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Kidney disease patient died after artery, vein accidentally punctured during catheter insertion procedure for dialysis

SINGAPORE – A kidney patient at Tan Tock Seng Hospital (TTSH) died in 2016 from acute haemorrhage after an artery and a 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 who was 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 circulates through the abdomen to draw impurities from the surrounding blood vessels in the abdominal cavity and is drained from the body.

On Wednesday (Aug 26) following an inquiry, Coroner Marvin Bay found Mr Lee Kuen Ngian’s death to be a “truly unfortunate medical misadventure”.

The coroner said: “This court would recommend that the circumstances leading to Mr Lee’s death… be closely investigated with a view to the establishment of a commonly acceptable protocol of best practices for such procedures.

“This would be all the better to prevent such tragic recurrences to patients hoping to avail themselves to the therapeutic benefits of peritoneal dialysis.”

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 then 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, which is a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument. Clear liquid, without blood, was flushed out.

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 then insufflated or filled with air.

Coroner Bay said: “The surgery thus far seemed uneventful, with no indication of any presenting complications, and the insufflation of air with the syringe did not show any return of blood suggestive of a bleed.

“Nevertheless, 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”.

Dr Cheng also said that the “technique falls short of what is an acceptable level of competency”, causing a “wholly preventable puncture” of the vessels.

Separately, Dr Tan expressed his concern that Dr See had undertaken the procedure only slightly after two months of being granted the “clinical privilege”.

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 independent AMS medical experts’ opinion that the pattern of Mr Lee’s injury was a direct consequence of the trocar being pushed too deep into the abdominal cavity.

Coroner Bay said: “Dr See maintained his alternative theory that the injury to the vessels had been inadvertently inflicted by the metal cannula, which had been within the peritoneal cavity after the trocar was removed for the sterile air insufflation process.

“While one of his hands was used to stabilise the cannula, he posited that minor movement of (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.

On Wednesday, Coroner Bay said that there is no basis to suspect foul play in this case.

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