AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE

Rodrigues, Fernanda Staub; Oliveira, Isabella Correa de; Cat, Mônica Nunes Lima; Mattos, Maria Clara Lopes; Silva, Gabriela Andrioli

doi:10.1590/1984-0462/2021/39/2019263

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Revista Paulista de Pediatria

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Original Article • Rev. paul. pediatr. 39 • 2021 • https://doi.org/10.1590/1984-0462/2021/39/2019263 copy

AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU).

Methods:

This is a cross-sectional, retrospective study on 31patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria.

Results:

Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. Therewas a 67% decrease in the number of autopsies over the last 10years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). Therewas greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Sevenpatients were admitted in critical health conditions and died within the first 24 hours of hospitalization.

Conclusions:

Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

Keywords:
Autopsy; Diagnostic errors; Pediatrics; Critical care

Classes	Definition
I	The correct diagnosis would have led to changes in conduct, with potential cure or increased survival.
II	The correct diagnosis would probably not lead to changes in conduct and outcome.
III	Diagnostic failure of pathology related to terminal disease, but not related to the cause of death.
IV	Other diagnoses of minor importance ceased to be identified.
V	Absolute agreement.

P	Sex	Ag	LHS	Clinical diagnosis	AP diagnosis	CMD	CDAR	CG
1	F	5	1	Sepsis/BPN	BPN	Yes	Yes	V
2	F	1	1	Gastrointestinal bleeding	Interstitial pneumonia Pulmonary hemorrhage	No	No	I
3	M	1	6	Necrotizing pneumonia	Necrotizing pneumonia	Yes	Yes	V
4	F	6	10	Mitochondriopathy	Mitochondriopathy	Yes	Yes	V
5	F	17	1	BPN	Bilateral lobar pneumonia	Yes	Yes	V
6	M	12	1	Septic shock Meningitis	Septic shock Acute viral myocarditis	Yes	No	I
7	M	53	1	GE/Sepsis	Acute colitis	Yes	Yes	V
8	F	18	1	Acute liver failure	Hepatic cirrhosis/Peritonitis	Yes	No	I
9	F	11	1	Congenital heart disease	Congenital heart disease Interstitial pneumonia	Yes	No	I
10	F	48	1	Acute lymphoblastic leukemia Veno-occlusive syndrome	Acute necrotizing pancreatitis	Yes	No	I
11	F	3	2	Congenital heart disease/BPN	Congenital heart disease/BPN	Yes	Yes	V
12	M	87	17	BMT/Pneumopathy	Pneumopathy/Toxoplasmosis	Yes	No	I
13	F	16	1	BPN	Sepsis/BPN/Purulent cystitis	Yes	Yes	V/III
14	M	5	7	GE	Necrotizing pneumonia	No	No	I
15	F	96	8	BPN	BPN/Myocarditis	Yes	No	I
16	F	32	1	BPN	BPN	Yes	Yes	V
17	M	5	2	Sepsis	Pneumopathy/DIC	Yes	Yes	V
18	F	1	1	Pneumopathy/Sepsis	Pneumopathy/GE	Yes	Yes	V/III
19	F	144	1	Meningitis	Meningitis/Myocarditis	Yes	No	I
20	M	5	1	BPN/Sepsis	BPN	Yes	Yes	V
21	F	3	3	BPN/Sepsis	Sepsis	Yes	Yes	V
22	F	121	1	Meningitis	Meningitis	Yes	Yes	V
23	F	5	2	Myocarditis	Myocarditis	Yes	Yes	V
24	F	14	1	Down/Cardiopathy	Cardiopathy/PH	Yes	Yes	V
25	F	156	1	Severe anemia	Myocarditis/Colitis	No	No	I
26	F	121	1	Meningococcemia	Meningococcemia	Yes	Yes	V
27	F	2	1	Pertussis syndrome	Pneumopathy	Yes	Yes	V
28	F	154	4	Sepsis	Sepsis/Peritonitis	Yes	No	II
29	M	84	18	Hepatic insufficiency	BPN/Hepatic cirrhosis	Yes	No	II
30	M	24	1	Sepsis/BPN	Necrotizing pneumonia	Yes	Yes	V
31	M	12	4	BMT/RPF	Fungal sepsis	No	No	I

Period	Local	Patient	Autopsy (%)	Autopsy (n)	Major error (%)	Class I error (%)
1984–1988	Texas University	Adults and children (surgical)	73	409	30.3	7.8
1997–1998	Ryder Trauma Center	Adults and children (traumas)	97	153	15.7	2.6
1984–1993	Lutheran General Children's Hospital	General Pediatrics	36	107	13.1	6.5
1989–1994	University of Rochester	General Pediatrics	74	157	6.4	NA
1992	Children's Hospital of New Jersey	General Pediatrics	29	23	13.0	4.3
1984–1993	Lutheran General Children's Hospital	NICU	61	296	0.3	11.8
1985–1990	Toronto Hospital for Sick Children	NICU	62	338	18.9	2.1
1985–1992	North Shore University Hospital	PICU	26	50	28.0	10
1991–1997	Royal Alexandra Hospital for Children	NICU	40	91	NA	5.5
1995–1996	King Edward Memorial Hospital	NICU	82	197	26.9	12.2
1985–1989	Children's Hospital of Western Ontario	Pediatric Emergency	75	52	15.4	0.0

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[1] *Corresponding author. E-mail: monica.lima.ufpr@gmail.com (M.N.L. Cat).