samples may occasionally need to be taken on PICU to complete diagnostic
work up immediately after death, or just prior to a planned withdrawal of care. The
most likely scenario is a child with a suspected metabolic disorder, where the
diagnosis has not been established in life, and has potentially important genetic
implications for the family. It is always better to collect the samples in life, so where
possible this should be discussed with the family and organised prior to death. It is
also better to collect the samples during working hours so they can be sent to the
appropriate labs, particularly as there is no official out of hours histopathology
cover.
Samples taken during life are subject to the usual Trust consent procedure, and are not
subject to the Human Tissue Act
Cases should be referred to the Coroner if the cause of death is unknown, or if there
are suspicious circumstances surrounding the death. However, the coroner may not
feel he needs to accept the case or order a post mortem if the death is obviously from
a natural cause. If a case is referred to the coroner, no samples can be taken after death
without his consent.
Hospital post-mortem should be offered to the family of any child dying on PICU.
However, if metabolic disease is suspected, early collection of tissue samples may
improve diagnostic capability. Hence particularly out-of-hours, PICU staff may be
required to obtain post mortem tissue samples.
If there is an anticipation of the death, liaison should take place with the Clinical
Biochemist, Geneticist and Paediatric Pathologist and a plan made in the child’s notes
for what to do when the child dies.
Investigations should be targeted according to clinical diagnosis, but there are a
number of specimens that should be obtained as a minimum (if not already taken).
Aim of Guidelines:
These guidelines are intended to provide basic information about gaining informed
consent from parents in the situation where urgent post mortem samples are thought to
be indicated. They will also list the samples that should be taken, how to take them,
when they should be taken, how they should be stored and where they should be sent.
They will provide some guidance about the equipment that is needed, and set out who
should be trained and how.
Human Tissue Act
This was developed in 2004 and came into practice in 2006, following national
concerns about retention of paediatric organs and tissues. It is a framework for
regulating the storage and use of human organs and tissue from the living, and the
removal, storage and use of tissues and organs from the deceased, for specific health
related purposes and public display (e.g. museums). It ensures that informed consent
is obtained for post-mortems and aims to ensure parents are aware of what is involved
and in what circumstances retention of tissues and organs may be beneficial. It does
however mean there are now very strict regulations around such cases, with an
accompanying increase in required paperwork and documentation. Much of this falls
to the pathology department, but you will be required to complete all the necessary
paperwork for any samples you are involved in taking on PICU.
Emily Barton / Megan Smith
August 2007
1
PICU is a licensed area for the collection of post-mortem tissue samples. Dr Megan
Smith is the “Person Designate” overseeing practice, but all PICU staff involved in
the collection of post mortem samples must read the official documentation from the
Trust Human Tissues Management Group and conform evidence to the regulations.
This involves a process of audit, staff training, health and safety and risk assessments.
Useful Contacts:
The guidelines should be used in conjunction with advice from the clinical biochemist
and paediatric pathologists, as well as advice from laboratory staff. These discussions
should take place as soon as death is anticipated and metabolic investigations are felt
to be indicated. There is no on-call histopathology rota - switch has Dr Padfield’s and
Dr. O’Neil’s numbers but they are not guaranteed to be contactable.
If the case might be a coroner’s case, then no samples of any kind can be taken
after death without his permission, so liason with him should take place to try
and ensure necessary samples can be obtained. He should be contacted as soon
as possible after death or prior to death if it is expected-there is an out of hours
number for advice, but he will not perform his PM out of hours.
Clinical metabolic advice is usually obtained from Birmingham Children’s Hospital
(Chris Hendrickz, Dr. Amnapam Chakrapani) or Sheffield Children’s Hospital (Dr
Mark Sharrard)
Dr Peter Prinsloo- Biochemist, City Hospital
Dr James Padfield- Paediatric Pathologist, QMC
Dr O’Neil-Paediatric Pathologist, QMC
Ruth Musson-Pathology Specialist Nurse, QMC
Dr Mohnish Suri-Consultant Clinical Geneticist, City
Coroner, Nottingham
Emily Barton / Megan Smith
August 2007
ex 55709
ex 61270
ex 61270
ex 63240
ex 56115
0115 9412324/9412322
Switch out of hrs
2
Samples to be taken
It is always best to get samples when the child is still alive where possible, preferably
within working hours. Most PM samples should be taken within 2 hours of death.
Metabolic screen (see table)
Blood and urine - most important samples
CSF – may be useful but is less crucial.
Skin, muscle and liver biopsies
If unsure about all the tests that are needed and out of hours then take the samples and
write clinical details on the request form, with “sample for storage, more details to
follow” in the request box. You should then phone the labs at the earliest opportunity
to discuss what tests are required. There may be additional tests after d/w
metabolic/neurology/genetics
Possible sepsis
Bloods
urine
CSF
swabs as indicated by clinical condition
these should be taken as usual in addition to the metabolic specimens.
Other
Photographs and skeletal surveys are also sometimes helpful. Consent needs to be
specifically taken for external photographs or individual identifiable photographs after
death
Kit you may need:
A “metabolic PM” kit is stored in “Jackie’s cupboard” on the unit containing:
Blood bottles-paediatric and adult, EDTA, Li Heparin, Serology(red top)
Needles/Butterflies/Syringes
3-4 Guthrie cards
Sterile saline
Universal containers
Spinal needles
Tape measure
Genetics Request forms
Foil
Glutareldehyde bottles (EM fix A&B)-store in fridge, labelled toxic
Formalin
Liver biopsy needle-trucut needle
Skin Biopsy needle-punch biopsy needle
You will also need:
Sterile gloves & gown
IV cutdown set-for muscle, skin, liver biopsies
Transport medium for liver/skin/muscle/some CSF samples-e.g liquid
nitrogen, cryovial (need to d/w lab for further instructions and collect
appropriate medium from labs prior to taking specimens)
Emily Barton / Megan Smith
August 2007
3
Metabolic Specimens
This is a basic list that provides a screening type approach to suspected metabolic conditions. Discussion with the metabolic consultant in Birmingham
or Sheffield, the neurologists and geneticists should help target investigations and discussion with the histopathologist and clinical biochemist will
ensure you collect the right specimens under the right conditions
Sample
Amount/Specifications
10mls(minimum 2 mls)
Universal container
-bladder tap if PM sample
-can be bag sample if alive
10mls EDTA(pink)
-cardiac puncture at PM possible
What to send for
Organic acids
Amino acids
Orotic acid
Acylglycines
DNA studies
Plasma
3-4mls Lithium Heparin(Green/Yellow)
Guthrie Card
2-3 cards(6-9 blood spots)
Amino acids
Acylcarnitine
VLCFA, FFA
Ammonia/Lactate/Gas
DNA PCR techniques
CSF
1ml(min 250microlitres)
Universal container
If sepsis suspected then will need additional
Must be free of red cells
Urine
Whole Blood
Emily Barton / Megan Smith
August 2007
Storage/Where to send
Clin Chemistry
Can send to lab anytime
Molecular Genetics
Can store in fridge-send to City am next
working day
Clin Chem
Send straight to lab
Should have been done on admission
Clin Chem
Next working day
Store in paper envelope
Clin Chem
Warn labs before sending, to lab asap(needs
freezing)
4
Sample
Skin
-within 6 hrs death
Liver
-within 2 hrs death
Muscle
-within 2 hrs death
-essential if
mitochondrial
disorder suspected
Amount/Specifications
3  2mm samples
Universal container with sterile saline
Full thickness-best from axilla
3  0.5cm cubes
-needle biopsy perimortem
-open biopsy post mortem
Wrap individually in foil and roll to exclude air,
put in universal container
Open Biopsy-need good end on samples
i)2  0.5cm cubes, wrapped in foil, place in
cryovial(enzymology)
ii)snap freezing(histochemistry)
iii)2 thin strips in formulin(histology) and
glutaraldehyde(electron microscopy)
Emily Barton / Megan Smith
August 2007
What to send for
Fibroblast culture
Non-ketotic
hyperglycinaemia
Enzymology
Histochemistry
Histology
Electron Microscopy
Storage/Where to send
Cytogenetics
Store in fridge, send to City next working
day
Histopathology
Inform labs before doing
Store at –70, transport on dry ice(-80)
Histopathology
Inform labs before doing and send asap
Can only be done in working hours
5
Consent:
Peri-Mortem Samples
Verbal consent should be obtained for bloods and genetics as usual way. Liver, skin
and muscle biopsies need to be consented for on the standard operative consent formbut whoever does the procedure needs to specifically gain consent for fibroblast
cultures (cytogenetics) and discuss the issue about keeping tissue samples for research
etc.
Post Mortem Samples
A Specialist Registrar or Consultant who has undergone specific training in taking
consent for post mortem examination must take consent.
The Trust “Consent Form for Post Mortem Examination” should be used. It specifies
whether the post-mortem is full or limited, covers tissue sampling and retention and
organ retention. It also covers consent for photographs and genetics and choices
about disposal.
Training:
All medical and nursing staff working on PICU should read these guidelines
alongside the documents in the Human Tissue Act folder. They should then sign the
Staff Records section to say that they understand them and accept the conditions
under which tissue samples should be collected and stored and their responsibility for
ensuring these are adhered to.
All staff working on the unit will have the standard hospital induction as well as an
induction to the unit. This will cover the basics of health and safety, infection control,
clinical governance, risk assessment. Particularly relevant to these guidelines is the
training around infection control, sharps disposal, handling blood and tissue samples.
Health and Safety- Sue Mager (Acting Senior Nurse) is lead for Children’s
Services and co-ordinates regular health and safety reviews.
Infection Control- Sr Jill Wilson is the PICU link nurse. The infection control
team and microbiologists are available for further advice.
Audit:
Collection of post mortem tissue specimens will be audited on an annual basis and
records kept. Audit results will be shared with the histopathology department and the
Human Tissue Management Group.
Incident Reporting:
As per hospital policy, an incident form should be completed if any adverse incidents
are associated with the collection of post mortem samples, or these guidelines are not
followed. Such incidents should be logged in the SOPS manual and reported to Dr
Megan Smith.
Emily Barton / Megan Smith
August 2007
6
Guide to taking biopsies:
During life liver biopsies should be taken by a surgical SpR or Consultant, or the
Gastroenterology Consultant. Muscle biopsies should be taken by a surgeon. PICU
staff are responsible for providing adequate sedation and analgesia if these procedures
are performed on the unit. Local anaesthesia may be adequate/appropriate.
Skin biopsies may be performed by a doctor with appropriate training.
Instruction is given below for obtaining post-mortem samples. Assistance may be
sought from the on-call surgical SpR if further advice is needed.
NB it is crucial that adequate specimens are obtained, as there will be no opportunity
for them to be repeated.
Documentation/Sample Labelling:
All issues around consent must be documented in the notes and the consent form need
comprehensively filled in.
The Human Tissues Management Group state that “all human tissue specimens must
be accompanied by essential identifying details relating to patient and specimen.”
The minimal details that must accompany every sample are;
Patient detailsfull name
date of birth
sex
NHS/Hospital number
Sender location
Specimen detailstype of specimen
consent details
date and time taken
(date received-lab must record)
Adequate clinical information and specific questions are essential. (it is useful to
make a note of any specific discussions that have already taken place with the lab)
Discuss with labs/histopathologists/biochemists and consultant in charge of patient’s
care to ensure all the appropriate investigations are requested
The record sheet in the Human Tissues Group local SOPS file must be completed
for all post mortem samples. Dr Megan Smith (Person Designate) should be
informed whenever post mortem samples are taken.
Liver Biopsy
This can be done as a percutaneous needle biopsy, or as an open biopsy. There are
advantages and disadvantages to both. Prior to death any clotting abnormalities must
be are corrected. Post mortem, an open biopsy may ensure better tissue samples and
there is less concern about the cosmetic implications of a larger scar and
complications such as bleeding.
Risks/Complications (not an issue if being done post-mortem)
-pain
-bleeding
-haemobilia
-bilary peritonitis
-pneumo/haemothorax
Emily Barton / Megan Smith
August 2007
7
Percutaneous Biopsy
Equipment needed- sterile gloves & gown
Betadine/Chlorhexidine
IV cutdown set
Scalpel
Sutures
Tru-Cut needle(appropriate gauge and length for size of child)
Dry ice (obtain from lab)
Procedure:
 Contact this histopathology lab to ensure they are ready to receive the sample
 Wash hands thoroughly and don sterile gloves & gown
 The patient should be supine with the right arm positioned behind the head.
The liver may well be enlarged if there is a metabolic condition in which case
you can adopt a subcostal approach(there is an increased risk of visceral
perforation with this approach). Otherwise, aim to take the sample from one
intercostal space below the onset of percussion dullness between the mid and
anterior axillary lines
 Clean the area and create a sterile field
 Make a 1-2cm incision through the skin in order to allow the Tru-Cut needle
to be inserted
 The Tru-Cut needle has an outer sheath and an inner notched obturator with a
20mm notch that will collect the sample that extends beyond the end of the
outer sheath.
o Pull back the inner section so you have a single cutting edge, and
advance through your incision 2-4 cm.
o hold the outer sheath and rapidly advance the inner obturator.
o advance the outer sheath over it which cuts the sample and secures it in
the notch.
o Withdraw the whole instrument
 Carefully remove the sample from the Tru-Cut needle – a green needle may be
needed to facilitate this.
 Wrap the sample in foil and roll to exclude air, then place in a universal
container
 Repeat the above so you have at least 2 samples (3 needed if you are
suspecting non-ketotic hyperglycinaemia)
 Suture the incision
 Send immediately to the histopathology lab on dry ice
Open Biopsy
Equipment needed-
sterile gloves & gown
Betadine/Chlorhexidine
IV cutdown set
Scalpel
Sutures
Dry ice (obtain from histopathology lab)
Emily Barton / Megan Smith
August 2007
8
Procedure:
 Same position as above
 Scrub hands and don gown & gloves
 Clean the skin and create a clean field
 Make an incision and dissect through the layers so you can directly visualise
the liver
 Using the scalpel cut 2-3 x 0.5cm cubes from the liver
 Package up the samples as above
 Suture the incision
 Send to lab as above
Muscle Biopsy
There are several types of muscle specimen that should be obtained and again you
will need special transport medium so speak to the labs
Risks/Complications- Pain
Haematoma
Infection
Equipment needed- sterile gown & gloves
Betadine/Chlorhexidine
IV cutdown set
Scalpel
Sutures
Transport media (glutaraldehyde, formalin & dry ice –
available from histopathology lab)
Procedure:
 Lateral quadriceps is usual site of biopsy-halfway between anterior superior
iliac spine and patella
 Wash hands thoroughly and don gown & gloves
 Clean skin and create a clean field
 Make a 2-4cm incision through the skin and subcutaneous fascia to expose the
muscle in the direction of the long axis of the muscle
 The muscle and its fascial sheath should be sampled so do not remove this
 Create a sling with suture thread at either end of the piece of muscle you
intend to sample
 Remove several thin strips of muscle with sharp scissors
o 2 thin strips need to be placed in glutaradehyde (bottles A&B-mix,
then put in sample)
o May also need formalin - liaise with histology
 Several end-on cubes of muscle are also required for enzymology
o Wrap in foil and transport on dry ice
 Suture wound
Emily Barton / Megan Smith
August 2007
9
Skin Biopsy
This must be a full thickness sample.
A punch biopsy is best or a full thickness sample of skin can be taken from under the
axilla using a scalpel
Risks/Complications- Pain
Bleeding
Infection
Equipmentsterile gown & gloves
Chlorhexidine
IV cutdown set
Punch biopsy needle
Sutures
Procedure:
 Forearm good site for punch biopsy
 Wash hands thoroughly and don gown & gloves
 Stretch skin in longitudinal axis
 Position biopsy needle perpendicular to skin and rotate down (you can’t go too
deep)
 Withdraw needle whilst applying pressure to punch site
 Remove skin sample using scalpel blade to ensure the fibroblasts aren’t
damaged
 Place in sterile saline in universal container (DO NOT PLACE IN
FORMALIN)
Emily Barton / Megan Smith
August 2007
10
References
1. GOSH Clinical Guidelines-liver biopsy/muscle biopsy/skin biopsy
www.ich.ucl.ac.uk
2. British Society of Gastroenterologists-Guidelines for the use of liver biopsy in clinical
practice
www.bsg.org.uk/pdf_word_docs_liver_biopsy.pdf
3. American Academy of Family Physicians-punch biopsy(good pictures)
www.aafp.org/afp/20020315/1155.html
4. New South Wales Biochemical Genetics Service-Children’s Hospital Westmead
www.chw.edu.au
5. Human Tissues Management Group Quality Manual
Emily Barton / Megan Smith
August 2007
11