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ENHANCING THE EFFICIENCY OF POST MORTEM DIAGNOSIS BY IMPROVING THE POST MORTEM FACILITY, TECHNIQUES AND HEALTH ISSUES

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ENHANCING THE EFFICIENCY OF POST MORTEM DIAGNOSIS BY IMPROVING THE POST MORTEM FACILITY, TECHNIQUES AND HEALTH ISSUES

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A postmortem examination, is the examination of the body/carcass after death. Post mortem is performed to obtain an accurate cause of death and when done properly which involves looking at the animal as a whole, as well as looking at each individual organ within the body.The efficiency of postmortem diagnosis depends on facilities and techniques that are used during PM, thorough knowledge, health aspects/biosafety and other supporting diagnostic methods.

A postmortem examination, is the examination of the body/carcass after death. Post mortem is performed to obtain an accurate cause of death and when done properly which involves looking at the animal as a whole, as well as looking at each individual organ within the body.The efficiency of postmortem diagnosis depends on facilities and techniques that are used during PM, thorough knowledge, health aspects/biosafety and other supporting diagnostic methods.

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ENHANCING THE EFFICIENCY OF POST MORTEM DIAGNOSIS BY IMPROVING THE POST MORTEM FACILITY, TECHNIQUES AND HEALTH ISSUES

  1. 1. 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
  2. 2. OVERVIEW  Introduction  Review of Literature  Facilities To Be Available  Techniques  Risk Assessment  Biosafety And Health Issues  Supportive Diagnostic Tests  Waste Management  Cleaning/Disinfection  Conclusions
  3. 3.  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?
  4. 4. 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….
  5. 5. 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….
  6. 6. RULES FOR POST MORTEM EXAMINATION (Sharma, 2009)  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. ( Severidt, 2001) Contd….
  7. 7. REVIEW OF LITERATURE “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) “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) “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)
  8. 8. 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)
  9. 9. 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) “National autopsy rates have declined for several decades, and the reasons for such decline remain contentious”. (Nemetz. et al, 2006) “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)
  10. 10. WHAT IS THE EFFICIENCY OF OUR POST MORTEM EXAMINATION ?  What are the Facilities available?  What Techniques that we are following?  How much knowledge and experience we have?  How far our diagnosis is efficient?
  11. 11. COMPONENTS OF AN EFFICIENT POST MORTEM DIAGNOSIS  POST MORTEM FACILITIES  POST MORTEM TECHNIQUE  THOROUGH KNOWLEDGE  HEALTH ASPECTS/ BIOSAFETY  SUPPORTING DIAGNOSTIC METHODS
  12. 12. FACILITIES TO BE AVAILABLE  All work should be conducted in a manner that will minimize accidents and also comply with environmental, health and safety laws and regulations.
  13. 13. A)TRANSPORT OF ANIMALS AND SAMPLES (Necropsy Room Policy and procedures, 2009)  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.
  14. 14. 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.
  15. 15. 1.NECROPSY SUPPLIES Animal necropsy table Autopsy sink wall mount
  16. 16.  Gloves  Boning knife  Steel - for sharpening  Scissors  Forceps  Pruning shears - Rib cutters [NADC Procedures for Incineration and Operation of the Necropsy Facility. (Sept. 2004)]
  17. 17. NECROPSY INSTRUEMENTS (Mortech manufacturing INC, 2012)
  18. 18. 2.PERSONAL PROTECTIVE EQUIPMENT (PPE)  Boots  Coveralls  Disposable bouffant cap (hair net)  Surgical or procedural mask  Protective glasses
  19. 19. 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
  20. 20. TECHNIQUES 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.
  21. 21.  Types of euthanasia: (AVMA Guidelines for euthanesia of Animals,2013) 1. Captive bolt 2. Gunshot 3. Chemical (OIE Guidelines, 2012) 4. Exsanguination (Bleeding out)
  22. 22. 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.
  23. 23. 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)
  24. 24. 4.Needle Necropsy: (Underwood et al 1983)  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.
  25. 25. 5.Postmortem Radiology and Imaging (Minimally invasive autopsy) (Virtopsy) (Levy, 2012)  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 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) MDCT was a more accurate imaging technique than MRI for providing a cause of death (Roberts et al,2012) Haematoma Haemorrhage Fracture
  26. 26. RISK ASSESSMENT - GENERAL (Latham Hall Necropsy Room 120A-Policy and procedures, 2009)  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 Animals known to contain a pathogen of zoonotic potential are not to be necropsied at this facility.
  27. 27. SAFETY PRECAUTIONS (University of Nebraska, Lincoln) 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. KEEP THESE RULES 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
  28. 28. 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.....
  29. 29. 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.
  30. 30. SEQUENCE FOR PUTTING ON PPE (Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity , 2011) 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
  31. 31. SEQUENCE FOR REMOVING PPE GLOVES • Grasp outside of the glove with opposite gloved hand; peel off • Slide finger of ungloved under remaining glove at wrist. 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.
  32. 32. INCIDENT RESPONSE PROCEDURES (Necropsy Room Policy and procedures, 2009)  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 .
  33. 33. 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
  34. 34. 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 monkeypox virus, 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)
  35. 35. 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.
  36. 36. showers The animal wing Three small animal rooms PM AREA LAB WING Isolator room ALKALI WASH ROOM Three rooms for lab animals. Four large animals rooms Pass through cabinet CLEAN CORRIDOR DIRTY CORRIDOR sshhoowweersrs Showers HSADL, Bhopal
  37. 37. Clean Corridor-Animal wing Entry to small animal room Dirty Corridor Exit from large animal room Leading to post-mortem area
  38. 38. SUPPORTIVE DIAGNOSTIC  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 TESTS (Foroudi and Cheung, 1995)
  39. 39. 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
  40. 40. WASTE MANAGEMENT (University of Nebraska, Lincoln)  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.
  41. 41. METHODS OF WASTE MANAGEMENT  1.Sanitary Land Fills Daily covering of soils (Strafuss,1988)
  42. 42. Rendering 3.Rendering Plant Efficient and safe manner
  43. 43. 2. Incineration/ Burning- • Limited to baby pigs, young chicks, and poults. • It is too time-consuming and costly to burn large animals. Carcass Incinerator
  44. 44. 4.Deep burial/ Disposal pit- Disposal of dead animals on the owner’s land. Deep burial of carcass (Schultz, 2012)
  45. 45. CLEANING/DISINFECTION (University of Nebraska, Lincoln)  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.
  46. 46. TYPES OF DISINFECTANTS (University of Nebraska, Lincoln)  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 Chlorhexidine Hydrogen peroxide Virkon
  47. 47. SOME DISINFECTANTANTS USED
  48. 48. CONCLUSIONS  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
  49. 49. 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

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