Safety Concerns with Thoracoabdominal Acupuncture: Experience at a Tertiary-Care Emergency Department

Navigating the layers of concern for safe dry needling of the rectus abdominis: a cadaveric study

OBJECTIVES

To assess needle placement accuracy in the rectus abdominis (RA) muscle during dry needling (DN) without entering the peritoneum.

METHODS

Two physical therapists performed DN on a cadaver, making 10 attempts each to needle the RA without entering the peritoneum. Techniques followed two common DN approaches. Ultrasound verified needle depth and safety.

RESULTS

Seventy percent of attempts were recorded as safe needle placement, while 30% were unsafe. Accurate RA needle placement without peritoneal entry occurred in 55% of attempts.

DISCUSSION/CONCLUSION

Inadvertent peritoneal needle placement during RA DN poses risks regardless of experience. Ultrasound guidance may enhance safety and precision in clinical practice.

Safety of acupuncture by Korean Medicine Doctors: a prospective, practice-based survey of 37,490 consultations

Background

To evaluate safety of acupuncture treatment by Korean Medicine Doctors (KMDs), a prospective, practice-based survey on adverse events (AEs) associated with acupuncture was conducted.

Methods

From July 2016 to October 2017, KMDs were invited to participate in an online survey. Frequency was calculated as the number of AEs per 10,000 treatments; severity was assessed with the Common Terminology Criteria for Adverse Events Grading (Severity) Scale; and causality was evaluated using the World Health Organisation-Uppsala Monitoring Centre system for standardised case causality assessment. Associations between AE occurrence and KMDs’ type of practice/clinical experience and patient age/gender/current medication(s) were analysed.

Results

Data on 37,490 acupuncture treatments were collected from 222 KMDs. At least one AE was reported from 4,518 acupuncture treatments, giving a frequency rate of 1,205 per 10,000 acupuncture treatments; this increased to 4,768 treatments when administrative problems related to defective devices or medical negligence were added, for a rate of 1,272 per 10,000 acupuncture treatments. Commonly reported AEs were bleeding, needle site pain, and bruising. Approximately 72.9% of AEs/administrative problems were assessed as they certainly occurred by acupuncture treatment in causality assessment. Most AEs/administrative problems were considered mild in severity and two life-threatening AEs were resolved with no sequelae. Compared to males, female patients were more likely to experience AEs and KMDs’ clinical experience was not associated with reported AE occurrence.

Conclusions

Although acupuncture-associated AEs occur commonly, they are largely transient and mild. Acupuncture performed by qualified KMDs may serve as a reliable medical treatment with acceptable safety profiles.

An Observational Study Using Ultrasound to Assess Allowable Needle Insertion Range of Acupoint CV12

Background: Abdominal organ injuries are a rarely reported complication when deep acupuncture needling is applied to the abdomen. In order to ascertain the allowable needle insertion range (ANIR) of the abdomen region, we selected acupoint CV12, which is commonly used for treating gastric disease, and ANIR was measured with an ultrasound device. Method: Eighty-five healthy volunteers were recruited, of which 83 cases of ultrasound images were obtained. To investigate the prediction factor of ANIR, we also measured several anthropometric factors. Results: The average ANIR was 25.3 ± 10.2; generally, the ANIRs of females were thicker than those of males; and the liver was observed in 62.7% subjects’ ultrasound images. The non-observed group showed thicker ANIR and higher BMI than the liver-observed group. Conclusion: There are reliable variables that make it possible to predict the ANIR. It is advised to refer to anthropometric factors in needling acupoint CV12 to avoid complications with the acupuncture treatment. However, individual differences are not negligible when applying deep needling. Thus, if the risk is not judged before or during the procedure, practitioners could consider the patient’s ANIR on CV12 when applying acupuncture by examining the individual anatomical structures using ultrasound and considering internal organ positions to prevent adverse events due to acupuncture.

Acupuncture-Induced Tension Pneumothorax Presenting as Acute Heart Failure

Takotsubo syndrome (TSS) is a reversible, acute cardiomyopathy with transient heart failure, often secondary to other disorders. A 64-year-old woman, with no history of ischemic heart disease, was admitted to the emergency department after developing sudden-onset dyspnea after a planned acupuncture treatment for back pain. Acute echocardiography showed decreased left ventricular function with basal hypercontraction and apical akinesia and was interpreted, and treated, as acute heart failure. When the attending cardiologist arrived, the patient still had dyspnea with a declining blood pressure (97/65 mmHg) and tachycardia (111/minute). The cardiologist suspected a tension pneumothorax induced by the penetration of an acupuncture needle to the apex of the lung, as well as secondary TSS cardiomyopathy. An acute chest X-ray was performed, which showed a large left-sided rim pneumothorax. The attending surgeon placed a chest tube in the left 6th intercostal space in the midaxillary line, and the patient reported immediate pain relief and improvement in her dyspnea. The patient's clinical condition improved, and a control X-ray showed that the lung was fully expanded. The chest tube was removed, but after a few minutes, the patient developed a massive subcutaneous emphysema in the upper chest and in the face and her clinical condition deteriorated rapidly. A new chest tube was inserted, and the patient's tachycardia diminished, with her clinical condition improving immediately. The patient remained hospitalized for the next seven days. After three continuous days without any escaped air in the chest tube, the tube was removed, and the patient was observed for another 48 hours. This time, the removal was without any complications and within two days, the patient was ready for discharge. The follow-up echocardiography showed complete recovery of left ventricular function.

Autopsy diagnosis of acupuncture-induced bilateral tension pneumothorax using whole-body postmortem computed tomography: A case report

RATIONALE

Acupuncture, a component of traditional Chinese medicine, is also a well-known form of complementary and alternative medicine. Serious adverse events of acupuncture have been reported, including the acupuncture-related pneumothorax which is a rare but fatal condition sometimes. The pneumothorax was related to needle insertion in the upper back or paraspinal area and the reported victims suffered from either unilateral or bilateral pneumothorax. Postmortem computed tomography has advantages in the detection of pathologic gas and is being considered as a useful visualization tool for diagnosing the cause of death.

PATIENT CONCERNS

A 52-year-old man underwent acupuncture and cupping treatment at an illegal Chinese medicine clinic for neck and back discomfort and was admitted to the hospital with severe gasp and dyspnea about 30 hours later. The patient suddenly became unconscious with heart rate and blood pressure lost and died after cardiopulmonary resuscitation. Diagnosis, interventions and outcomes: Whole-body postmortem computed tomography of the victim revealed collapse of the both lungs and mediastinal compression, which was also confirmed by autopsy. More than 20 pinprick injuries were found on the skin of the upper and lower back in which multiple pinpricks were located on the body surface projection of the lungs. The cause of death was concluded as acute respiratory and circulatory failure due to acupuncture-induced bilateral tension pneumothorax.

LESSONS

Acupuncture-induced tension pneumothorax is rare and should be recognized by forensic pathologists. Postmortem computed tomography can be used to detect and accurately evaluate the severity of pneumothorax before autopsy and can play a supporting role in determining the cause of death.

Infectious Adverse Events Following Acupuncture: Clinical Progress and Microbiological Etiology

BACKGROUND

We investigated the clinical progress and bacteriological characteristics of infectious adverse events (AEs) following acupuncture and compared patient characteristics between serious and non-serious outcome groups.

METHODS

A retrospective observational study was conducted in 1,174 patients with infectious complications associated with acupuncture at the emergency department (ED) in a tertiary hospital in Korea between 2010 and 2014. Serious outcome was defined as development of septic shock, admission to intensive care unit (ICU) or attaining permanent morbidity.

RESULTS

Forty-eight patients had certain causality and cellulitis, necrotizing fasciitis and osteomyelitis were common in order. Among them, 9 patients (18.8%) were categorized into serious outcome group, and they showed devastating outcomes such as septic shock (n = 2), ICU admission (n = 4), and permanent sequelae (n = 5). The serious group had delayed admission to the ED after acupuncture (30.0 [4.0-55.0] vs. 3.0 [1.0-10.0] days, P = 0.023). Methicillin-sensitive Staphylococcus aureus was the most frequently identified microorganism. The patients in the serious group required longer treatment duration (139.0 [49.0-183.5] vs. 14.0 [7.0-34.0] days, P < 0.001) as well as more operation with local (44.4% vs. 10.3%, P = 0.031) or general anaesthesia (33.3% vs. 2.6%, P = 0.017).

CONCLUSION

The infectious AEs after acupuncture may cause serious outcomes. Patients and primary physicians should be aware of the risk of infectious complications and make efforts to prevent them.

Systematic Review on Acupuncture for Treatment of Dysphagia after Stroke

OBJECTIVE

To assess the therapeutic efficacy of acupuncture for dysphagia after stroke.

METHODS

Seven electronic databases were searched from their inception until 31 September 2016. All randomized controlled trials (RCTs) incorporating acupuncture or acupuncture combined with other interventions for treatment of dysphagia after stroke were enrolled. Then they were extracted and assessed by two independent evaluators. Direct comparisons were conducted in RevMan 5.3.0 software.

RESULTS

6010 patients of 71 papers were included. The pooled analysis of efficacy rate of 58 studies indicated that acupuncture group was superior to the control group with moderate heterogeneity (RR = 1.17, 95% CI: 1.13 1.21, Z = 9.08, and P < 0.00001); meta-analysis of the studies using blind method showed that the efficacy rate of acupuncture group was 3.01 times that of control group with no heterogeneity (RR = 3.01, 95% CI: 1.95 4.65, Z = 4.97, and P < 0.00001). Only 13 studies mentioned the safety evaluation.

CONCLUSION

The result showed that the acupuncture group was better than control group in terms of efficacy rate of dysphagia after stroke. And the combining result of those researches using blind method was more strong in proof. Strict evaluation standard and high-quality RCT design are necessary for further exploration.