AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE

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 31patients 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. Therewas a 67% decrease in the number of autopsies over the last 10years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). Therewas greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Sevenpatients 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.

摘要
一、研究目的：尽管尸检被视为诊断的金标准，但其开展率持续下滑，不良事件发生率却不断攀升，其中17%的不良事件为诊断失误。本研究旨在评估某儿科重症监护病房（Pediatric Intensive Care Unit, PICU）内基于解剖病理诊断的诊断失误患病率。
二、研究方法：本研究为横断面回顾性研究，纳入2004年至2014年间死亡的31例患者。通过比较临床主要诊断（clinical major diagnosis, CMD）与尸检记录中记载的死亡原因（cause of death as described in the autopsy record, CDAR），依据戈德曼标准（Goldman Criteria）对二者的诊断一致性进行评估。
三、研究结果：在3117例总收治患者中，共计263例死亡（占比8.4%）。其中38例接受了尸检（占死亡病例的14.4%），最终纳入本研究的共31例。近10年间尸检开展数量下降了67%。诊断完全一致（V级）的病例有18例（占比58.0%），诊断不一致（I级）的病例有11例（占比35.4%）。急性疾病及快速致死性疾病（如心肌炎）的诊断难度相对更高。另有7例患者因危重病情入院，并在住院首24小时内死亡。
四、研究结论：尸检不仅可用于识别诊断失误，还为临床团队从诊疗错误中汲取经验提供了重要契机。本研究结果凸显了尸检检查在明确诊断方面的核心价值，同时可为儿科重症监护病房内快速进展至死亡的患者构建主要诊断信息数据库提供数据支撑，进而提升该科室医护团队的临床怀疑指数。