Feasibility of postmortem examination in the era of COVID-19 pandemic: the experience of a Northeast Italy University Hospital

Abstract

With the continuous spreading of SARS-CoV-2 and increasing number of deaths worldwide, the need and appropriateness for autopsy in patients with COVID-19 became a matter of discussion. In fact, in the COVID-19 era protection of healthcare workers is a priority besides patient management. No evidence is currently available about the real risk related to the procedure as well as to the subsequent management of the samples. We herein describe the procedure that has been used to perform the first series of postmortem examinations in the COVID center of the Padua University Hospital, Padua, Italy, after the implementation of an ad hoc operating procedure, to minimize the risk of infection for pathologists and technicians. Provided that the procedure is performed in an adequate environment respecting strict biosafety rules, our data indicate that complete postmortem examination appears to be safe and will be highly informative providing useful insights into the complex disease pathogenesis.

Keywords: Autopsy; Biosafety; COVID-19; Hazard group; Infectious disease protocols.

Fig. 1

Containers for whole organs and tissue sampling with formalin and other fixative available in the autopsy suite for a COVID-19 postmortem examination. a Distinct test tubes filled with Karnovsky’s fixative and RNA later (recognizable based on shape or cap’s color, for kidney, heart, lungs, liver, skeletal muscle, brain): two fragments 0.5 cm in size were placed in Karnovsky solution, whereas 1 fragment 1 cm in size was placed in RNAlater. b Endobronchial swab and saline phosphate buffer tube for lung tissue molecular and cultural analysis. c Five jars filled with 10% formalin (lungs, liver-spleen-kidney, heart, brain and multiorgan sampling), were used for the specific tissue samples

Fig. 2

Essential instruments available in the autopsy suite for a COVID-19 postmortem examination

Fig. 3

Personal protective equipment (PPE) used for a COVID-19 postmortem examination. Head cover, shoes cover, leg cover, Tyvek chemical protection coverall (Cat. III), impermeable gown, plastic protective goggles, 3 pairs of surgical sterile gloves, 1 pair of powder-free nitrile gloves, FFP3 protective face mask

Fig. 4

Flowchart for tissue processing in COVID-19 postmortem examination. After 24 h, samples, placed in RNAlater and kept at 4 °C, are snap frozen and stored at − 80 °C in a dedicated freezer. Samples fixed in Karnovsky fixative solution were embedded in both EPON and acrylic resins (LR white). After 3–6 days, tissue blocks were cut 4 μm thick and stained with hematoxylin and eosin for microscopic examination. Semithin sections from EPON/acrylic resin embedded samples were stained with toluidine blue stain. After 7–10 days, ultrathin sections were prepared for ultrastructural examination. If necessary, histochemical and immunohistochemical stains were requested at this time. Blocks and slides are stored in our storeroom indefinitely