Operating Specifications And Safety Review On Deep Acupuncture At Tianshu Under CT Observation

ObjectiveTianshu (ST25) is an important acupoint for abdomen and intestine diseases treatment. It is reported that deep acupuncture has better effect than routine depth. But at the point of the anatomical structure of Tianshu, excessive deep acupuncture may lead to abdominal viscera punctured, even cause potential risks of celiac infection. So it is very important to research the optimal acupuncture depth and deep acupuncture safety related issues. This paper explores the definition of deep acupuncture, clinical operation norm of individualized deep needling and the safety evaluation from two aspects including literature research and clinical verification.Methods2.1 Literature researchIn this paper, the literature research summarizes and reviews the safety problems related to the Tianshu acupuncture at the point of the depth of acupuncture, needle selection and acupuncture operation gimmick three aspects by means of statistics and induction. On the basis of mining and inducing a large amount of literature, this paper puts forward the definition of deep acupuncture which is to break through peritoneal 1-2mm as the standard of individual deep needling and regulates the clinic operation of deep needling at Tianshu. The standard combines the operation feasibility and clinical curative effect.2.2 Clinical researchIn the clinical research, this paper verifies the feasibility and safety of individual deep acupuncture standard based on individual 39 cases of clinical practice deep test.39 patients are hospitalized patients for the acupuncture department of Guang'an men hospital, and doctors responsible for needling are all clinical physicians of this hospital. Before the operation, the doctors are trained for the deep needling operation briefly. We give the explanation of the pain before the operation, so that the patients can easily understand their feeling.Patients had their breakfast as usual, and then go to examining room in the company of their doctors. Doctors measure the abdomen circumference before treatment, place patients in supine position then deep needle bilateral Tianshu. The physicians fast break the skin using 75mm length needle (No.28), then deep puncture slowly and vertically, until the peritoneum is broken through 1-2mm (patients have obvious clench pain or the doctors have falling sense) and no insertion and twisting. In the process of acupuncture, the doctors record the pain of patients and the falling sense of themselves. Then measure the length of vitro needle, and calculate the real depth of needling. Such patients without discomfort after acupuncture take abdominal CT examination.The needle point of Tianshu is the center of CT examination. The cross-sections adversary foot side 150mm respectively is collected, again with the needle points as the center, in a layer of 5mm thick,5mm distance, and 8-10 layers are scanned axially of abdomen which contains all the filiform needle stitch. Needles are drawn out after CT inspection. The radiologist described the places needles passed through, the places needles reached, and whether intestinal penetration existed in report form.We measure the depth of the abdominal peritoneum position and calculate abdominal aspect ratio on CT images. Then multiple factor regression method is applied with the deviation of acupuncture depth (the difference between the actual needling depth and the depth of the peritoneal position) is interpreted as explained variables, and dummy variables clench pain and falling sense are explanatory variables (existence is 1, and 0 otherwise). We verify the feasibility of deep acupuncture proposed in this paper marked by clench pain and falling sense of the standard.In this paper, we analyze the influence of abdominal circumference, abdominal aspect ratio and other factors on the personalized optimal acupuncture depth with individual research methods. The most direct factor on the depth of peritoneal position is the patient's Abdominal Circumference (AC).In addition, people in China are often considered as abdominal obesity, and there is a direct link between the abdominal shape and the depth of abdominal peritoneum at Tianshu, so this article also introduces an explanatory variable abdominal aspect ratio. Abdominal aspect ratio (ratio) is the ratio of the vertical length through the navel and lumbar spine to the width through the upper edge of the lateral lumbar transverse at the point of Tianshu in CT cross section. The depth of peritoneal position (depth) under CT observation is interpreted as explained variable, the patient's abdominal circumference, abdominal aspect ratio, sex, and the position difference between the left and right Tianshu are considered as explanatory variables. The dummy variable (male) values 1 for men and 0 for women to analyze the difference of the depth of peritoneal position between men and women. The other dummy variable (left) values 1 for left and 0 for right to analyze the differences of the depth of peritoneal position between left side and right side. And finally we comprehensively analyze the influence about these factors on the personalized optimal depth of acupuncture. Now that variable male is positively correlated to AC (male has lager abdominal circumference than female), the dummy variable male is eliminated from our regression.We track and observe 39 patients with the abdominal CT examination within one month, including body temperature, pulse, blood pressure of everyone daily, take abdomen medical examination contained whether the tenderness and rebound tenderness, masses, voiced such mobility everyday, and 39 patients are taken the regular add occult blood test before and after acupuncture.Outcome and analysis3.1 Literature research conclusionThe depth of acupuncture at Tianshu for adult mainly distribute in the range of 25-50mm according to the existing literature. The needle of this depth must have reached peritoneum by drawing on the experience of anatomical research of the points which are close to Tianshu. Neither the reports of clinical experience nor laboratory tests, there is no adverse reaction as for the literature which has been identified peritoneal pierced or organs touched. Thus, the operation of deep needling at Tianshu is relatively safe. In a clear reference of needle diameter in the literature, the needle most commonly used is 0.32mm diameter. It is not critical for choosing needles in modern literature for needling at Tianshu. The needles whose diameter is 0.32mm-0.38mm often are used in clinical operation. So I propose that maneuver skills for deep needling at Tianshu should not be imposed, or only confined to slightly twisting. Because the patients will have obviously clench pain for a short time when the doctors make the operation of deep needling and pierce peritoneum.3.2 Verify the feasibility of the standard of deep needingThe clench pain of 39 patients and the falling sense of doctors are recorded in the process of deep needling at Tianshu. Patients have significant clench pain in 58 stabs (74.4%), and patients do not feel obvious pain in 20 stabs (25.6%). Doctors have obviously falling sense in the hands in 53 stabs (68.0%) and do not have obvious falling sense in 25 stabs (32.0%). Clench pain and falling sense are significantly negative correlated to the deviation of needling depth according to the regression results, namely the more obvious of the clench pain or falling sense is, the smaller of the deviation of needling depth is. So the standard of deep needling which is to break through peritoneal 1-2mm is the practice norm and has feasibility. Clench pain depends on the patient's tolerance to pain and falling sense depends on the accumulation of clinical experience of doctors. The correlation coefficient between the two variables is 0.226 and the significance is 0.047, which means that the co-linearity between two explanatory variables is low, and the regression results are reliable.3.3 The analysis of factors which affect the personalized optimal depth of needlingThere are linear problems between gender (male) and abdominal circumference (AC) variables when we analyze the data. The two variables' correlation coefficient is 0.419 and the significance is 0.013, So we retain only abdominal circumference (AC) as explanatory variables and gender variable (male) is not active participation.The regression results considering abdominal circumference, abdominal aspect ratio, differences between left and right at Tianshu show that the depth of peritoneal position (depth) is significantly positive correlated to the abdominal circumference (AC) and abdominal aspect ratio (ratio), which means that the larger abdominal circumference or the thicker vertical abdominal fat of a person is, the deeper the peritoneal position of the person is. The depth of peritoneal position is not significantly negative correlated to the position of Tianshu(left) indicating there is no significant difference between the left and right in the depth of peritoneal position.We can draw the theoretical optimal depth formula(cm) of personalized deep needling at Tianshu by synthesizing above regression results:depth=-1.413+0.039·AC+2.311·ratioSome factors are not reflected in the regression formula, as there is too much factors impacting the depth of peritoneal position. Therefore, there is a whole standard deviation for the deviation from the regression residuals between the depth of needle in regression results and the actual optimal depth of needle. So the optimal depth range of needling is the theoretical optimal depth of needling with a fluctuation of 0.211cm, namely the optimal depth range of needling isdepth'=β0'+0.039·AC+2.311·ratioβ0'∈(-1.892,-0.934)3.4 Safety evaluationThe occurrence of local pain with acupuncture and severity of 39 patients (total 78 stabs) are recorded in clinical operation. None of the 39 patients are reported severe pain or adverse events. All patients complete the deep needling operation.78 stabs at bilateral Tianshu except one stab have penetrated the peritoneum according to patients' radiological reports and 77 needles all go through the subcutaneous tissue and peritoneum and reach the abdominal cavity. The results of the regular and occult blood test of 39 patients before and after the needling operation show that all patients'test results are normal and occult blood tests are negative. I observe and record all 39 patients (including one case that is penetrated the intestine) in the process of acupuncture and after the acupuncture, found none of them has diarrhea bloody stool fainting on needle or secondary infection. And up to 1 month, patients have no fever and pulse blood pressures are within normal range. Abdominal examinations show no positive signs and abdominal infection is not reported and so on. Therefore, this research proposes that deep needling in accordance with the proposed standard deep needling operating is safe.4 Conclusion and outlookIn this paper, CT imaging observation is used as a research tool. A simple visual-estimated abdominal aspect ratio can replace the corresponding variable in the personalized optimal deep needling formula, which is economical and ease of operation, so it is convenient for clinical practice.The standard of deep needling which breaks through the peritoneum 1-2mm is scientific and practical. The operation standard is high of security, simple and easy to master. The optimal formula of personalized deep needling depth at Tianshu is scientific and can be applied flexibly in clinical practice. This study is the foundation of investigating the safety of the other abdomen acupoints needling depth and has a certain reference to the security research of deep needling for many points in abdomen.