Scientific letter
Cardiac tamponade and right ventricle perforation after an acupuncture procedure
Taponamiento cardíaco y perforación del ventrículo derecho después de un procedimiento de acupuntura
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In extreme cases, acupuncture can endanger the life of the person treated. There is a growing literature on adverse effects of this technique. Acupuncturists must be aware of the risks for which they may be responsible and be prepared to act as well as having adequate facilities if any of the patients suffer any of the life threatening problems.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of a 58-year-old female patient with previous history of hypersplenism and thrombocytemia on treatment with iron replacement therapy and aspirin that presents to the emergency department (ED) with dyspnoea, epigastric and chest pain. The patient has had previously acupuncture treatment consisting in the insertion of three sternal needles before admission to ED. On arrival, the patient was haemodynamically unstable with blood pressure of 70/50<span class="elsevierStyleHsp" style=""></span>mmHg, tachycardic 130<span class="elsevierStyleHsp" style=""></span>bpm, tachypnoea 22<span class="elsevierStyleHsp" style=""></span>rpm and GCS of 13 (E3V4M6). On physical examination, jugular veins were distended. ECG demonstrated sinus tachycardia and electrical alternans. Chest X ray showed cardiomegaly and vascular redistribution, point-of-care-ultrasound (POCUS) demonstrated a pericardial effusion with diastolic collapse of the right ventricle. The patient was transferred to the reference Hospital.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At arrival, a contrast CT was requested that demonstrated severe pericardial effusion (suspected haemopericardium). The patient was taken immediately to the operating theatre. A small but actively bleeding perforation of the right ventricle was found and successfully closed. The patient had a complete recovery after the operation. The professional involved in the treatment has been on “naturist” practice for 25 years, the medical college admits that he has not received any complaint from his patients during his time as a doctor. The case is currently under investigation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Acupuncture is practiced by doctors, nurses, and physiotherapists with varying levels of training and with the growing popularity of acupuncture therapy in the world, the safety of acupuncture has attracted more attention; however, there is existing literature on adverse events (AEs) from acupuncture treatments. An NHS report evaluated the harm caused to patients through acupuncture treatments within NHS organisations.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Adverse events reported include retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), Bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorised as low or no harm. Other prospective studies has been conducted in Germany, Norway and Northern Ireland. About 90 deaths after acupuncture have been anecdotally documented in the medical literature.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Most instances of theses cases are reported in the Asian literature which is not easily accessible.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In rural China, where the use of acupuncture is more widespread than in the West, the majority of acupuncturists are not well educated. However, the doctor involved in this case had a long-standing experience in this technique. A systematic review of the Chinese literature in 2010 <a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>reported 479 cases of adverse events after acupuncture. Fourteen patients died. Most of the acupuncture-related adverse events were related to improper technique. A recent article <a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>that synthesise existing systematic reviews on adverse events associated with acupuncture and related therapies described that serious AEs are rare, but need significant attention as mortality can be associated with them.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cardiac complications have included syncope and tamponade. Eight cases of cardiac tamponade associated with acupuncture have been reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The mechanism causing cardiac tamponade have been either with direct perforation of myocardium or migrated acupuncture needles from a remote site. The distance from the surface of the skin to the anterior surface of heart has been estimated to be about 13–19<span class="elsevierStyleHsp" style=""></span>mm, therefore as the reported case even an experienced acupuncturist might penetrate the cardiac chamber or the coronary arteries with acupuncture needles (which are 30<span class="elsevierStyleHsp" style=""></span>mm in length).</p><p id="par0035" class="elsevierStylePara elsevierViewall">This case shows a life threatening adverse event of acupuncture, the insertion of needles in the chest should be reconsidered due to the dangerous anatomical landmarks. Even in the hand of experience practitioners although the risks are low, they can outweigh the benefits, which are close to zero.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The manuscript has been read and approved by all the authors, and the requirements for authorship in this document have been met, and that each author believes that the manuscript represents honest work.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient safety incidents from acupuncture treatments: a review of reports to the National Patient Safety Agency" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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Chung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/s41598-017-03272-0" "Revista" => array:5 [ "tituloSerie" => "Sci Rep" "fecha" => "2017" "volumen" => "7" "paginaInicial" => "3369" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28611366" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse events of acupuncture: a systematic review of case reports" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Xu" 1 => "L. Wang" 2 => "E. Cooper" 3 => "M. Zhang" 4 => "E. Manheimer" 5 => "B. 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