Clinical review: What is the role for autopsy in the ICU?

Abstract

The availability of advanced diagnostic tools has grown in the past decades. Hence, a growing false belief exists that everything is known about the patient before death. Moreover, intensivists may wrongly believe that autopsy findings do not contribute to the understanding of pathophysiological events. The immediate result is that few ICUs nowadays assemble enough autopsy cases with new and interesting clinicopathological features. However, we believe that, at least in tertiary ICUs, autopsies remain a valuable examination, as a tool for quality control, as a way of establishing gold standards for diagnostic examinations and as an aid in developing guidelines for treatment and diagnosis of diseases frequently encountered in the ICU. Finally, due to the ever-expanding armamentarium of immunosuppressive agents, a growing list of opportunistic infections is discovered during autopsy. The present article gives an overview of autopsy studies conducted in the ICU and discusses the pros and cons of performing these.

Postmortem CT is more accurate than clinical diagnosis for identifying the immediate cause of death in hospitalized patients: a prospective autopsy-based study

“…Cancer should in most cases not be listed as immediate cause of death, but rather an underlying cause of death. Cancer as such might be the direct cause of death in only 10 % of cases [ 22 , 37 ].…”

The value of autopsies in the era of high-tech medicine: discrepant findings persist

“…A reason for the persistently high discrepancy rates may be selection bias because clinicians are thought to request autopsies mainly for the clinically challenging cases 19. Nevertheless, several groups have shown that clinicians were not able to predict, based on their clinical certainty, cases that would uncover discrepant autopsy findings 20–22.…”

Missed Diagnosis of Cancer in Critically Ill Patients: A Single-Center Experience

“…There is an on-going debate between supporters of autopsy and others who consider the post mortem investigation somehow outdated. The former advocate its use mainly to verify the overall diagnostic and therapeutic appropriateness and thus to reduce avoidable deaths by identifying MD which could have influence negatively the outcome both in patients died in the regular wards and in the ICU [14][15][16]9], whereas the latter claim that its value is reduced, but not totally abolished, in the era of unrelenting advances of the imaging techniques [17,18]. Besides these, in the past years other factors contributed to determine a worldwide decrease in the rate of autopsies in patients died in the hospital, including poor training of pathologists in its execution, costs and the fear of litigation (Table 5- Actually, even if some investigators demonstrated that in patients admitted to regular wards the occurrence of major MD decreased along two or three decades [21,22], other studies showed that in patients died in the ICU the rate of potentially treatable conditions escaping to the clinical and radiologic investigations remains relatively high primarily because of the elevated lack of specificity of the symptoms prompting the ICU admission and to the rapidly evolving clinical conditions [1,9].…”