An elderly patient is in a critical condition after a machine for scanning blood vessels malfunctioned during an operation at a Hong Kong public hospital, with health authorities investigating the incident.
The Hospital Authority said on Thursday that the 66-year-old male patient suffering from a brain condition underwent a procedure at Queen Elizabeth Hospital in Yau Ma Tei on Monday.
The condition – known as cerebellar arteriovenous malformation – occurs when arteries in the brain link directly to nearby veins without passing through the normal small vessels that should be between them.
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In a normal situation, an angiography machine would show real-time images of the blood vessels in a patient’s brain, the authority said.
It said that during “the procedure when the patient was injected with tissue glue to control bleeding from a small blood vessel, the screen of the angiography machine did not show the normal flow of tissue glue in the blood vessel”.
The authority said the doctor immediately suspended the injection procedure after considering the situation was “unusual”.
“The clinician then used the angiography machine to scan the blood vessels in the patient’s brain again, and found that tissue glue was found in other blood vessels in the brain,” it said.
“Besides, bleeding was found in the blood vessels in the cerebellum. The clinical team then immediately stabilised the patient’s condition with appropriate treatment.
“The patient is now in the high dependency unit [in a] critical condition.”
The cerebellum is the part of the brain in the back of the head and is responsible for muscle control, including balance and movement.
The authority said it was “very concerned” about the incident and that the hospital would review the causes of the adverse event including “workflow and operational” aspects.
It said it had suspended the use of the same model of the machine, and had asked the manufacturer to investigate the reasons behind the incident.
“The equipment company subsequently arranged for its staff to check the angiography machine on-site and retrieved the event log, which confirmed the machine did not produce any X-ray when the tissue glue was injected,” it said.
“The exact cause of the incident is still under investigation.”
It said authority and hospital representatives met the manufacturer on Tuesday and were told such an incident was rare.
The company had reported the incident to the head office for investigation and would maintain close communication with the authority’s biomedical engineers.
The Department of Health said on Thursday that its Medical Device Division (MDD) had contacted the authority and the “local responsible person” (LRP) of the device for further details and to follow up with the incident.
It said the device, known as the Artis Zee Biplane, was used for X-ray imaging in medical procedures and was made by German firm Siemens Healthcare.
The department said the device was installed in the hospital in April 2011 and that the manufacturer carried out regular maintenance on it. The last maintenance check was carried out on July 24 and no abnormalities were detected.
It said the device had been distributed to two public hospitals and one private hospital.
“Apart from maintaining liaison with the [authority], the [department] will inform stakeholders to remind them of the incident and request them to contact the LRP as soon as possible if they are using the angiography system concerned,” it said.
“A special safety alert will be also posted on the MDD’s website.”
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