ENHANCING THE EFFICIENCY OF

POST MORTEM DIAGNOSIS

BY IMPROVING

THE POST MORTEM FACILITY,

TECHNIQUES AND

HEALTH ISSUES

Asha Ann Philip

MVSc Scholar

Division of Pathology (VPL)

Indian Veterinary Research Institute

OVERVIEW Introduction

Review of Literature

Facilities To Be Available

Techniques

Risk Assessment

Biosafety And Health Issues

Supportive Diagnostic Tests

Waste Management

Cleaning/Disinfection

Conclusions

Post mortem is the systematic and scientific examination of the

dead body to ascertain the cause of death.

(Rajan and Valsala, 2002)

Types of Post mortem Examination

1.Complete Post mortem examination

2.Incomplete Post mortem examination (Eg:Rabies)

3.Cosmatic Post mortem examination( VVIP/ pet animals)(Sinha, 2011)

INTRODUCTION

WHAT IS POST MORTEM DIAGNOSIS?

WHY ONE SHOULD PERFORM A NECROPSY?

i. • Identification of disease.

ii. • Indicate appropriate treatment of disease in a herd.

iii. • Limit future losses.

iv. • Improve understanding of disease effects on animals.

v. • Enhance discussion of health maintenance programmes

with animal health specialists.

.

( Severidt, 2001)

Contd….

IMPORTANCE OF POST MORTEM REPORT ?

1. Outbreak of diseases - Vaccination of healthy animals

2.Insured animals - Death certificate

3.Government animals

4.Experimental animal

5.Medico-legal or vetero-legal

(Sinha, 2011)

Contd….

RULES FOR POST MORTEM EXAMINATION

Conducted as early as possible within 20 minutes

Site of necropsy

Done in sufficient light (preferably in daylight)

Anamnesis and Clinical history of the disease- not be guided

by it.

Person should wear protective coverings.

Post mortem kit.

Record the observed changes.

(Sharma, 2009)

( Severidt, 2001)

Contd….

“Once a cornerstone of medical education and medical practice, the

autopsy has fallen into disuse and disregard in many circles in the

USA”. (Hill,1993)

“Autopsy can represent a key instrument in auditing clinical diagnosis

performance, on which in turn the accuracy of diagnoses, as used in a

variety of epidemiological investigations depend.”

(Saracci,1993)

“Since most autopsies are for the coroner, there is a need to emphasize the importance of taking tissue for histology, of pathologists having access to the information they require, and of clinicians and relatives being properly informed of the results.”

(Carr, 2002)

REVIEW OF LITERATURE

Contd…..

“The autopsy continues to be a vital part of medical education and

quality assurance if a problem-oriented autopsy can be performed

based on questions raised by the clinician and the pathologist as a

result of the gross dissection and microscopic evaluation.”

(Garner, 2002)

“The one major category clearly falling below the recommended

standard was Conclusions/Commentary. Other major categories such

as History, External description and Histology report were also in

need of improvement.”

(Bjuqn and Berland , 2002)

“The overall quality of sudden unexpected infant death necropsies in

Ireland is less than adequate. A minimum accepted standard of necropsy

is required before a diagnosis can be made.”

( Sheehan et al, 2003)

Contd….

“ Necropsy organ weights are largely useless.

We should stop this ritualistic, pseudoscientific practice and

concentrate on providing a relevant, meaningful service to our

colleagues.” (Barker, 2005)

“The autopsy rate has declined world wide in the last decades due to

several reasons; progress in diagnosis of diseases, fear of legal

consequences if wrong diagnosis is made, infectious risk to the

pathologists and time consumption.” (Ioan et al, 2012)

“National autopsy rates have declined for several decades, and the

reasons for such decline remain contentious”.(Nemetz. et al, 2006)

What are the Facilities available?

What Techniques that we are following?

How much knowledge and experience we have?

How far our diagnosis is efficient?

WHAT IS THE EFFICIENCY OF OUR

POST MORTEM EXAMINATION ?

COMPONENTS OF AN EFFICIENT POST

MORTEM DIAGNOSIS

POST MORTEM FACILITIES

POST MORTEM TECHNIQUE

THOROUGH KNOWLEDGE

HEALTH ASPECTS/ BIOSAFETY

SUPPORTING DIAGNOSTIC METHODS

All work should be conducted in a manner that will minimizeaccidents and also comply with environmental, health and safety laws and regulations.

FACILITIES TO BE AVAILABLE

A)TRANSPORT OF ANIMALS AND SAMPLES

Animals to be necropsied will be double-bagged and

transported.

Large animals wrapped and covered as much as practical.

The transport cart should be left outside the entrance of Room.

Any blood on sample bottles must be disinfected before

removed from the necropsy room.

(Necropsy Room Policy and procedures, 2009)

B)NECROPSY ROOM (Sadalla, 2004)

A large room that is self contained

(separate air system, light and

drainage)

The room can accommodate an

animal as large as a rhinoceros.

A special I-beam with a hoist.

A large walk-in cooler can be

attached to this room for storage of

deceased animals until they can be

properly disposed of.

Animal necropsy table Autopsy sink wall mount

1.NECROPSY SUPPLIES

Gloves

Boning knife

Steel - for sharpening

Scissors

Forceps

Pruning shears - Rib cutters

[NADC Procedures for Incineration and Operation of the Necropsy

Facility. (Sept. 2004)]

NECROPSY INSTRUEMENTS(Mortech manufacturing INC, 2012)

2.PERSONAL PROTECTIVE EQUIPMENT (PPE)

Boots

Coveralls

Disposable bouffant cap

(hair net)

Surgical or procedural

mask

Protective glasses

3.SHIPPING SUPPLIES

Plastic wide mouth

containers

10% buffered formalin

Sealable bag

(Zip-lock bags)

Permanent marker

Needles and Syringes

10% buffered formalin Microbiology collection tools

1.Euthanasia

" The intentional causing of a painless and easy death to a

patient suffering from an incurable or painful disease"

(Webster II University Dictionary, 1996)

Beneficial to euthanize an affected animal for examination,

especially if there is an outbreak of disease within the herd.

TECHNIQUES

Types of euthanasia:

1. Captive bolt

2. Gunshot

3. Chemical (OIE Guidelines, 2012)

4. Exsanguination (Bleeding out)

(AVMA Guidelines for euthanesia of Animals,2013)

2.Diagnostic Sampling

(Severidt, 2001)

Anything that does not

look normal.

Samples should reflect

the clinical signs of

animal.

Don't worry about

taking too many

samples, too much is

better than too little.

3.The "digital" necropsy

Feedlot Health

Management Systems (FHMS)

trains its own non-veterinarian

personnel to perform standard

necropsies, digitally photograph

them and load them onto a web-

based application for evaluation

and diagnosis by trained FHMS

veterinarians on the same day.

(Wren, 2012)

4.Needle Necropsy:

Limited necropsy by histological examination of needle tissue cores obtained percutaneously.

Indicated when a full necropsy is not justified due to risk of infection or when tissue for special investigations is needed soon after death, and owner’s sentimence.

(Underwood et al 1983)

5.Postmortem Radiology and Imaging (Minimally invasive

autopsy) (Virtopsy) Conventional radiography complement the forensic autopsy

document.

Forensic pathologist can view postmortem anatomy in 2 and 3

dimensions without dissection

Radiography, C-arm fluoroscopy, MDCT scanning ,

Angiography and MDCT angiography and MRI

(Levy, 2012)

MDCT was a more accurate imaging

technique than MRI for providing a

cause of death (Roberts et al,2012)

MIA is a feasible procedure with high diagnostic performance

for detection of common causes of death such as pneumonia and

sepsis . (Weustink et al, 2009)

Haematoma Haemorrhage

Fracture

Inhalation exposure: Aerosols

Epidermal invasion: cut/ wound/scratches

Ingestion: Food/ water/contaminated hand

Ocular or mucous membrane exposure: Splashing. ( Rabies)

Contact contamination: Outside necropsy room

RISK ASSESSMENT - GENERAL

(Latham Hall Necropsy Room 120A-Policy and procedures, 2009)

Animals known to contain a pathogen of zoonotic

potential are not to be necropsied at this facility.

SAFETY PRECAUTIONS

1.Unauthorised persons are not allowed within the necropsy hall.

2.Personal belongings must be stored and secured outside the necropsy room.

3.Individuals should not work alone in the necropsy room.

4.Food and drink of any type is not allowed in the necropsy room.

5.Motorized tools will not be used during any necropsy, with the exception of fish and turtle.

Unauthorised persons are not

allowed within the necropsy hall.

Personal belongings must be

secured outside the necropsy

room.

Individuals should not work alone

Food and drink of any type is not

allowed in the necropsy room.

Motorized tools will not be used

KEEP THESE RULES

(University of Nebraska, Lincoln)

6.Personal protective equipment (PPE)

must be worn at all times during a

necropsy.

7. An N100 respirator must be worn for

avian and rodent necropsies

8. Protective eye wear should be used

where ocular exposure to animal fluid

might occur.

Contd.....

9.Special precautions must be taken with sharp items.

10.Perforated or split gloves should be changed and new

gloves put on after washing hands.

11.PPE must be removed and either disposed or

disinfected.

12.Hand-washing with soap and warm water is required

before exiting the necropsy room.

Contd.....

SEQUENCE FOR PUTTING ON PPE

GOWN

• Fully cover from neck to knees, arms to end of wrist and wrap around the back.

• Fasten the back of neck and waist

MASK

• Secure ties or elastic bands at middle of head and neck

PROTECTIVE EYE WEAR OR FACE SHIELD

• Place over face and eyes and adjust to fit.

GLOVES

• Extend to cover writ of isolation gown

(Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity , 2011)

SEQUENCE FOR REMOVING PPE

PROTECTIVE EYE WEAR OR FACE SHIELD

• Outside the eye protection or face mask is contaminated

• To remove handle by head band or eye pieces.

GOWN

• Unfasten the ties

• Pull away from neck and shoulder touching only the inside.

MASK

• Do not touch front of the mask since contaminated

• Grasp bottom ,then top ties and then remove.

GLOVES• Grasp outside of the glove with opposite gloved hand;

peel off

• Slide finger of ungloved under remaining glove at wrist.

INCIDENT RESPONSE PROCEDURES

In the case of an eye exposure

Immediately flush eyes at the eye-wash station

for 5-10 minutes, using continuous irrigation

In the case of a needle stick:

Clean and wash affected area thoroughly (use antimicrobial hand soap or mild disinfectant) for a minimum of 5 minutes. Gently massage the affected area to encourage bleeding while washing.

In the case of a mucous membrane exposure

Immediately flush the affected membrane area as much as physically possible. Then, proceed to an appropriate healthcare provider .

(Necropsy Room Policy and procedures, 2009)

BIOSAFETY AND HEALTH ISSUES

“Tuberculosis acquired in staff of laboratories and necropsy rooms by

inhalation of aerosols and skin lesions through cut and abrasions”.

(Collins and Grange ,1999) and (Posthaus et al, 2011)

“Salmonella typhimurium was isolated from two adult cows and a veterinary

pathologist who performed necropsy examination of one of the cow”.

(Bemis et al, 2007)

ZOONOTIC DISEASES

Tuberculosis

Rabies

Avian influenza

Nipah and Hendra virus

Brucellosis

Anthrax

Botulism

Monkey pox

Rift valley fever

1.Respiratory Protection Program and completion of fit-testing will be required for avian and rodent species.

2.Rabies and tetanus vaccination will be offered (Latham Hall Necropsy Room

120A-Policy and procedures, 2009)

3.The workers handling specimens from animals with monkeypoxvirus, should use Smallpox Vaccine (CDC Guidelines And Resources,2003)

Excluded Necropsies

1. Animals suspected for Anthrax

2.Old World monkeys or apes where there is no knowledge of the origin and current health status

3. Badgers from known TB-affected areas(Post Mortem Room Code Of Practice, 2013)

BSL – 3 NECROPSY BUILDING

( University of Minnesota, 2006) and (HSADL, Bhopal)

The BSL-3 Laboratory diagnose diseases of animals and birds with highly pathogenic organisms in a safe and secure facility.

(The project cost $2,146,200)

Biosafety level 3 (BSL-3) facilities established responding to outbreaks of highly pathogenic avian influenza (‘bird flu’) and other zoonotic (transmissible to humans) diseases including West Nile virus, rabies, anthrax, mad cow disease, and more recently, bovine tuberculosis.

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Three small

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ALKALI

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LAB WINGPM AREA

Isolator

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Three rooms for

lab animals.

Four large

animals rooms

Pass through

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HSADL, Bhopal

Clean Corridor-Animal wing

Entry

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Exit from

large

animal

room

Leading to post-mortem area

Dirty Corridor

Histopathology:

Microbiology, Toxicology and Other Services:

Tru-cut biopsy post mortems.

Clearly needle post mortem is inferior (11%) to the conventional autopsy in determining cause of death.

Dr. Radasch performs a tru cut biopsy

Tru-cut biopsy needle

Nylon biopsy bag

SUPPORTIVE DIAGNOSTIC

TESTS

(Foroudi and Cheung, 1995)

PATHOLOGY LABORATORY FACILITIES IN

NECROPSY ROOM

FOR STAINING PROCEDURES

Rapid seller’s staining for Rabies

Peripheral blood smear for Anthrax

Leishman’s staining for Pasturella

Acid fast staining for Mycobacterium

Giemsa staining for Haemoprotozoans

Cytology for tumours

A waste container with lid and autoclave bag for

disposable PPE other non-animal solid wastes.

The waste must be decontaminated by autoclaving.

Liquid biological waste may be flushed down the drain.

Animal parts and all solid biological remains transported

double bagged to a dedicated rendering.

WASTE MANAGEMENT

(University of Nebraska, Lincoln)

METHODS OF WASTE MANAGEMENT

1.Sanitary Land Fills

Daily covering of soils

(Strafuss,1988)

Rendering

3.Rendering Plant

Efficient and safe manner

Carcass Incinerator

2. Incineration/ Burning-

• Limited to baby pigs, young chicks, and poults.

• It is too time-consuming and costly to burn large

animals.

4.Deep burial/ Disposal pit-

Disposal of dead animals on the owner’s land.

Deep burial of carcass (Schultz, 2012)

The necropsy room (floors and walls) and equipment must

be cleaned thoroughly with disinfectant.

Drains must be flushed with warm water and disinfectant

as well.

Reusable PPE (e.g: rubber boots, eye protection) must be

disinfected, air-dried, and left in the room.

CLEANING/DISINFECTION

(University of Nebraska, Lincoln)

TYPES OF DISINFECTANTS

Best to choose one that kills wide spectrum of microbes.

1. Phenolics -General disinfectant

Active against most bacteria (except for spore forming bacteria, such as Anthrax and Clostridium)

2. Alkalies -Lye, Lime, and Sodium Carbonate

These act against most bacteria including spore forming bacteria (i.e. Anthrax,Clostridium) as well as some viruses.

3. Chlorine compounds

Hypochlorites - Eg:Sodium hypochlorite ,Chlorinated lime

Quaternary Ammonium

Chloramine

(University of Nebraska, Lincoln)

Chlorhexidine

Hydrogen peroxide

Virkon

SOME DISINFECTANTANTS USED

Evolution of veterinary science was heavily influenced by

examination of dead cadavers.

Post mortem examination is “a message from dead to the living”.

Necropsy is pushed back due to advancement in other diagnostic

techniques, the health issues and time consumption for the procedure

The lack of adequate facilities and poor technical knowledge is always

challenging the efficiency of necropsy diagnosis.

PM examination can be done accurately and efficiently with

improvement in PM facilities, techniques, biosafety and also with

support of other laboratory tests.

SOP and Biosecurity programs are designed to minimize the risks

associated with infectious and zoonotic diseases.

Always go for a complete necropsy, but in case of emergency we can

think of needle necropsy, digital necropsy or virtopsy

CONCLUSIONS

REFERENCES A.C. Strafuss ,Procedures and Basic Diagnostic Methods for

Practicing Veterinarians .1988. pages-195-203

A predesign study for the construction of the Veterinary diagnostic laboratory building BSL – 3 necropsy laboratory University of Minnesota, 2006

B.K.Sinha, Post mortem techniques and diagnostic procedures, 3rd

edition, 2011.Page 1-9

J. L .Burton, Health and safety at necropsy. J Clin Pathol. 2003; 56(4): 254–260.

J.C.Underwood et al, The needle necropsy. Br Med J.1983. 26(6378):1632-4

J. A. Severidt et al .2002. Integrated Livestock Management. Colorado State University.

Latham Hall Necropsy Room 120A-Policy and procedures, 2009

NADC-:TSE–SOP–005 Necropsy Procedure(21 AUG 2006)

United States Department of Agriculture Guidelines for Necropsy