Punctured artery, vein during surgery led to man’s death: Coroner
Kidney disease patient's death after catheter insertion process a medical misadventure, says coroner
A kidney disease patient at Tan Tock Seng Hospital (TTSH) died in 2016 from acute haemorrhage after an artery and vein were accidentally punctured during the catheter insertion procedure for his peritoneal dialysis.
This is believed to be the first case of death of its kind here, according to an independent doctor nominated by the Academy of Medicine Singapore (AMS) to look into the matter.
According to the National Kidney Foundation's website, peritoneal dialysis is a treatment for kidney failure in which a sterile fluid is introduced into the body through a permanent tube placed in the peritoneal cavity - a space within the abdomen that contains the intestines, stomach and liver.
The fluid then draws impurities from the surrounding blood vessels in the abdominal cavity and is drained from the body.
Coroner Marvin Bay yesterday found Mr Lee Kuen Ngian's death to be a ''truly unfortunate medical misadventure''.
He said that Dr See Yong Pey, a consultant at TTSH's renal medicine department, reviewed Mr Lee on Nov 2, 2016.
The 74-year-old Singaporean was admitted to day surgery eight days later, and Dr See started the catheter insertion procedure.
An incision was made in Mr Lee's abdomen and normal saline was flushed into a cannula - a thin tube inserted into a vein or body cavity to administer medication, drain off fluid or insert a surgical instrument.
Mr Lee was then placed in a Trendelenburg position where his head was placed facing upwards at a lower level than his feet to facilitate access to the abdominal organs.
The peritoneal space was insufflated, or filled with air.
Coroner Bay said: ''Shortly after 800ml of air was introduced into his peritoneal cavity, Mr Lee... collapsed at 1.10pm. The procedure was abandoned and the cannula was removed immediately.''
The AMS later nominated two experts to look into the case: Dr Cheng Shin Chuen, a surgeon in private practice from Mount Elizabeth Novena Specialist Centre, and Dr Tan Chieh Suai from the Singapore General Hospital's department of renal medicine.
Dr Cheng expressed his view that ''Dr See most likely punctured the (vessels) unknowingly with a faulty technique. He basically passed the sharp point of the trocar (a sharp-pointed surgical instrument used with a cannula to puncture a body cavity) all the way in, injuring the artery and vein at the same time''.
Coroner Bay said that to the best of Dr Tan's knowledge, this was the first case of death of its kind in Singapore.
Dr See, however, questioned the experts' opinion.
Coroner Bay said: ''Dr See maintained his alternative theory that the injury to the vessels had been inadvertently inflicted by the metal cannula... he posited that minor movement on (Mr Lee's) part... may have occurred when Mr Lee was placed in the Trendelenburg position despite his being strapped down to the operating table.''
Dr See believed that this movement by Mr Lee led to the injuries seen in his vessels, said the coroner.