Belluomini - Clean Needle Technique

C
TU
STS
AND O T H E R HEALTHCARE PROFESSIONALS
ACUPUNCTURISTS
A N D O T H E R HEALTHCARE PROFESSIONALS
Clean Needle Technique A Manual for Acupuncturists and Other Healthcare Professionals
Copyright 01999, 2000 by Jenny Belluomini ISBN# 0-9673034-0-0
Library of Congress Cataloging-in-Publication Data: Belluomini, Jenny, 1947Clean needle technique for acupuncturists / Jenny Belluomini. p. cm. Includes bibliographical references. ISBN 0-9673034-0-0 (pbk. : alk. paper) 1. Acupuncture--Safety measures. 2. Hypodermic needles--Safety measures. I. Title. RM184 .B438 1999 615.8'92--dc21 99-050659
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Printed in the United States of America
DISCLAIMER:
This is not medical or legal advice. In all cases, Complementary Medicine Press and the author have provided the most up-to-date and specific information possible. Different circumstances and laws may apply to you based on your license and site of practice. For your own protection-and that of your patients-always be aware of changes in applicable laws, regulations, and available health data.
COMPLEMENTARY MEDICINE PRESS

44 Linden Street, Brookline, MA 02445 USA
The author is grateful to Kevin Ergil, L.Ac., Brian La Forgia, L.Ac., Michael Katz, M.D., Lixin Huang, Thomas Haines, Ph.D., Rod Sperry, and to the students and colleagues who have made this manual possible.
This book is dedicated to C.S. Cheung, M.D.
This book is intended as a manual for students and practitioners of acupuncture, and as a textbook for courses of clean needle technique. Every effort has been made in this manual to elucidate aseptic technique based on the highest standards of practice and to explain the rationale for the recommendations made by the author. The student should be aware that specific procedures for needle insertion recommended by individual State and Board certification exams may vary from the contents of this manual.
PART 1
ASEPSIS A N D STERILIZATION
OBI ECTIVES
After completing Part 1, the reader will have:
1.An understanding of the physiologic basis of principles of asepsis and sterilization.
2. A familiarity with the common pathogens as related to the clinical practice of acupuncture.
3. An understanding of infection control and prevention of contamination.
4. An understanding of the proper care, sterilization, packaging, storage, and disposal of needles.
5. A familiarity with the different methods of sterilization, and the different types of antiseptics and disinfectants.
CHAPTER O N E CLINICAL APPLICATIONS OF MICROBIOLOGY
DEFINITION OF TERMS
Camer: a person who harbors one or more specific pathogens in the absence of clinical disease. Chronic carrier: one who sheds pathogens continuously or intermittently during their lifetime. Asepsis: the absence of pathogens. Sterile: the absence of pathogens and nonpathogens. Pathogen: an organism that is capable of producing an infection under conditions favorable for growth. Source: the object or individual from which an infectious agent passes to a host. Contamination: the transmission of pathogens to a sterile object. Infection: invasion of the body by a pathogen capable of producing disease under favorable conditions. Disinfectant: an agent that destroys all pathogens except spore-bearing ones on inanimate surfaces.
- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS
Antiseptic: an agent that destroys or inhibits the growth of pathogens on skin. Sterilization: the process that destroys all microbial life on inanimate objects. Bacteriocide: an agent that destroys bacteria. Bacteriostatic agent: an agent that inhibits the growth of bacteria. Virucide: an agent that destroys viruses.
ORGANISMS RELEVANT TO THE PRACTICE OF ACUPUNCTURE

Two species of staphylococcus exist: aureus and epidermis. They are found in dust, air, clothing, bedding, skin, hair, and the respiratory tract. They may cause wound infections, abscesses, pneumonia, skin infections, and urinary tract infections. Portal of entry: Skin, respiratory tract, and gastrointestinal tract. Carrier status: 30-70% of adults carry staph on skin, 40% of adults carry staph in the nasopharynx, and 60% of children and adolescents carry staph in the nasopharynx. Prevention: Good ventilation in treatment rooms, disinfection of work areas and treatment tables, good practitioner hygiene, hand washing, clean needle technique.
More than one type of strep exists. Streptococcus may cause wound infections, bacterial endocarditis, upper respiratory
CHAPTER ONE-CLINICAL APPLICATIONS OF MICROBIOLOGY -
infections, pneumonia, sinusitis, par0 titis, conjunctivitis, and arthritis. Portal of entry: Respiratory tract. Carrier status: 20-70% of the population are carriers. Prevention: Good ventilation in treatment rooms, hand washing.
Clostridium tetanus
Tetanus is a life-threatening illness caused by an anaerobic, spore-forming bacillus, which infects deep puncture wounds. It has a high incidence in intravenous drug using (IVDU) populations. Prevention: Current tetanus vaccination (every five years) is recommended for health practitioners. Tetanus prophylaxis following needle-stick. Sterilization of needles and equipment.
Myobacterium tuberculosis
Tuberculosis is an infection of the respiratory tract caused by the non-spore forming Tubercle bacillus. It is pandemic and has been increasing in incidence, particularly in immunodepressed populations. Tuberculosis primarily is a disease of the lungs, but may spread from the lungs to infect bone, skin, the gastrointestinal tract, and fallopian tubes. Symptoms and signs: Cough, shortness of breath, fatigue, dyspnea, blood-tinged sputum, chest tightness, fever, night sweats, weight loss. Prevention: Good ventilation of treatment rooms, hand washing. Many states require yearly screening for health practitioners. A reactive skin test requires a follow-up chest x-ray to determine if active disease is present. If the chest x-ray is positive,
CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -
appropriate treatment is required. If the chest x-ray is negative, follow-up x-rays are generally not required in the absence of clinical symptoms. Public Health policies on management of screening and treatment change frequently. The BCG vaccine given in some countries may cause a false positive Tuberculin skin test for five years or more.
Hepatitis
Symptoms and signs: Fatigue, nausea and vomiting, decreased appetite, jaundiced skin and sclera, amber-colored urine, white feces, right-sided upper quadrant abdominal pain, hepatomegaly, and low-grade intermittent fever. Western diagnosis: Clinical symptoms and signs, and serum antigen testing to determine type and infectiousness. Antibody testing can help stage current illness and determine past exposure and immunity. Serum markers: IgM: indicates acute or recent immune response. IgG: indicates past infection and immunity. IgA: present in breast milk. Western treatment: Rest, hydration, maintenance of food intake, low-protein diet, household enteric precautions, sexual precautions if appropriate. Alpha-Interferon has been used, producing remission in 35% of chronic active cases with HBV and in 10-15% with HCV. Sequelae: Course of disease may be mild, moderate or severe. Most patients recover without sequelae. Certain types of
CHAPTER ONE-CLINICAL
APPLICATIONS OF MICROBIOLOGY
hepatitis have a higher incidence of chronic active hepatitis, a recurrent illness that may result in liver cirrhosis and death from liver cancer in some patients. Infection with Hepatitis B or C virus has the risk of carrier status.
Hepatitis A
Formerly called infectious hepatitis, HAV causes sporadic epidemics in many countries. Caused by a single-stranded RNA virus. Route of transmission: Oral-fecal, sexual if oral contact occurs. Incubation period: Two-six weeks; mean 4 weeks. Severity: Usually mild to moderate, may be asymptomatic. Morbidity and mortality increase with age. Fatality: 0.6%. No chronic infection. Serum markers: IgM anti-HAV in acute disease, remains elevated 3-9 months. Total (IgM and IgG) anti-HAV in prior infection. Carrier state: None known. Active Vaccine: Commercially available synthetic vaccine; two injections six months apart. Prior to receiving the vaccination, the serum IgG and IgM should be negative, demonstrating non-immunity and absence of recent infection. . Passive prophylaxis: Immune globulin after suspected or known exposure, recommended for household and sexual contacts of persons with hepatitis, and for travelers to endemic areas.
- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -
Caused by a medium-sized DNA virus that is unique among human viruses. Animal forms have not produced disease in humans. Route of transmission: Sexual (26%), blood-borne, IVDU, perinatal, oral. Incubation period: Six weeks-six months, with a mean of four months. Severity: May be asymptomatic (65%), mild to severe course in others. Jaundice occurs in only 25% of cases. Fulminating hepatitis occurs in 1.4% of patients, with high incidence of mortality. 90% of cases resolve without sequelae. The remaining 10% develop a carrier state or chronic active hepatitis. Acute infection is rare in older people. Serum markers: HBsAg (surface antigen) in acute or chronic disease and in carrier state. IgM antibody to HBcAg (core antigen) in acute disease. IgG antibody to HBcAg indicates chronic active disease with positive HBsAg, and indicates prior disease with negative HBsAg. IgG antibody to HBsAg indicates immunity. HBeAg: indicates acute infectiousness. Antibody to HBeAg: recovery phase or ongoing infection. HBV DNA: indicates ongoing infectiousness. Carrier state: Occurs in 2-10% of adult patients, and in 2550% of children less than 5 years old.
- CHAPTER ONE-CLINICAL
Vaccine: Commercially available synthetic vaccine in series of three injections over a six-month period produces immunity in 92% of recipients. An additional booster may be effective in non-converters. Antibody titers should be rechecked five years post vaccination. Prior to receiving the vaccination, serum HBsAg and IgG should be negative, demonstrating non-immunity and the absence of hepatitis. Response rate to HBV vaccination decreases with age.
Hepatitis C
Hepatitis C virus is an RNA virus which was formerly known as non-A, non-B and was a major cause of post-transfusion acquired hepatitis. The disease is found worldwide. Route of transmission: Blood-borne (lo%), IVDU (40%),rare transmission by sexual (1- 10%) and perinatal contact. Incubation period: Two-twelve weeks; seven-eight weeks if post-transfusion acquired. Severity: Mild-severe course, becomes chronic active in 5080% of cases, with sequelae of cirrhosis andlor liver cancer. Acute disease is usually milder in older patients. Serum markers: Anti-HCV assay with a mean seroconversion of six months, does not distinguish between IgM and IgG antibody, and alone is not reliable for diagnosis. Newer EIA anti-HCV and PCR tests are more specific. Carrier state: Develops in up to 60-80% of cases. Vaccine: Under development.
Hepatitis D
Hepatitis D is caused by a small defective RNA virus that is capable of causing infection only in individuals concurrently
infected with hepatitis B, either as carriers of HBV (superinfection) or simultaneously with HBV (coinfection) . Route of transmission: Blood-borne, IVDU, possibly sexual. Incubation period: Superinfection: 30-60 days. Coinfection: same as HBV. Severity: Those with coinfection generally recover; fatality 110%. The majority of those with superinfection develop 7 5 % ) , with a high incidence of morchronic active HDV ( tality (5-20%). Acute infection lasts approximately 2-6 weeks with superinfection, and 4-12 weeks in coinfection. The prognosis worsens in children. Serum markers: IgM anti-delta: chronic infection (IgM-positive, high titer). IgG anti-delta: prior infection (low-titer, IgM negative). Carrier state: Unclear. Vaccine: None available specific to HDV, but immunity to HBV protects against HDV infection.
Hepatitis E
HEV is a small RNA virus that was formerly classified under non-specific hepatitis. it is pandemic but occurs mosr commonly in the countries of Asia, India, Central and South America, and in Africa and the Middle East. Route of transmission: Oral-fecal. Incubation period: 20-60 days. Severity: Usually mild to moderate, fatality 2%, but has an increased mortality (20%) if acquired during pregnancy.
Carrier state: None. Vaccine: None available. Serum markers: Anti-HEV serum assay not commercially available, HEV antigen in feces.
Non-specific Hepatitis
Non-specific hepatitis not due to any of the above viruses or any other known etiology was previously diagnosed as nonA, non-B. Until recently, Hepatitis C and E types belonged in this category, and HCV accounted for the majority of posttransfusion acquired cases. Recently other viral agents have been identified. Hepatitis F is a single-stranded RNA virus and has an enteric mode of transmission. Hepatitis G is a blood-borne RNA flavivirus and frequently occurs as a coinfection with other hepatitis viruses, particularly HBV and HCV. It is also called GBV-C virus and different subtypes have been found in liver tissue samples. Those at risk for HGV are intravenous drug users, and patients undergoing dialysis, transfusion, and organ or bone marrow transplant. Both perinatal and sexual transmission have been documented. At present, it is not known whether HGV is associated with clinical disease, acts as a passenger virus, or becomes virulent only under certain conditions. Coinfection with HCV may be common It is likely that there are other unidentified viruses responsible for cases of non-A-G hepatitis. Hepatitis may also be caused by other pathogens, such as Herpes simplex virus. In the United States, The Centers for Disease Control (CDC) Hepatitis Hotline number for recorded information is (888)443-7232.
CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS
TABLE I : SUMMARY OF CHARACTERISTICS OF VIRAL HEPATITIS
Primary route of transmission Incubation period severity of symptoms Chronic active state Carrier state Vaccine available
oral-fecal parenteral 2-6

W ~ S
parenteral
W ~ S
parenteral 4-8 W varies yes unclear

~ S
oral-fecal 3-8 W
~ S
6 W ~ S -~ 6 O 2-12 S
mild-mod. varies no no Yes yes Yes Yes
varies yes Yes no
mild-mod. no no no
HBV
H u m a n immunodeficiency virus (HIV)

The HIV virus is a human retrovirus that requires a specific cell-surface receptor site for attachment and penetration into a cell. This receptor site can be found on T-helper cells, Blymphocytes, and macrophages. Seroconversion usually occurs three to fourteen weeks after infection. Nearly 100% of infected individuals seroconvert within six months post exposure. Antibody tests are commercially used for screening for the virus widely suspected of causing HIV-related illnesses in men, women, and children. Viral load tests are available for those with positive HIV screening tests. Two types of HIV have been isolated-HIV-1 and HIV-2. HIV-1 infection is pandemic among men, women, and children. The HIV-2 form of the virus is more common in West African countries. Highest risk groups in Western Europe and the United States are men with male partners, IVDU
APPLICATIONS OF MICROBIOLOGY -
individuals (self or partner), and inner-city teenagers. Worldwide HIV infection is less confined to marginalized groups and is more widespread among men, women, and children. High-risk behavior for male-to-male and male-tofemale transmission is lack of condom use, non-monogamous activity and IVDU (self or partner). Female-to-female transmission is rare. HIV can cross the placenta to infect the fetus if the mother is seropositive, and can be transmitted in breast milk. HIV infection has been transmitted by organ transplant, donor sperm, blood transfusion, and dialysis prior to the onset of testing in March, 1985. There are case reports of seroconversion among healthcare workers resulting from needle-stick injury, mucosal splashes, or exposure to non-intact skin. The Center for Disease Control (CDC) recommends universal precautions for all healthcare practitioners. Hypodermic needle-sticks are more likely to expose the practitioner to infection as compared to solid acupuncture needles. Whether or not gloves are protective against infection during needle-stick is controversial in the literature. Gloves are recommended if the practitioner is likely to contact body fluids. In the United States, the CDC post-exposure prophylaxis (PEP) number is 1-8884-48-4911. Route of transmission: Blood-borne, IVDU, sexual, perinatal. 0ther routes unclear. Incubation phase: Unclear. May be seven to 10 years. Medications may delay development of opportunistic infections. Incubation phase is shorter in perinatallyacquired cases. Severity: Varies according to opportunistic infection developed by patient, which may differ according to gender and in pediatric vs. adult cases. Prognosis is improved in countries where patient has access to healthcare.
Symptoms and signs: Headache, muscle aches, sore throat, fever, night sweats, diarrhea, lymphadenopathy, photophobia, rash, flu-like symptoms, symptoms and signs of opportunistic infections which may differ according to gender. Serum marker: Antibody test. Viral load and antigen testing are now available. Decreased T-4 lymphocytes. Vaccine: Under development. Opportunistic infections: Candidiasis of esophagus, trachea, bronchi, lungs. Recurrent vaginitis in women. Cervical dysplasia and intraepithelial neoplasia (CIN) in women. Coccidiomycosis, disseminated. Crytptococcus, extrapulmonary. Cryptosporidiosis with diarrhea persisting longer than one month. Cytomegalovirus disease other than liver, spleen, or lymph. Herpes simplex virus persisting longer than one month. Histoplasmosis, disseminated. HIV wasting syndrome. Human papilloma virus (HPV) condyloma, proliferative. Kaposi's sarcoma (rare in women). Lymphoma, especially non-Hodgkin's. Lymphoid pneumonia or pulmonary lymphoid hyperplasia. Mycobacterium complex. Pneumocystis pneumonia. Progressive leukoencephalopathy. Salmonella, recurrent. Toxoplasmosis of the brain. Tuberculosis, particularly dissemina ted.
REFERENCES F O R CHAPTER ONE

Aids epidemiology update. (Dec. 1998) UNAIDSIWorld Health Organization, New York. Chow WC, Ng H. (1997). Hepatitis C, E and G virus: Three new viruses identified by molecular biology technique in the last decade. Ann Acad Med Singapore, 25(5): 682-686.
Cohn JA. (1989). Virology, immunology, and natural history of HIV infection. J Nurs Midwif, 34(5):242-52. Daugherty JS, Hutton MD, Simone PM. (1993). Prevention and control of Tuberculosis in the 1990s. Nurs Clin North Amer, 28(3):599-611. Ellerbrock TV, Rogers MF. (1990). Epidemiology of human immunodeficiency virus infection in women in the United States. Obstet Gynecol Clin North Amer, 17(3):523-543. Ergun GA, Miskovitz PF. (1990). Viral hepatitis: the new ABC's. Postgrad Med, 88(5):69-76. Gold JW. (1992). HIV- 1 infection: Diagnosis and management. Med Clin North Amer, 76(1):1-16. Hoofnagle JH, Di Bisceglie AM. (1991). Serologic diagnosis of acute and chronic viral hepatitis. Seminars in Liver Dis. 11:73-83. Kools AM. (1992). Hepatitis A, B, C, D, and E. Postgrad Med, 91(3): 10914. Krzysztof K. (1993). Hepatitis E. Hepatology, 17:932-41. Legg JJ. (1993). Women and HIV. J Am Board Fam Pract, 6:367-77. Levy JA. (1993). The transmission of HIV and factors influencing progression to AIDS. Am J Med, 95:86-100. Lynch-Salamon DI, Cooinbs CA. (1992). Hepatitis C in obstetrics and gynecology. Obstet Gynecol. 79:62 1-629. Marcus EL, Tur-Kaspa R. (1997). Viral hepatitis in older adults. J Am Geriatr Soc, 45(6):755-763. Mphahlele MJ, Lau GK, Carman WF.(1998) HGV: The identification, biology and prevalence of an orphan virus. Liver, 18(3): 143-145. OSHA Compliance System. (1999). OSHAGUARD, Clearwater, FL. Pinho JR, da Silva LC. (1996). GB virus CIHepatitis G virus and other putatitive hepatitis non A-E viruses. Rev Inst Med Trop Sao Paulo, 38(6): 441-450. Quinn TC. (1990). Epidemiology of the human immunodeficiency virus. Ann Emerg Med, 19(3):225-31. Shafran SD, Conly JM. (1996). ABCDEFG. Canad J Inf Dis. 7(3): 181-182. Tang, E. (1991). Hepatitis C virus: a review. West J Med. 155:164-168.
Valenti WM. (1993). Infection control and the pregnant health care worker. Nurs Clin North Amer, 28(3):673-686. Viscarello RR. (1990). AIDS: Natural history and progression. Obstet Gynecol Clin North Amer, 17(3):545-55.
CHAPTER T W O INFECTION CONTROL
PRACTITIONER HYGIENE
Adequate hygiene for the practitioner includes not only good hand-washing technique, but physical cleanliness. A clean lab coat should be worn, and long hair worn by male and female practitioners should be tied back. Practitioners should make every effort to avoid working when they have an acute upper respiratory infection. Non-intact skin should be covered with a Band-Aid or gloves. Nails should be kept clean and short.
Hand washing
Hand washing should be performed before and after each patient contact. A mild hand soap is sufficient, preferably dispensed by pump. Some practitioners prefer a soap with an antibacterial agent. Regulations in some areas may specify brush-scrubbing as part of adequate hand washing. Clean paper towels should be used to dry the hands. Protocols for hand washing as part of needle insertion procedure are presented later in this manual. Even adequate hand washing will
not sterilize the skin, but will remove surface germs from the epidermal layer of the skin. Friction and running water are essential.
G e r m theory
Any sterile object that touches a non-sterile surface is no longer considered sterile. The shaft of the acupuncture needle needs to be maintained in a sterile manner for needle insertion. The shafts of long needles can be stabilized with a sterile cotton ball or sterile gauze. A needle that touches the patient's clothing, the practitioner's hand, or is dropped on the floor, is considered contaminated and should not be used. Since germs are not static organisms, there is a one-inch margin that is considered non-sterile on any sterile object or field. Used alcohol swabs and used needle packaging are discarded away from the clean area. Ear press needles and balls should be sterile prior to use and discarded afterwards. Guide tubes, needle holders, and clamps should be sterile prior to each use. Skin rollers and cups that contact unbroken skin require either sterilization or disinfection prior to each use. Sevenstar needles and any instruments for bleeding, including cups, require sterilization prior to each use.
Sterile jield
Some licensure or certification exams require sterile or clean fields as part of the practical examination. When a sterile field is opened by hands not gloved with sterile gloves, the field is no longer sterile. A clean field should be held by the corners while positioning it on the work area to keep it as clean as possible. Clean paper toweling will serve as a clean area in the same way. Needles should be removed from their
CHAPTER TWO-INFECTION
CONTROL
packaging without touching the shaft or the inside of the packaging.
Packaging
Any package of sterile needles or equipment should be checked for sterilization expiration date, integrity, and positive sterile indicator strip. The contents of a package that is wet, torn, or expired are no longer considered sterile. Old-fashioned syringe envelopes have been used in the past as needle packaging for sterilization of non-disposable needles. If they are used, both top and bottom ends should be taped with autoclave masking tape to prevent air leaks. Packaging manufactured specifically for sterilization is preferable because it is moisture-resistant and less permeable to air. The clear peel-back packaging available from medical supply stores has heat-sealed edges and a longer shelf life. Clear packaging is available in rolls or envelopes with selfseal tops. Instruments and needles should be inserted enddown into packaging prior to sterilization, so that the handles are nearest the side to be opened. Single-wrapped packaging has a shelf life of 30 days. Double-wrapped packaging has a shelf life of six months. Packs larger than 12 by 12 by 20 inches (26.4 by 26.4 by 44 cm) cannot be sterilized in a steam autoclave because the steam is unable to penetrate that size package even under pressure.
CHAPTER THREE STERILIZATION
Steam
Saturated steam under pressure is the most practical sterilization method for the office setting. The addition of moisture to heat reduces the required temperature and exposure time required for sterilization. Pressure and exposure time have an inverse relationship to temperature. At the minimum temperature of 250F (121C) the exposure time required is either 15 minutes at 30 PSI or 30 minutes at 15 PSI. Temperature and pressure dials should be monitored during the sterilization cycle. Newer office autoclaves have pre-programmed cycles for wrapped instruments, unwrapped instruments and liquids. Newer autoclaves have an automatic steam venting cycle, while older autoclaves require manual venting. The venting cycle is necessary to rupture cell membranes of organisms. The contents should be allowed to dry prior to removal. Repeated steam sterilizations will dull stainless steel instruments. Heat-sensitive sterile indicator strips that turn positive when a sufficient temperature has been reached are required inside the package. If the indicator strip is negative after sterilization, the contents should not be considered sterile, and
the cause investigated. The possible causes are autoclave malfunction or air block. If the indicator strip is missing, the items should be resterilized. Some packaging is manufactured with dots or strips that function as external indicator strips. Packages should be labeled with a special pen prior to sterilization. If an ordinary pen is used, the package should be labeled only after it is completely dry. Ordinary pen and pencil are not used prior to sterilization because their markings penetrate packaging during the pressure cycle. Articles should be arranged inside the autoclave in a way that ensures free circulation of air and steam between items to avoid an air block. Containers should be sterilized with lids off and open side down to avoid filling up with water. Distilled water should be used for autoclaves unless the manufacturer specifies otherwise. Sterilizers should be cleaned with a vinegar and water solution if lime deposits accumulate on the inside walls of the autoclave. The inside of the autoclave should always be allowed to dry completely to avoid the growth of organisms such as Pseudomonas. Local Public Health Department regulations may require interval testing of the autoclave with a biological indicator. The indicator is a test item purchased in medical supply stores containing a non-pathogenic organism specific either for steam or gas autoclaves. The organism for steam autoclaves is Bacillus stearmophilw, a heat-resistant non-pathogenic organT T eL, , , , , , , , , , , , , , , , &11. 11 LK V ~ ~ & ~ L L I 3 U I v ; v C ~ the autoclave cyck, an autaclave malfunction should be suspected. A log of weekly or monthly testing should be kept in the office, according to local regulations.
,
Boiling
Boiling does not adequately sterilize instruments. Heat-resistant microorganisms, bacterial spores, and some viruses can
CHAPTER THREE-STERILIZATION
withstand boiling water (212F or 100C) even for many hours. Pressure cookers are not considered effective sterilizers because the degree of temperature above boiling (212F) and the amount of pressure per square inch achieved are unknown.
Dry heat stevilization

Dry heat convection autoclaves require increased temperatures (340F or 171C) for an hour. At 250F or 121C, six hours of exposure time is required.
Chemical sterilization
There are two types of chemical sterilization: gas and cold chemical. Ethylene oxide gas is the least damaging to fine instruments, but it has characteristics that make its use impractical in an office setting. It is flammable in the presence of air, and toxic, thus requiring long exposure and aeration times. Biological indicators designed to test ethylene oxide autoclaves are inoculated with Bacillus subtilis. The different types of liquid agents are formaldehyde and aqueous glutaraldehyde. Both are odorous, irritating to tissue, and require long exposure times. They are used in hospital settings for instruments that must be soaked and disinfected prior to sterilization, or that are unable to be sterilized by gas or steam methods. The corrosiveness of the agents make them impractical for office use.
CHAPTER FOUR DISINFECTION

To meet the United States Food and Drug Administration definition of a disinfectant, an agent must be capable of killing non-sporulating vegetative bacteria on inanimate surfaces. A disinfectant need not be effective against the Tubercle bacillus, viruses, or spores. Therefore disinfection is a less effective method of destroying organisms than sterilization. Agents effective against certain viruses or the Tubercle bacillus add that information to their labeling. Generally, manufacturers use the Hepatitis B virus as a gold standard for the term virucidal. Agents effective against HBV are considered effective against the human immunodeficiency virus, since the HIV is more fragile. There are five types of disinfectants: halogens, phenols, heavy metals, quaternary compounds, and alcohols. Halogens: Includes chlorines and iodines. They are both oxidants and are effective disinfectants. Iodines may be purchased combined with soap (scrubs) or as a solution. Manufacturing instructions should be followed when using the iodines in dilution. Chlorine bleach is effective diluted with water (1:10). Neither the chlorines nor iodines are good sporicides.
Phenols: Pure phenol is derived from coal tar. Phenol was first used as an antiseptic in the form of carbolic acid by Joseph Lister in 1865 to prevent post-surgical infection. Phenol disinfects by denaturing protein. It is ideal for disinfecting countertops and treatment tables, and is marketed in many household cleaners, using 2% phenol in an aqueous solution. Heavy metals: This group of mercurial compounds are bacteriostatic, not bactericidal, and make poor disinfectants. They are highly toxic. Quaternary compounds: Quats are primarily bactericidal, and are products derived from ammonium chlorides. Many are neutralized by soap, and are corrosive. Alcohols: There are two types of alcohol, isopropyl and ethyl. They are not sporicidal and are more effective as antiseptics than as disinfectants.
C H A P T E R FIVE ANTISEPSIS
An antiseptic is an agent used on skin to destroy or inhibit the growth of pathogenic organisms and to remove surface debris. There are three types of antiseptics: iodines, alcohols, and hexachlorophenes. The iodines are effective antiseptics, and must be used in concentrations of 70-90%. Iodine solution, more appropriate for patient use, is available in bottles of liquid and on singleuse swabs. Iodine scrub, combined with a soap, is more appropriate for practitioner use in the form of a liquid and on hand brushes. Some individuals are allergic to iodine, and may develop redness or rash after use. Iodine products cause permanent stains on clothing. Isopropyl alcohol in a concentration of 70% is more useful as a skin antiseptic than as a disinfectant. Isopropyl is preferred to ethyl alcohol because it is more effective. Absolute alcohol (100%) has little germicidal action. Alcohol stored in spring-top dispensers may allow the solution to evaporate below a 70% concentration unless the top is kept closed. For patient use, the effectiveness of alcohol as a lipid solvent on the epidermis is combined with the use of friction when firmly wiping the skin. The swab or cotton ball should not be applied in a back and forth or circular motion, but in one
firm wipe. Alcohol should not be applied to mucous membranes or open wounds. For practitioner use, alcohol is available in packaged wipes, and in aerosol foam products. Alcohol use is not as effective as hand washing in removing debris from the skin because of the absence of mechanical friction under running water. However, alcohol foam or wipes may be used as a substitute when running water is not available. Repeated use of alcohol as a hand antiseptic has a drying effect on the skin. Hexachlorophene is a bacteriostatic agent that has limited effectiveness against bacteria but not fungi. It has a cumulative bacteriostatic action, and thus may be useful for practitioner use as a hand-washing agent. Chlorhexidine gluconate is similar in action. These agents should not be used for ear antisepsis since they may damage the middle ear, and are inappropriate for pediatric use.
CHAPTER SIX NEEDLE DISPOSAL OR RESTERILIZATION

Disposable needles must be discarded in a safe manner according to local Public Health regulations that pertain to hazardous waste disposal. Sharps containers, or needle and syringe disposal containers, are available in different sizes and types at medical supply stores and from acupuncture equipment vendors. Only needles should be discarded in the sharps containers. Alcohol swabs or cotton balls should be discarded in the regular trash unless they are totally saturated with blood. Dressings or cotton balls that drip body fluids are considered to be hazardous waste. Hazardous waste should be discarded in red plastic bags, picked up by the appropriate disposal services, and incinerated. Regular trash is disposed of in the usual manner. Even clean or disinfected needles should never be disposed of in regular trash, but in sharps containers. Reusable needles or equipment should be disinfected prior to resterilization. Disinfecting equipment reduces the risk of transmission of disease during handling and packaging. Equipment and needles should be soaked in a chlorine or iodine solution for 20 minutes. After disinfection, needle holders, skin rollers, and cups should be cleaned with a scrub pad or brush to remove blood and skin cells. Non-disposable
needles should be wiped with gauze. Items should then be rinsed in tap water and then packaged for resterilization.
REFERENCES FOR CHAPTERS TWO THROUGH SIX

Block SS. (1983). Disinfection, sterilization and preservation. Lea and Febiger: Philadelphia. Bond WW, Favero MS, Peterson NJ, Ebert JW. (1983). Inactivation of Hepatitis B virus by intermediate to high level disinfectant chemicals. J Clin Microbiol, 18(3):535-8. Clean needle technique: Guidelines and standards for the clean and safe clinical practice of acupuncture (4th ed.) . (1997). National acupuncture foundation: Washington, DC. Crow S. (1993). Sterilization processes: Meeting the demands of today's health care technology. Nurs Clin North Amer, 28(3):687-695. Drummon DC, Skidmore AG. (1991). Sterilization and disinfection in the physician's office. Can Med Assoc J , 145(8):937-943. Huth ME. (1976). Principles of asepsis. AORN J, 24:790. Sisco V, Winters LL, Zange LL, Brennan PC. (1988). Efficacy of various methods of sterilization of acupuncture needles. J Manipulative Physiol Ther, 11(2):94-7. Valenti WM. (1993). Infection control and the pregnant health care worker. Nurs Clin North Amer, 28(3) :673-686.
PART 2
PATIENT EMERGENCIES AND COMPLICATIONS
OBJECTIVES
After having completed Part 2, the reader will have:
1. A knowledge of the most common complications and side effects related to the clinical practice of acupuncture and appropriate intervention for each. 2. A knowledge of assessment techniques to prevent complica tions.
3. A knowledge of screening methods for patients at high risk for complications.
4. A knowledge of contraindications for treatment with acupuncture. The best prevention of complications is the identification of high-risk patients by means of a thorough history and physical exam on the initial patient visit. In case of an emergency, the patient should be transported by ambulance to an emergency room. If a patient refuses treatment or medical referral,
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noted on the patient's chart. Complete charting is essential. The patient's physician should be notified of the emergency, the interventions taken, and the medical center to which the patient was transported for further treatment.
C H A P T E R SEVE N CARD IOVASCULAR COMPL ICATIONS
Angina
Commonly called chest pain, this is a symptom of hypoxia of the heart muscle. The most common cause of cardiac hypoxia is underlying coronary artery disease (CAD). Angina is a steady pain or pain of varying duration, and may be local or diffuse. Pain may be mild, moderate or severe, and may present as tightness or pressure. Typical angina is located in the middle or upper one-third of the sternum, and may radiate to the neck, jaw, and left shoulder or left arm. Atypical angina may not present with these characteristics, but as throat tightness, epigastric pain, sensation of choking, chest pressure, or numbness and weakness of one or both arms. Typically, angina occurs following exertion, large meals, or periods of emotional stress, which increase heart rate and blood pressure. Angina is relieved by rest and nitroglycerine, a prescription medication given sublingually or by cutaneous patch, which dilates the coronary blood vessels to increase blood flow. Some patients with known CAD may need more than one dose of their nitroglycerine to eliminate symptoms.
It may be taken at 3-5 minute intervals up to a maximum of three tablets. If the chest pain persists, the patient should be taken to the nearest emergency room by ambulance. All patients who present with a new onset of chest pain should be transported by ambulance to an emergency room. Those who report a new, recent history of chest pain should be medically evaluated to rule out cardiac etiology. Patients at risk: Patients with a history of CAD (coronary artery disease), ASHD (atherosclerotic heart disease), arrhythmia, or angina, or patients taking any cardiac-related prescription medication. Symptoms and signs: Changes in blood pressure, shortness of breath (SOB), pallor or cyanosis, chest pain, arrhythmias, tachycardia, bradycardia, diaphoresis, restlessness. First symptom may be a patient sensation of air hunger. Prolonged angina should be treated as a heart attack (MI).
Myocardial infarction (MI)

A prolonged episode of angina (more than two minutes) indicates that hypoxia may be causing permanent damage to the heart muscle cells. When the angina is unrelieved by rest or by nitroglycerine, there is additional cause for concern that the patient is experiencing a myocardial infarction (MI). Precipitating events include rest or sleep (59%): exercise (3 1%) , or emotional events. Patients with a history of angina who present with chest pain not relieved by their nitroglycerine, and patients without a history who present with chest pain should be transported to an emergency room by ambulance. Practitioners should know the phone numbers in their geographical area for immediate access to the Emergency
CHAPTER SEVEN-CARDIOVASCULAR
COMPLICATIONS -
Medical Services system (EMS). A good history and physical on the initial patient visit will identify high-risk patients. The patient's primary-care physician should be identified on the patient chart and notified. Presumptive MI should be managed by admission into the emergency medical service (EMS) system via ambulance. The patient's primary-care physician should be identified on the patient chart. Symptoms and signs: Persistent angina, or angina unresponsive to medication, changes in blood pressure, shortness of breath (SOB), pallor or cyanosis, arrhythmias, tachycardia, bradycardia, diaphoresis, restlessness.
C a r d i a c arrest
Cardiac arrest is defined as either the absence of cardiac activity or as insufficient cardiac output due to life-threatening arrhythmias. It is usually accompanied by respiratory arrest. By law, cardiopulmonary resuscitation (CPR) should be performed even if the patient seems unlikely to recover. Masks with one-way valves enable the practitioner to perform CPR on patients while preventing oral or respiratory transmission of infectious disease. Symptoms and signs: Patient is unresponsive to verbal and physical stimulation. There is an absence of blood pressure, pulse, and breathing. Cyanosis, diaphoresis, coldness of the extremities. Patients at risk: Previous history of cardiac arrest, patients with history of coronary artery disease (CAD) or MI, arrhythmias, hypertension, severe respiratory disease, angina, CVA (cerebrovascular accident) or stroke, or patients on cardiac medications who deny symptoms. Local licensure boards may require that acupuncturists have current certification in cardiopulmonary resuscitation (CPR) .
- CLEAN NEEDLE TECHNIQUE
FOR ACUPUNCTURISTS -
It is recommended that not only practitioners but also their office staff be trained in CPR in order to assist during an emergency. Failure to initiate CPR may leave the practitioner liable for claims of wrongful death or negligence. Emergency acupuncture treatment may be initiated if there are enough personnel available to do both. Treatment: Contact the Emergency Medical Services system (EMS) and inform them that a cardiac arrest has occurred and to send an ambulance. Note the time of witnessed arrest or the time that the patient was discovered in a state of arrest. Quickly remove any acupuncture needles to prevent the patient from being injured, and initiate CPR. The practitioner is bound by law to continue CPR until exhausted, until relieved by another, or until medical personnel arrive. The patient's physician should be notified as soon as possible.
Fainting
Fainting requires first aid treatment to protect the patient until he recovers. Practitioners may want to treat with ammonia salts (smelling salts). When the patient fully recovers, fluids may be given. The patient should be kept supine and warm until they feel well enough to stand. The blood pressure and pulse should be taken. Patients at risk are those with a history of fainting or those on medications that lower blood pressure. Elderly patients may experience orthostatic hypotension when standing following treatment. Patients who complain of fainting associated with palpitations or arrhythmias should be referred to a physician to rule out cardiac etiology.
CHAPTER SEVEN-CARDIOVASCULAR
COMPLICATIONS
Vasovagal response
Acupuncture treatment may cause a temporary reduction in blood pressure and pulse, presumably due to parasympathetic stimulation. The symptoms and signs of a vasovagal response are pallor, diaphoresis, drop in blood pressure, slow pulse, sensation of light-headedness, or disorientation. The patient should be kept prone and warm until they are fully recovered. Patients who have a history of fainting, who are normally bradycardic (pulse less than 60/bpm), or who have a low blood pressure (less than 90160) may have a lower tolerance to strong needle or electrical stimulation. A severe vagal reaction can present as shock.
Epistaxis
Nosebleed is an uncommon occurrence but may be lifethreatening in patients with bleeding disorders. First aid should be sufficient to stop bleeding in the uncomplicated patient. Patients at risk are those with a history of epistaxis, bleeding disorders, hypertension, or low platelet counts; those taking decongestants or anti-coagulant medications such as aspirin, Coumadin and Heparin; and those undergoing chemotherapy or radiation. Treatment: Apply pressure at the soft lobular portion of the nostrils with a clean gauze. The patient should tip his head forward. The patient tipping his head backward allows blood to irritate the layrnx and swallowed blood may cause nausea. Persistent epistaxis may require emergency treatment by a physician.
REFERENCES FOR CHAPTER SEVEN

Albarran-Sotelo R, Flint LS, Kelly KJ (Eds.).(1990). Healthcare provider's manual for basic life support. American Heart Association, Dallas, TX. Phipps C. (1936). Contributory causes of coronary thrombosis. JAMA, 1061761-2.
CHAPTER EIGHT IATROGENIC COMPLICATIONS
Forgotten needle
A practitioner in a busy practice may occasionally forget to remove a needle. Keeping a needle count will reduce the likelihood of leaving a needle in place. The practitioner should not allow a patient to get up until all needles are accounted for. The patient may be injured either by a needle left in place, or by a needle that falls to the floor unnoticed.
Broken needle
Very thin needles ( 2 34 g ~ g e are ) most like1y to break during insertion or patient movement. The site most most vulnerable to breakage is the junction of the handle and the shaft. Non-disposable needles that have been sterilized repeatedly may pit and weaken along the shaft. A broken needle that has a portion of shaft visible above the skin may be safely removed with a sterile clamp by the acupuncturist, but a needle buried beneath the skin requires a medical referral. Applying downward pressure on the skin surrounding the needle may assist in visualization. Depending upon the location of the needle, the patient may be unable to drive safely
to the physician's office or emergency room, and transportation by ambulance may be necessary.
Figure 8.1 : Posteroanterior chest radiographs which reveal fine metallic opacities, representing indwelling gold acupuncture needles aligned along vertical meridians in the soft tissues of the back. (Photo courtesy of New England journal of Medicine)
Migratory needle
There have been reported cases of needles, intentionally left in place as part of the treatment, migrating via the lymph system to lodge in the spinal canal or muscle tissue. The retained needle technique, especially popular in Japan, may not be included in the scope of practice of acupuncture in other countries. Suturing and injection may also not be legal. Migratory needles may wall off and pose no danger to the patient, or may migrate and damage internal structures. In the case of migratory needle, medical referral is necessary. A retained needle may also result in an infection.
CHAPTER EIGHT-IATROGENIC
COMPLICATIONS
Locked needle
Needles may be difficult to remove if the muscle tissue around the acupuncture site spasms and locks the needle in place. The use of strong electrical stimulation may cause the muscle to spasm. A needle should never be forcibly removed. Electricity should be discontinued and the patient allowed to rest momentarily on the table. Gentle massage of the surrounding muscle and meridian facilitates release of the needle.
Figure 8.2: A chest x-ray film revealing bilateral pneumothoraces (Photo courtesy of the Western journal of Medicine)
Organ puncture: Pneurnothorax

Pneumothorax is a loss, resulting from trauma or puncture, of the negative pressure that allows for expansion of the lungs inside the pleural cavity. Pneumothorax is one of the most
commonly reported complications of acupuncture in the medical literature. The most common point involved is GB-21. The best prevention is the use of correct needle depth and angles on all points across the back, over the ribcage, and near the apices of the lungs, such as with GB-21 ,]ianJing (Shoulder Well). The small needle gauge of acupuncture needles (2 32) is protective against the development of an air leak large enough to cause a pneumothorax. Symptoms and signs: Dyspnea, shortness of breath, increased pulse rate, breath sounds absent to auscultation, angina, increased respiratory rate, feeling of air hunger. Diagnosis is made by chest x-ray. A pneumothorax should always be referred to a physician for follow-up. Pneumothorax may be life-threatening in patients with underlying cardiac and pulmonary disease. Patients at high risk include: those with a history of spontaneous pneumothorax, thin or emaciated patients, and emphysemics, because their lung tissue is closer to the surface.
O r g a n puncture: blood vessel

Arterial puncture is more serious than venous puncture. The practitioner should be aware of the anatomical location of blood vessels beneath acupuncture points, and observe whether or not a hematoma is present when removing the needle Puncture of small superficial veins is not uncommon and requires mild pressure for less than a minute after needle removal. The practitioner should inform the patient of the presence of a hematoma. Arterial puncture is more serious. In addition to bleeding, an aneurysm may form at the site of the vesssel puncture. For bleeding due to puncture of a small artery, three to five minutes of firm pressure may be required; and ten to thirty
COMPLICATIONS -
minutes for a large vessel. If a large artery is punctured, the size of the hematoma should be monitored, and the patient observed for signs of hypovolemic shock. The use of manual needle manipulation over blood vessels and large-gauge needles make puncture more likely. Acupuncture may be contraindicated in patients with low platelets or bleeding disorders.
O r g a n puncture: other organs

Any organ can be punctured if needling is done incorrectly or if the depth is inappropriate for the patient. Organs most susceptible to puncture include the bladder, kidneys, an enlarged spleen or liver, and the peritoneal cavity. If lower abdominal points are used, the patient should have an empty bladder. The needling angle should be oblique in cases of bladder distention or enlarged uterus.
Spinal cord t r a u m a
A needle that penetrates the spinal canal can cause a loss of sensation or movement. The practitioner should needle points near the governing meridian without penetrating beneath the spinous processes of the vertebrae. Cases of hemorrhage, motor and sensory loss, and abscess following acupuncture therapy have been reported.
Neuritis
Needling points located directly over nerves, or needling using strong electrical stimulation, may cause an inflammation of the local nerve. The patient may experience tinnitus, prolonged numbness, electrical sensations, or motor weakness if neuritis occurs. Electricity is used with caution in points on the face and head.
M o x a burns
The normal response from moxibustion is a mild redness and warmth. Intentional burning and blistering with direct moxibustion is an additional therapeutic technique. The practitioner should be aware that not all patients may be amenable to blisters or burns for cosmetic reasons. Direct moxibustion is often an exclusion in malpractice insurance coverage. The practitioner may wish to have a separate consent form for moxibustion, and an instruction sheet for patients prescribed to perform moxibustion at home. Moxibustion is contraindicated on the lower back and abdomen during pregnancy and direct moxibustion is used with caution in children. Elderly patients, or those with systemic diseases such as diabetes, may have a reduced sensitivity to heat, and may be prone to burns.
REFERENCES FOR CHAPTER EIGHT

Asano K. (1969). Foreign body granuloma caused by a broken silver needle for acupuncture. Otolaryngol (Tokyo), 41:289-9 1. Blanchard BM. (199 1). Deep vein thrombophlebitis after acupuncture (letter). Ann Intern Med, 115(9):748. Bodner G, Topilsky M, Grief J. (1983). Pneumothorax as a complication of acupuncture in the treatment of bronchial asthma. Ann Allergy, 51:401. Campbell AE (1982). The hazards of acupuncture. Br J Radiol, 55(659):875-7. Chiu, ES, Austin JHM. (1995). Acupuncture needle fragments (letter). New Engl J Med, 332(5): 304. Corbett M, Sinclair M. (1974). Acupuncture and pleuro-puncture. New Engl J Med, 290(3):167-8. Drago F et al. (1996). Localized lipoatrophy after acupuncture. Lancet, 332(5):304.
COMPLICATIONS -
Ernst E et al. (1999). Indwelling needles carry greater risks than acupuncture techniques. BMJ, 318(7182):536. Ernst E et al. (1997). Life-threatening adverse reactions after acupuncture? A systematic review. Pain, 71(2):123-6. Ernst E et al. (1997). Acupuncture: Safety first (editorial) BMJ, 314(709l): 1362. Gerard PS, Wilck E, Schiano T. (1993). Imaging applications in the evaluation of permanent needle acupuncture. Clin Imaging, 17(1):36-40. Goldberg I. (1973). Pneumothorax associated with acupuncture. Med J Aust, 1:941-2. Gray R, Maharajh GS, Hyland R. (1991) Pneumothorax resulting from acupuncture. Can Assoc Radio1J, 42(2): 139-40 Halvorsen TB, Anda SS, Naess AB, Levang OW. Fatal cardiac tamponade after acupuncture through congenital sternal foramen. Lancet, 345 (8958) :1175. Ilhan A, Aglioglu Z, Adanir M, Ozmenoglu M. (1995). Transverse myelopathy after acupuncture therapy. Acupunct Electrother Res, 20(34:191-4). Isu T, Iwasaki Y, Sasaki H, Abe H. (1985). Spinal and root injuries due to glass fragments and acupuncture needles. Surg Neurol 23(3):255-60. Jawahar D, Elapavaluru S, Leo, PJ. (1999). Pneumothorax secondary to acupuncture (letter). Am J Emerg Med, 17(3) :310. Kataoka H. (1997). Cardiac tamponade caused by penetration pf an acupucture needle into the right ventricle. J Thorac Cardiovasc Surg, 114(4):674-6. Keane, JR, Ahmadi J, Gruen P. (1993). Spinal epidural hematoma with subarachnoid hemorrhage caused by acupuncture. Am J Neuroradiol, 14(2):365-6. Keller WJ, Parker SG, Garvin JP. (1972). Possible renal complications of acupuncture. JAMA, 222: 1559. Kelsey, JH. Pneumothorax following acupuncture is a generally recognized complication seen by many emergency room physicians (letter). J Emerg Med, l6(2) :224-5. Kida Y, Naritomi H, Sawada T, Kuriyama Y, Ogawa M, Miyamoto S. (1988). Cervical spinal cord injury caused by acupuncture (letter). Arch Neurol, 45(8):83 1. Kondo A, Koyama T, Ishikawa J, Yamasaki T. (1979). Injury to the spinal cord produced by acupuncture needle. Surg Neurol, 11 (2) :155-6.
Kuiper JJ. (1974). Pneumothorax as a complication of acupuncture. JAMA, 229: 1422. Latter CE. (1983). The hazards of acupuncture (letter). Br J Radiol, 56(667):504. Lewis-Driver DJ. (1973). Pneumo thorax associated with acupuncture. Med J Aust, 2(7):296-7. Lord, RV, Schwartz P. (1996.) False aneurysm of the popliteal artery complicating acupuncture. Aust NZ J Surg, 66(9) :645-7. Matsuyama H, Nagao K, Yamakawa G, Akahoshi K, Naito K. (1998). Retroperitoneal hematoma due to rupture of pseudoaneurysm caused by acupuncture therapy. J Urol, l59(6) :2087-8. Mazal DA, King T, Harvey J. (1980). Bilateral pneumothorax following acupuncture (letter). N Engl J Med, 302 (24) : 1365-6. Murata K et al. (1990). Subarachnoid hemorrhage and spinal root injury caused by acupuncture needle: A case report. Neurol Med Chir (Tokyo), 30(12)956-9. Neida S, Abe T, Kuribayashi R. (1973). Cardiac trauma as a complication of acupuncture treatment. Kyobu Geka Jap J Thoracic Surgery, 26:881-3. Norheim AJ. (1996). Adverse effects of acupuncture.: a study of the literature for the years 1981-1994. J Compl Med, 2(2): 291-7. Norheim A J et al. (1995). Adverse effects of acupuncture. Lancet, 345(8964):1576. Ri tter HG, Tarala R. (1978). Pneumo thorax following acupuncture. BMJ (London), 2:602-3. Rosted P. (1996). Literature survey of reported adverse effects associated with acupuncture treatment. Amer J Acup, 24(1):27-34.
---*---a---
crhnp;Jpr LR et al. (1984). Bilateral pneurnnthorax following acupuncture (letter). Am Emerg Med, 13(8):643.
Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. (1979). Spinal cord injury as a complication of acupuncture. Neurology, 29(8):1188-90. Sobel E, Huang EY, Wieting CB. (1997). Drop foot as a complication of acupuncture injury and intragluteal injection. J Am Podiatr Med Assoc, 87(2):52-9. Southworth SR, Hartwig RH. (1990). Foreign body in the median nerve: A complication of acupuncture. J Hand Surg (Br), l 5 ( l ) : l l l 2 .
COMPLICATIONS
Stack, BH. (1975). Pneumothorax associated with acupuncture. BMJ (London), 4:75. Tanita Y, Kato T, Hanada K, Tagami H. (1985). Blue macules of localized argyria caused by implanted acupuncture needle: Electron microscopy and roentgenographic microanalysis of deposited metal. Arch Dermatol, 121(12)1550-2. Turner RN, Low RH. (1981). The principles and practice of moxibustion. Thorsons:Wellingborough, Northhampton-shire. Valenta JL, Hengesh JW. (1980). Pneumothorax caused by acupuncture (letter). Lancet 1980 Aug 9, 2(8189):322. Vilke GM, Wulfert EA. (1997). Case reports of two patients with pneumo thorax following acupuncture. J Emrg Med, 15(2): 155-7. Waldman I. (1974). Pneumothorax from acupuncture. New Engl J Med, 290(11):633. Willms D. (199 1). Possible complications of acupuncture. West J Med, 154(6):736-7. Wright RS, Kupperman JL, Liebhaber MI. (1991). Bilateral tension pneumothoraces after acupuncture. West J Med, 154(1):102-3.
CHAPTER N I N E INFECTIONS
Abscess
Symptoms and signs: Local redness, swelling, tenderness, warmth, pain. Purulent drainage may be present. Patients at risk: Immunodepressed patients, those with diabetes mellitus, peripheral vascular disease. The lower extremities are more vulnerable due to decreased venous return. Repeated needling of the same acupuncture site increases the risk of infection. Sterile technique is essential. Acupuncture may be contraindicated in high-risk patients. Treatment: Referral to a physician for treatment by incision and drainage or antibiotic therapy. Immediate referral is essential in high-risk patients to avoid septicemia.
Auricular chondritis
Symptoms and signs: Local redness, swelling, tenderness, warmth, pain. Purulent drainage may be present. Patients at risk: Those with ear needles or balls left in place, whether or not intended to pierce the skin. The cartilaginous
area of the external ear is susceptible to infection because of reduced vascular circulation. The length of time that a needle may be safely left in place, if at all, is unknown. Warm humid climate, poor hygiene, oily skin, and high-risk patients increase the risk of infection. Treatment: Referral to a physician for treatment. Untreated chondritis may lead to irreversible deformity of the external ear.
sm.!!
Figure 9.1 : Radiological findings of the simple abdomen showing need!es. (Phntn cncrtesy nf ]numa1 of Clinical Microbiolo_q)
Miscellaneous infections
Cases of septicemia, osteomylitis, bacterial endocarditis, pyarthrosis, meningitis, and hepatitis following acupuncture have all been reported. Sterile technique during needle insertion, the use of sterile needles, and identification of high-risk
CHAPTER NINE-INFECTIONS
patients are the only methods of prevention.
Allergic d e r m a t i t i s
Cases of allergic dermatitis associated with ear needles or acupuncture needles containing nickel and chromium have been reported. Symptoms and signs include redness, itching, burning, pain or discomfort at the site of insertion. Some patients may be more sensitive to alloy needles. Sterile, solid stainless steel needles or balls are recommended for ear use, even those that are not intended to pierce the skin.
REFERENCES FOR CHAPTER NINE

Alexis J. (1988). Acupuncture and non-A, non-B hepatitis (letter). South Med J , 81(1):101. Allison G, Kravitz E. (1975). Auricular chondritis secondary to acupuncture. New Engl J Med, 293:780. Baltimore RS. (1976). Perichondritis of the ear as a complication of acupuncture. Arch 0tolaryngol, lO2(9) :572-3. Boxall EH. (1978). Acupuncture-associated hepatitis in the West Midlands. J Med Virol, 2:377-9. Castelain M et al. (1987). Contact dermatitis to acupuncture needles. Contact Dermatitis, 16(1):44. Chen CY, Liu GC, Sheu RS, Huang CL. (1997). Bacterial meningitis and lumbar epidural hematoma due to lumbar acupunctures: A case report. Kao Hsiung I Hsueh KO Hsueh Tsa Chih, 13(5):328-31. Cheng TO. (1983). Acupuncture needles as a cause of bacterial endocarditis (letter). BMJ (London), 287:689. Davis 0, Powell W. (1985). Auricular chondritis secondary to acupuncture. Arch Otolaryngol 111(11):770-1. Eun HC. (1981). Nickel in acupuncture needles. Contact Dermatitis, 7:334. Fisher AA. (1986). Allergic dermatitis from acupuncture needles. Cutis,
CLEAN
NEEDLE TECHNIQUE
Garcia AA, Venkataramani A. (1993). Bilateral psoas absecesses following acupuncture. West J Med, 161(l):9O. Gilbert JG. (1987). Auricular complication of acupuncture. New Z Med J , 100:142-5. Ha GY, Yang CH, Kim H, Chong Y. Case of sepsis by Bifidobacterium longum. J Clin Microbiol, 37((4):1227-8. Hadden WA, Swanson AJ. (1982). Spinal infection caused by acupuncture mimicking a prolapsed intervertebral disc. J Bone Joint Surg, 64A(4):624-6. Hussain KK. (1974). Serum hepatitis association with repeated acupunctures. BMJ (London), 2(3):41-2. Izatt E and Fairman M. (1977). Staphylococcal septicemia with disseminated intravascular coagulation associated with acupuncture. Postgrad Med, 53:285-6. Jeffreys DB, Smith S, Brennand-Roper DA. (1983). Acupuncture needles as a cause of bacterial endocarditis (letter). BMJ (London), 287:689. Jones RO, Cross G. (1980). Suspected chronic osteomyelitis secondary to acupuncture treatment. J Am Podiatr Med Assoc, TO(3):149-51. Kent GP, Brondum J , Keenlyside RA, La Fazia LM, Scott HD. (1988). A large outbreak of acupuncture-associated hepatitis B. Amer J Epidemiol, 127(3):591-598. Kirschenbaum AE et al. (1997). Glenhumeral pyarthosis following acupuncture treatment, Orthopedics, 20(12) :1184-6. Lau SM, Chou CT, Huang CM. (1998). Unilateral sacrolitis as an unusual complication of acupuncture. Clin Rheumatol, 17(4) :357-8. Lee JS et al. (1995). Factitial panniculitis induced by cupping and acupuncture. Cutis, 55(4):217-8. Lee RJ, Mcllwain JC. (1985j. Subacute bac~eriaiendocarditis iroiiowing ear acupuncture. Int J Cardiol, 7(1):62-3. Matsumura Y et al. (1998). Peritemporomandibular abscess as a complication of acupuncture: A case report. J Oral Maxillofac Surg, 56(4):495-6. Pierik MG. (1982). Fatal staphylococcal septicemia following acupuncture: Report of two cases. R I Med, 65:251. Rosted P. (1996). Literature survey of reported adverse effects associated with acupuncture treatment. Amer J Acup, 24(1):27-34.
- CHAPTER NINE-INFECTIONS
Romaguera C, Grimalt F. (1979). Nickel dermatitis from acupuncture needles. Contact Dermatitis, 5: 195. Romaguero C, Grimalt F. (1981). Contact dermatitis from a permanent acupuncture needle. Contact Dermatitis, 7:156. Savage-Jones H. (1985). Auricular complications of acupuncture. J Laryngol Otol, 99(11):1143-5.
'
Scheel 0 , Sundsfjord A, Lunde P, Andersen BM. (1992). Endocarditis after acupuncture and infection: Treatment by a natural healer. JAMA, . 267(1):56. Smith DL et al. (1986). Acupuncture-needle-induced compartment syndrome. West J Med, 144(4):478-9. Stryker WS, Gunn RA, Francis DP. (1986). Outbreak of hepatitis B associated with acupuncture. J Fam Pract (US), 22(2):155-8. Tanii T et al. (1991). A case of prurigo pigmentosa considered to be contact allergy to chromium in an acupuncture needle. Acta Derm Venereol, 71(1):66-7. Trautermann HG. (1981). Perichrondritis of the ear auricle after acupuncture. HNO (Berlin), 29(9) :312-3. Vittecoq D, Mettetal JF, Rouzioux C, Bach JF, Bouchon JF. (1989). Acute HIV infection after acupuncture treatements (letter). New Engl J Med, 320(4):250-25 1. Warwick-Brown NP, Richards AE. (1987). Perichrondritis of the ear following acupuncture. J Laryngol Otol, lOO(10):1177-9 Yazawa S, Ohi T, Sugimoto S, Satoh S, Matsukura S. (1998). Cervical spinal epidural abscess following acupuncture: Successful treatment with antibiotics. Intern Med, 37(2): 161-5.
CHAPTER TEN OTHER COMPLICATIONS AND NORMAL SIDE EFFECTS
Seizures
Epilepsy is a disorder of unknown etiology characterized by recurrent seizures which may be convulsive or non-convulsive in nature. Complex partial seizures appear as a period of loss of awareness, or confusion, without loss of consciousness. Absence seizures (petit mal) appear as staring attacks, or brief periods of unresponsiveness. These types of seizure activity require no first aid, but the patient should be monitored. Of the convulsive seizures, the tonic and clonic movements of the grand ma1 are the most easily recognized. Other conditions such as cardiac arrest, metabolic disorders, and drug or alcohol withdrawal can simulate epilepsy or cause seizure activity. Triggers include flashing light and hyperventilation. The most important first aid during a patient seizure is to protect the head from trauma. An object or hand should not be inserted into the patient's mouth. Use a pillow or folded piece of clothing to cradle the head. Remove all needles from the patient. The practitioner should protect the patient until the seizure activity has ceased. Aspiration of food during a
seizure is common if it occurs following meals. The patient should be assessed for airway blockage and proper treatment initiated if necessary. Do not offer food or drink to the patient until he is fully recovered. For patients with a well-documented history of benign seizures, it may be safe to let the activity resolve spontaneously, but if the seizure activity lasts longer than several seconds, the EMS should be called. For a patient without a history of seizures, EMS should be called immediately to evaluate the patient. Patients with a history of status epilepticus may seize continuously or intermittently for up to thirty minutes, and the EMS should be called immediately to prevent sequelae of prolonged seizure activity.
N a u s e a and emesis
Nausea and vomiting is not a benign complication. Transient nausea may be experienced by the patient if strong parasympathetic stimulation occurs during needling. If nausea persists, or if the patient vomits, electrical stimulation should be discontinued and the needles removed.
N o r m a l side effects o-f a c u p u n c t u r e

Transient light-headedness, euphoria, and mild disorientation are all normal side effects of acupuncture. The patient may feel cold with prolonged needle time (more than 20-30 minutes) or with strong eiectricai stirnula tion. Fa tients should be reassured that the above symptoms are normal and transient. Patients should fully recover before driving home.
CHAPTER TEN-OTHER
COMPLICATIONS AND SIDE EFFECTS -
REFERENCES FOR CHAPTER TEN

Albarran-Sotelo R, Flint LS, Kelly KJ (Eds.). (1990). Healthcare provider's manual for basic life support. American Heart Association, Dallas, TX. Moritz Carneiro NM et al. (1995). Acupuncture technique. Lancet, 345(8964):1577. Yamashita H et al. (1998). Adverse events related to acupuncture. JAMA, 280(18):1563-4. Yamashita H, Tsukayama H, Tanno Y, Nishijo K. (1999.) Adverse events in acupuncture and moxibustion treatment: A six-year survey at a national clinic in Japan. J Compl Med, Jun;5(3):229-36.
CHAPTER ELEVEN CONTRAINDICATIONS TO TREATMENT

According to Traditional Chinese Medicine, the following patients should not be treated: those with an empty stomach, those who are very emotionally agitated, and those who have recently used street drugs or alcohol or have engaged in extreme physical exertion.
HIGH-RISK PATIENTS:
Patients with a cardiac history or abnormal cardiac valves. Immune-compromised patients. Patients receiving radiation treatment or chemotherapy. Patients with diabetes mellitus, particularly those who are insulin-dependent or with late-stage disease: renal or opthalmic complications, ulcerations or amputations of the lower extremities. Pregnant patients. Patients with systemic medical diseases such as lupus (SLE). Patients on high doses of steroids (cortisone, prednisone). Asthma tics. Patients with hypertension: points that move qi upwards should be used with caution, and moxa may be contraindicated. Patients with a history of CVA (cerebrovascular accidents or stroke) or TIAs (transient ischemic attacks).
Patients who have had lymph nodes removed surgically. (Anatomical areas of the body that have altered lymphatic drainage are at increased risk for infection.)
Contraindications to moxibustion, needling, or electroacupuncture

It is essential that the student and practitioner be familiar with the prescribed needle depths and angles for each point as well as the underlying anatomy to avoid harming the patient, as well as which points are forbidden to needles and moxibustion. Loss of peripheral sensation to heat occurs in the elderly, in post-CVA (stroke) patients, in diabetics, and in patients with edema. Moxibustion and needling are contraindicated for areas of ulcerations, surgical incisions, varicose veins, and phlebitis. Moxibustion is contraindicated on the lower back and abdomen during pregnancy and direct moxibustion is used with caution in children. In electroacupuncture the current of electrical stimulation should never cross the back or chest, but should be applied so that the two branches of the same electrode are on the same side of the patient's body. Electroacupuncture is contraindicated during pregnancy due to the risk of initiating uterine activity, and in those patients with any type of cardiac pacemaker; due to the risk of inhibiting pacemaker activity.
REFERENCES F O R C H A P T E R ELEVEN
Fujiwara H, Taniguchi K, Takeuchi J , Ikezono E. (1980). The influence of low frequency acupuncture on demand pacemaker. Chest, 78(1):96-7. Turner RN, Low RH. (1981) The principles and practice of moxibustion. Thorsons: Wellingborough, Northhamptonshire, UK.
CHAPTER TWELVE PREGNANCY

Traditional Chinese Medicine recommends against needling during an asymptomatic, normal pregnancy. If the pregnancy is symptomatic, minimal needling specifically directed towards the symptoms is allowed. The only point described in texts to harmonize the blood and qi between the mother and fetus is KI-9 (Tnubin, House Guest). Moxibustion should not be applied to the maternal lower back or abdomen since the fetus does not have heat-dispersing mechanisms, and due to the risk of initiating uterine activity Any needling of the maternal abdomen is contraindicated after 20 weeks' gestation, but upper abdominal needling is permitted prior to that time. Gestational age is calculated from the first day of the last menstrual cycle of the patient, based on a pregnancy duration of 280 days or ten lunar months. Points contraindicated during pregnancy to needling and to moxibustion can be found in traditional texts.
Labor induction
The acupuncture points SP-6 and LI-4 are listed in texts as labor induction points, and thus are contraindicated during
pregnancy. The induction and management of labor may not be included in the scope of acupuncture practice and may not be covered by malpractice insurance. Labor induction is contraindicated in any high-risk pregnancy and ideally would be performed with low-risk patients under monitored conditions in a collaborative setting.
A c u p u n c t u r e version
Acupuncture points for the correction of malposition of the fetus or version are listed in traditional texts. Malposition is defined as any non-vertex position, such as transverse or breech lie. External version can be performed by a Western physician but is always done so under monitored conditions due to the risks of spontaneous rupture of the membranes, onset of uterine contractions, and fetal distress due to cord compression. External version is less likely to be successful closer to 40 weeks' gestation or once the fetal head has engaged, and is performed at 37 weeks' gestation to avoid preterm delivery. It is difficult to estimate if these risks would be similar for the less invasive acupuncture version, since the effects of the treatment may not be immediate. A recent study using moxibustion demonstrated increased rates of vertex presentation at term but similar rates of preterm delivery. The practitioner who chooses to perform acupuncture version should secure an additional informed consent from the patient. Acupuncture version may not be covered by the scope of acupuncture practice or by malpractice insurance. Since obstetrics is an area of increased liability for the practitioner, referral or collaboration with an obstetrician may be appropriate, particularly in high-risk patients: lack of
C H A P T E R WELVE-PREGNANCY-
prenatal care, polyhydramnios, unsure dates, fetus small or large for dates, suspected fetal anomalies, history of third trimester fetal demise, and decreased or absent fetal movements. Version is contraindicated in cases of multiple gestation and oligohydramnios.
REFERENCES FOR CHAPTER TWELVE

Cardini F, Huang W. (1998). Moxibustion for correction of breech presentation: A randomized controlled trial. JAMA, 280(18): 1580-4. Dunn PA, Rogers D, Halford K. (1989). Transcutaneous electrical nerve stimulation at acupuncture points in the induction of uterine contractions. Obstet Gynecol, 73(2):286-290. Flaws, R. (1983). Path of pregnancy (1st ed). Paradigm Publications: Brookline, MA. Gabbe SG, Niebyl JR, Simpson JL (eds.). (1991). Obstetrics: Normal and problem pregnancies. Churchill Livingstone: New York. Hayashida Y. (1987). Cephalic version by moxibustion and acupuncture. J Med Soc Toho Japan, 34(2):196-206. Kubista E and Kucera H. (1974). Acupuncture as a method of preparation in obstetrics. Am J Chin Med, 2:283-7. Kubista E, Kucera H, Muller-Tyl E. (1975). Initiating contractions of the gravid uterus through electroacupuncture. Am J Chin Med, 3:343-6. Lyrenas S, Lutsch H, Hetta J, Lindberg B. (1987). Acupuncture before delivery: Effect on labor. Gynecol Obstet Invest, 24:2 17-224. O'Connor J, Bensky D (Eds.) . (1981). Acupuncture: A comprehensive text. Eastland: Chicago. So JT. (1985). The book of acupuncture points (vol 1). Paradigm: Brookline, MA. Tempfer C, Zeisler H, Heinzl H, Hefler L, Husslein P, Kainz CH. (1998). Influence of acupuncture on maternal serum levels of interleukin-8, prostaglandin f2alpha and beta-endorphin: a matched pair study. Obstet Gynecol, 92:245-8.
CLEAN NEEDLE TECHNIQUE
Tsuei JJ, Lai YF, Sharma SD. (1977). The influence of acupuncture stimulation during pregnancy: The induction and inhibition of labor. Obstet Gynecol, 50(4):479-488. Tsuei JJ, Lai YF. (1974). Induction of labor by acupuncture and electrical stimulation. Obstet Gynecol, 43(3):337-342. Turner RN, Low RH. (1981). The principles and practice of moxibustion. Thorsons: Wellingborough, Northamptonshire.
PART 3
C L I N I C PROTOCOLS
CHAPTER THIRTEEN
GENERAL CLINIC PROTOCOLS

Explain the treatment to the patient. Assist the patient in positioning himself comfortably on the treatment table and arranging his clothes so that the desired points are available. To decrease the risk of fainting, needling should not be done with the patient standing or sitting unless absolutely necessary. The use of latex gloves is advised if the practitioner expects to come into contact with bodily fluids, e.g., copious sweat, open wounds, discharge from skin lesions, or blood, or if the practitioner has an area of non-intact skin that cannot be covered with a bandage. A needle shaft that touches anything prior to insertion is considered contaminated and must be discarded in a commercially manufactured sharps container. A sterile gauze or sterile cotton ball may be used to stabilize the shaft of a long needle. Hand washing should be performed before and after each patient contact. The site and number of the needles used should be noted in the patient chart in order to avoid forgotten needle. The patient should not be allowed to get up until all needles have been removed and accounted for.
CLEAN NEEDLE INSERTION PROTOCOL

Wash hands for at least ten seconds with soap running under running water prior to any patient contact. Dry hands with a clean paper or cloth towel. Perform physical exam, abdominal palpation, palpation of points of tenderness, or extensive point location before needling. Wash and dry hands. Open packaging to expose needles without contaminating the needles. Minimal palpation with clean hands may be used to relocate acupuncture points at this time. Swab the insertion site with alcohol using a sterile or clean cotton ball, or a sterile alcohol swab. Use one alcohol swab or clean cotton ball per location. Insert the needle without touching the shaft. If a long needle is being used, a sterile gauze or sterile cotton ball may be used to stabilize the needle shaft with the other hand. Wash and dry hands after needle insertion is completed. After treatment time is completed, wash and dry hands prior to removal of needles. Remove needles one at a time while covering the site with a clean or sterile cotton ball or sterile alcohol swab. Insert needles into the sharps container one at a time immediately ioliowing i'rieir removal. The praciiiioiier is most vulnerable to accidental needle-sticks during needle removal. A portable sharps container is best, since it can be placed at the patient's bedside. The patient should not be allowed to get up until all needles have been removed and accounted for. Discard cotton balls or swabs into trash unless completely saturated with body fluids. Hazardous waste must be discarded in appropriately marked trash or sharps containers for incineration.
CHAPTER THIRTEEN-CLINIC
PROTOCOLS -
EAR NEEDLE INSERTION PROTOCOL

Clean the external ear thoroughly with an alcohol or iodine solution, using a clean or sterile cotton ball or sterile alcohol swab. If the practitioner prefers iodine, verify that the patient does not have an allergy. Allergic reactions include redness, pruritus, and rash at the site. Use only sterile press needles or balls in the ear. 100%stainless steel instruments are optimum since some patients are allergic to alloy products. Sterile needles or balls should be inserted with a sterile clamp. Hypoallergenic (silk) tape is ideal for taping over a press needle left in place. The amount of time a press needle or ball can safely left in place is unclear. The patient should be informed of signs of infection (redness, pruritus, discomfort, warmth, swelling) and told to remove the needle if there are any symptoms. Since the blood supply to the cartilage is poor, ear infections are a risk for any foreign body left in the external ear. High-risk patients should not be sent home with a needle or ball in place. When removing press needles or balls, the practitioner should check for signs of infection, and note in the patient chart that there are none. If any sign is present, a small amount of antibiotic ointment that can be purchased over the counter can be applied, unless the patient has an allergy to the antibiotic. Since infection of the external ear can result in a permanent deformity, a patient with any symptoms or signs of infection should be referred to a physician.
4
abdominal pain: 8 abscess: 45, 5 1, 54-55 absence seizures: 57 acupuncture needles: 15, 32, 38, 42, 44, 47, 53-55 air hunger: 36, 44 alcohol withdrawal: 57 alcohols: 27-29 alloy: 53, 71 ammonia salts: 38 ammonium chlorides: 28 aneurysm: 44,48 angina: 35-38, 44 anti-coagulant medications: 39 antigen: 8, 10, 13, 16 antiseptics and disinfectants: 4 aqueous glu taraldehyde: 25 arrhythmias: 36-39 arterial puncture: 44 arthritis: 7 asepsis: 3-5, 32 ASHD (atherosclerotic heart disease): 36 aspirin: 39 atherosclerotic heart disease: 36 aureus: 6 auricular chondritis: 5 1, 53 autoclave: 21, 24
BCG vaccine: 8 blood transfusion: 15 boiling: 24-25 bradycardia: 36-37 breast milk: 8, 15 broken needle: 41 bronchi: 16
B B-lymphocytes: 14 bacillus stearmophilus: 24 bacillus subtilis: 25 bacterial endocarditis: 6, 52-54 bacteriocide: 6 bacteriostatic agent: 6, 30
-
CAD (coronary artery disease): 3537 cancer: 9, 11 candidiasis of esophagus: 16 cardiac arrest: 37-38, 57 cardiac hypoxia: 35 cardiopulmonary resuscitation: 3 738 carrier: 5-7, 9-14 CDC (Centers for Disease Control 65 Prevention): 13, 15 cerebrovascular accident: 38 cervical dysplasia: 16 chemical sterilization: 25 chemotherapy: 39, 6 1 chest pain: 35-37 chlorhexidine gluconate: 30 chlorines: 27 chromium: 53, 55 chronic carrier: 5 CIN (cervical dysplasia and intraepithelial neoplasia) : 16 cirrhosis: 9, 11 clean needle insertion protocol: 70 coccidiomycosis: 16 coldness of the extremities: 37 condyloma: 16 conjunctivitis: 7 coronary artery disease: 35-37
- CLEAN NEEDLE TECHNIQUE
cortisone: 6 1 Coumadin: 39 CPR ( cardiopulmonary resuscitation): 37-38 cryptosporidiosis: 16 crytptococcus, extrapulmonary: 16 CVA: 3 8 , 6 1 cyanosis,: 36-37 cytomegalovirus disease: 16
fatigue: 7-8 feces: 8, 13 female-to-female transmission: 15 fever: 7-8, 16 flashing light and hyperventilation: 57 flu-like symptoms: 16 forgotten needle: 41, 69 formaldehyde: 25
D
decongestants: 39 decreased appetite: 8 decreased or absent fetal movements: 65 diabetes: 46, 51, 61 dialysis: 13, 15 diaphoresis: 36-37, 39 diarrhea: 16 disposal of needles: 4 donor sperm: 15 drug: 7, 13, 27, 57 dry heat convection: 25 dyspnea: 7, 44
G grand mal: 57
H
halogens: 27 hand washing: 6-7, 19, 30, 69 hazardous waste: 31, 70 headache: 16 heavy metals: 27-28 hemorrhage: 45, 47-48 heparin: 39 hepatitis: 8-14, 16-18, 27, 32, 5255 hepa tomegaly: 8 herpes simplex: 13, 16 hexachlorophenes: 29 high-risk patients: 34, 37, 5 1-53, 61, 64, 71 histoplasmosis: 16 history of third trimester fetal demise: 65
HTV. 14-17, 27, 55
E ear needle insertion protocol: 71 elderly patients: 46 electrical sensations: 45 electricity: 43, 45 electroacupuncture: 62, 65 Emergency Medical Services system (E-MS~: 37-38, 58 epidermis: 6, 29 epilepsy: 57 epistaxis: 39-40 ethyl: 28-29 ethylene oxide gas: 25 euphoria: 58
-
HIV wasting syndrome: 16 HPV: 16 human papilloma virus: 16 hypertension: 38-39, 61 hypovolemic shock: 45
fainting: 38-39, 69
increased pulse rate: 44 increased respiratory rate: 44
INDEX -
infection: 4-5, 7-12, 14-15, 17-19, 28, 32, 42, 51-52, 54-55, 62, 71 insurance: 46, 6 4 intraepithelial neoplasia: 16 iodines: 2 7 , 2 9 isopropyl: 2 8 - 2 9 IVDU: 7, 1 0 - 1 2 , 14-15
muscle aches: 16 mycobacterium complex: 16
N
nasopharynx: 6 nausea: 8, 40, 58 nausea and vomiting: 8, 58 needle-stick: 7, 15 nickel: 53, 55 night sweats: 7, 16 nitroglycerine: 35-36 non-disposable needles: 2 1, 41 normal side effects: 57-58 nosebleed: 39 Q oligohydramnios: 65 opportunistic infections: 15-16 organ puncture: 43-45 organ transplant: 15 orthostatic hypo tension: 39 osteomylitis: 52
-
1
jaundice: 1 0
-
Kaposi's s a r c o m a : 16 KI-9, Zhu bin: 63

-
LI-4: 63 lime: 24 Lister, Joseph: 28 local redness: 5 1 low platelet counts: 39 lungs: 7, 16 , 43-44 lupus: 61 lymphadenopathy: 16 lymphoid pneumonia: 16 lymphoma: 16
M macrophages: 1 4 male-to-fernale transmission: 15 male- to-male transmission: 15 malposition of t h e fetus: 64 malpractice: 4 6 , 64 mellitus: 5 1,6 1 meningitis I 52- 53 mercurial c o m p o u n d s : 28 metabolic disorders: 57 migratory n e e d l e : 42 mild disorientation: 58 motor and sensory loss: 45 moxa b u r n s : 4 6 moxibustion: 46, 49, 59, 62-66
packaging: 4, 20-21, 24, 31, 70 packaging, storage, and disposal of needles: 4 pallor: 36-37, 39 palpation: 70 palpitations: 39 parotitis: 7 pathogens: 4-6, 13 patients on cardiac medications: 38 peripheral vascular disease: 5 1 persistent angina: 37 petit mal: 57 phenols: 27-28 photophobia: 16 pneumocystis pneumonia: 16 pneumonia: 6-7, 16 pneumothorax: 43-44, 46-49 polvhvdramnios: 64
prednisone: 6 1 pregnancy: 12, 46, 62-66 progressive leukoencephalopathy: 16 prolonged numbness: 45 pulmonary lymphoid hyperplasia: 16 purulent drainage: 5 1 pyarthrosis: 52
tinnitus: 45 toxoplasmosis: 16 trachea: 16 transient light-headedness: 58 tubercle bacillus: 7, 27 tuberculosis: 7, 16-17
u United States Food and Drug Administration: 27 urinary tract infections: 6 urine: 8
quaternary compounds: 27-28
y
radiation: 39, 61 rash: 16, 29, 71 vaginitis: 16 vasovagal response: 39 venous puncture: 44 version: 64-65 viral load: 14, 16 virucide: 6 vomiting: 8, 58
salmonella: 16 seizures: 57-58 septicemia: 51-52, 54-55 severe respiratory disease: 38 sharps containers: 31, 70 shortness of breath: 7, 36-37,44 sinusitis: 7 sore throat: 16 SP-6: 63 staph: 6 Staphylococcus: 6 steam: 21, 23-25 sterilization: 3-4, 6-7, 21, 23-25, 27,32 steroids: 61 streptococcus: 6 stroke: 38, 61-62 swelling: 51, 71
-
W
warmth: 46, 51, 71
-
x-ray: 7-8, 43-44
T-helper cells: 14 tachycardia: 36-37 tenderness: 51, 70 tetanus: 7
ABOUTTHE TEXT
A l l healthcare professioilals
who utilize needles in their
practice must follow protocols for asepsis and sterilization, patient emergencies and complications, and clean needle insertion in their patient care practice. This book gives practical consideration t o all aspects of needle use, including an overview o f relevant microbiology, issues o f infection control, sterilization, disinfection, antisepsis, and needle disposal and resterilization. It covers pertinent complications-cardiovascular, iatrogenic, infectious, and others including normal side effects pertaining to the use o f acupuncture needles in practice, and complications and contraindications in pregnancy. Important protocols concerning clean needle insertion and ear needle insertion are reviewed.
It will be a significant valuable resource for all professionals who wish to have current and complete information o n techniques for proper and safe utilization o f needles in their practice or clinical study.
ABOUTTHE AUTHOR
Jenny Belluornini, M.S.N., L.Ac., is a Licensed Acupuncturist and a Nurse-Practitioner specializing in women's primary care. She has conducted clinical research in high-risk obstetrics, and has published articles on both Western and Traditional Chinese Medicine. She is a member of the faculty and Department Chair of Western Medicine. at the American College of Traditional Chinese Medicine in San Francisco, California.

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AND O T H E R HEALTHCARE PROFESSIONALS

COMPLEMENTARY MEDICINE PRESS

This book is dedicated to C.S. Cheung, M.D.

CHAPTER O N E CLINICAL APPLICATIONS OF MICROBIOLOGY

- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS

ORGANISMS RELEVANT TO THE PRACTICE OF ACUPUNCTURE

CHAPTER ONE-CLINICAL APPLICATIONS OF MICROBIOLOGY -

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS

TABLE I : SUMMARY OF CHARACTERISTICS OF VIRAL HEPATITIS

oral-fecal parenteral 2-6

parenteral 4-8 W varies yes unclear

mild-mod. varies no no Yes yes Yes Yes

varies yes Yes no

H u m a n immunodeficiency virus (HIV)

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

REFERENCES F O R CHAPTER ONE

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

CHAPTER T W O INFECTION CONTROL

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS

packaging without touching the shaft or the inside of the packaging.

CHAPTER THREE STERILIZATION

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

Dry heat stevilization

CHAPTER FOUR DISINFECTION

- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS

CHAPTER SIX NEEDLE DISPOSAL OR RESTERILIZATION

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS

REFERENCES FOR CHAPTERS TWO THROUGH SIX

PATIENT EMERGENCIES AND COMPLICATIONS

3. A knowledge of screening methods for patients at high risk for complications.

mDmh~rthic CLLIAII~A h~ LlllJ J I I U U I U U L

C H A P T E R SEVE N CARD IOVASCULAR COMPL ICATIONS

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

Myocardial infarction (MI)

- CLEAN NEEDLE TECHNIQUE

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

REFERENCES FOR CHAPTER SEVEN

CHAPTER EIGHT IATROGENIC COMPLICATIONS

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

Organ puncture: Pneurnothorax

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

O r g a n puncture: blood vessel

O r g a n puncture: other organs

- CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

REFERENCES FOR CHAPTER EIGHT

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

patients are the only methods of prevention.

REFERENCES FOR CHAPTER NINE

CHAPTER TEN OTHER COMPLICATIONS AND NORMAL SIDE EFFECTS

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

N o r m a l side effects o-f a c u p u n c t u r e

COMPLICATIONS AND SIDE EFFECTS -

REFERENCES FOR CHAPTER TEN

CHAPTER ELEVEN CONTRAINDICATIONS TO TREATMENT

CLEAN NEEDLE TECHNIQUE FOR ACUPUNCTURISTS -

Contraindications to moxibustion, needling, or electroacupuncture

CHAPTER TWELVE PREGNANCY