針刺補瀉手法及意外情況的處理

蚌埠醫學院第二附屬醫院陳莉秋主任醫師教授研究生導師針刺補瀉

ReinforcingandReducingMethods

凡是能鼓舞人體正氣，使低下的功能恢復旺盛的叫補法

；凡是能疏泄病邪，使亢進的功能恢復正常的叫瀉法。它們都是通過刺激腧穴，激發經氣來調節臟腑功能，達到陰陽平衡的。針刺補瀉效果的產生，主要取決于以下幾個方面：

Themethodwhichisabletoinvigoratethebodyresistanceandtostrengthentheweakenedphysiologicalfunctioniscalledreinforcing,whiletheotheronewhichisabletoeliminatethepathologicalfunctionsofisknownasreducing.ThereinforcingandreducingfortheregulationofthefunctionsofZang-FuorgansandthebalanceofYinandYangareachievedbystimulatingthepointstoactivatetheQiofmeridians.Theeffectsofreinforcingorreducingmainlydependuponthefollowingfactors:⑴機體的機能狀態

（TheFunctionedConditionsofthePatien）在不同的病理狀態下，針刺可以產生不同的調節作用即補瀉效果。如當機體處于虛脫狀態時，針刺可以起到回陽固脫的作用，當機體處于熱邪壅閉的情況下，針刺又起到泄熱啟閉的效果。針刺對機體的這種調節作用，與人體正氣的盛衰有著密切的關系，如機體正氣充盛，則經氣易于激發，針刺的調節作用就顯著；若正氣不足，經氣不易激發，則針刺的調節作用就較差。⑴TheFunctionedConditionsofthePatientUnderdifferentpathologicalconditions,acupuncturemayproducedifferentregulatingfunctions,eitherreinforcingorreducing.Ifanindividualisinacollapsecondition,acupuncturefunctionstorescueYangfromcollapse;whenanindividualisunderaconditionofinternalpathogenicheat,acupuncturefunctionstoexpeltheheat.Thisdualregulatingfunctioniscloselyrelatedtothedefensiveabilityofhumanbody.Ifitisvigorous,themeridianQiiseasytobeactivatedandtheregulatingfunctionisgood.Onthecontrary,ifitislowered,themeridianQiisdifficulttobeexcitedandtheregulatingfunctionispoor.⑵腧穴特征

(TherapeuticPropertiesofthePoints)不同的腧穴在功能上具有相對的特異性，有些腧穴適宜補虛，有些腧穴適宜瀉實。如氣海、關元、命門、足三里、膏肓俞等穴，具有強壯作用，多用于虛損病證；而少商、十宣等穴具有清熱的作用，多用于實熱病癥。⑵TherapeuticPropertiesofthePointsAcupuncturepointshaverelativespecificityasfarasthetherapeuticpropertiesareconcerned,somepointstendtoreinforcethebodyresistance,suchasQi-hai(CV6),Guangyuan(CV4),Mingmen(GV4),Zusanli(ST36),Gaohuang(BL43)etc,whicharemainlyappliedfordeficiencysyndromes;andsomepointssuchasShaoshang(LU11)andShixuan(EX-UE11),whichhavethepropertyofclearingawayheatandpromotingtheresuscitationareemployedoftenforexcessiveheatsyndromes.⑶針刺手法

(NeedlingMethods)此法是捻轉角度的大小和速度的快慢來區別補瀉。針下得氣后，捻轉角度小，用力輕，頻率慢，操作時間短者為補法。捻轉角度大，用力重，頻率快，操作時間長者為瀉法。也有以左傳時即拇指向前的角度大，用力重者為補；右轉時即食指向前的角度大，用力重者為瀉

①捻轉補瀉：(ReinforcingorReducingbyTwirlingandRotatingtheNeedle)⑶NeedlingMethods

①ReinforcingorReducingbyTwirlingandRotatingtheNeedleThereinforcingandreducingofthiskindcanbedifferentiatedbytheamplitudeandspeedused.WhentheneedleisinsertedtoacertaindepthandtheQiarrives,rotatingtheneedlegentlyandslowlywithsmallamplitudeforrelativelyashortperiodiscalledreinforcing,onthecontrary,rotatingtheneedlerapidlyandheavilywithlargeamplitudeforrelativelyalongperiodisknownasthereducing.Itisalsoconsideredthatrotatingtheneedlewiththethumbforwardforcefullyinlargeamplitudeisreinforcing,whilerotatingtheneedlewiththeindexfingerforwardforcefullyinlargeamplitudeisreducing.②提插補瀉

(ReinforcingandReducingbyLiftingandThrustingtheNeedle)此法是以提插時用力輕重和速度快慢來區分補瀉。針刺得氣后，提時用力較輕，速度較慢，而插時用力較重，速度較快為補法；提時用力較重，速度較快，而插時用力較輕，速度較慢為瀉法。②ReinforcingandReducingbyLiftingandThrustingtheNeedleInthismethod,thereinforcingandreducingcanbedifferentiatedbytheforceandspeedused.Aftertheneedleisinsertedtoagivendepthandtheneedlingsensationappears,thereinforcingisobtainedbyliftingtheneedlegentlyandslowly,whilethrustingtheneedleheavilyandrapidly.Thereducingisachievedbyliftingtheneedleforcefullyandrapidlywhilethrustingtheneedlegentlyandslowly.③徐疾補瀉

(TheReinforcingandReducingAchievedbyRapidandslowInsertionandwith-drawaloftheNeedle)此法是以進針、退針過程的快慢來區分補瀉。行補法時，進針要慢，逐步進針達到一定的深度，出針要快，迅速提至皮下，稍停片刻出針；行瀉法時，進針要快，一次就插到所需的深度，出針要慢，逐步分層退出。TheReinforcingandReducingAchievedbyRapidandslowInsertionandwithdrawaloftheNeedle

Thissortofreinforcingandreducingmethodisdistinguishedbythespeedofinsertionandwithdrawaloftheneedle.Duringmanipulations,thereinforcingmethodisconductedbyinsertingtheneedletoagivendepthslowlyandliftingitrapidlyjustbeneaththeskin,andamomentlaterwithdrawit.Thereducingisperformedbyinsertingtheneedlerapidlytothegivendepthinonestepandwithdrawingitslowlyinafewsteps.④開合補瀉

(TheReinforcingandReducingAchievedbyKeepingtheHoleOpenorClose)此法是以出針時是否按閉針孔來區分補瀉。補法時，出針較快，出針后立即按閉針孔，意在使真氣留存；行瀉法時，出針時右手持針搖大針孔，一面搖一面推出，出針后不閉針孔。④TheReinforcingandReducingAchievedbyKeepingtheHoleOpenorCloseOnwithdrawingoftheneedle,pressingtheneedlingholequicklytocloseitandpreventthevitalQifromescapingiscalledreinforcingshakingtheneedletoenlargetheholewhilewithdrawingit,andkeepingtheholeopenisknownasreducing.⑤迎隨補瀉

(TheReinforcingandReducingAchievedbytheDirectiontheNeedleTipPointingto)此法是以經脈循行的順逆來定補瀉。行補法，將針尖順經而刺；行瀉法時，針尖要逆經而刺。⑤TheReinforcingandReducingAchievedbytheDirectiontheNeedleTipPointingtoTheneedletippointinginthedirectionofthemeridianisknownasreinforcing,andtheneedletippointingagainstthemeridiandirectionisconsideredasreducing.⑥呼吸補瀉

(TheReinforcingandReducingAchievedbyMeansofRespiration)與病人呼氣時進針，吸氣時出針為補法，吸氣是進針，呼氣時出針為瀉法。⑥TheReinforcingandReducingAchievedByMeansofRespirationInthemethod,thereinforcingisachievedbyinsertingtheneedlewhenthepatientbreathesinandwithdrawingtheneedlewhenthepatientbreathesout.Thereducingisachievedinanoppositeway.⑦平補平瀉

(EvenReinforcingandReducingMovement)進針得氣后均勻地提插，捻轉后即可出針。⑦EvenReinforcingandReducingMovementWhentheneedleisinsertedintothepointandtheneedlingsensationappears,lift,thrustandrotatetheneedleevenly,thenwithdrawtheneedle.留針與出針

RetainingandWithdrawingtheNeedle⑴留針（Retaining）留針是指將針刺入腧穴行針施術后，將針留置穴內。留針的目的是為了加強針感和便于繼續行針施術。留針與否和留針時間的長短，主要依病情而定。一般病癥，針下得氣后留針15-20分鐘；但對某些慢性頑固性疼痛，痙攣性病癥，可適當延長留針時間，有的病癥留針可達數小時之久，在留針過程中作間歇行針，以增強療效。對針感較差患者，留針還可以起到候氣的作用。⑴RetainingRetainingmeanstokeeptheneedleinplaceafteritisinsertedtoagivendepthbelowtheskinandmanipulated.Thepurposeofitistoprolongtheneedlingsensationandforfurthermanipulation.Pathologicalconditionsdecidetheretaininganditsduration.Ingeneral,theneedleisretainedforfifteentotwentyminutesafterthearrivalofQi.Butforsomechronic,intractable,painfulandspasticcases,thetimeofretainingtheneedlemaybeappropriatelyprolonged.Forsomediseases,thedurationmaybeaslongasseveralhours.Meanwhile,manipulationsmaybegivenatintervalsinordertostrengthenthetherapeuticeffects.Forpatientswithadullneedlingsensation,retainingtheneedleservesasamethodtowaitQitocome.

⑵出針（Withdrawing）出針時先以左手拇、食兩指按住針孔周圍皮膚，右手持針輕微捻轉并慢慢將針提至皮下，然后將針起出，并用消毒棉球輕揉針孔，以防出血。最后檢查針數，以防遺漏。⑵WithdrawingOnwithdrawingtheneedle,presstheskinaroundthepointwiththethumbandindexfingerofthepressinghand,rotatetheneedlegentlyandliftitslowlytothesubcutaneouslevel,thenwithdrawitquicklyandpressthepuncturedpointwithasterilizedcottonballforawhiletopreventbleeding.Besurenottoleaveanyneedleonthebody.針刺意外情況

的處理

ManagementofPossibleAccidents一、暈針（Fainting）原因：由于患者精神緊張、體質虛弱、疲勞、饑餓，或因體位不適，或醫者操作不當，手法過重等因素造成。Cause:Thisisoftenduetonervousnessdelicateconstitution,hunger,fatigue,improperpositionormanipulation,suchastooforcefulmanipulation.

現象：患者在針刺過程，突然感覺心慌、頭暈目眩，或惡心欲吐，出冷汗，面色蒼白，脈象微弱；嚴重者出現肢體厥冷，血壓下降，二便失禁，不省人事等。Manifestations:DuringAcupuncturetreatment,theremayappearpalpitation,dizziness,vertigo,nausea,coldsweating,pallorandweakpulse.Inseverecases,theremaybecoldextremities,dropofbloodpressure,incontinenceofurineandstool,andlossofconsciousness.

處理：立即停止針刺，將已經針刺的毫針取出，令患者平臥，頭部稍低，注意保暖。輕者靜臥片刻，喝點溫開水或熱水,即可恢復。重者以指掐或針刺人中、合谷、內關、足三里等穴，如仍不緩解時，可配合其他急救措施。

Management:Stopneedlingimmediatelyandwithdrawalltheneedle,thenhelpthepatienttoliedown,andoffersomewarmorhotwatertothepatient.Thesymptomswilldisappearafterashotrest.Inseverscases,presshardwiththefinger-nailorneedleRenzhong(GV.26),Hegu(LI4),Neiguan(PC.6)andZusanli(ST.36).Generally,thepatientwillrecover,butifnot,otheremergencymeasuresshouldbetaken.

預防：對于初次接受針灸治療和精神緊張者，應先做好解釋工作，消除顧慮，手法不宜過重，盡量采取臥位，少留針或留針時間不宜過長；對于過度疲勞、饑餓者不宜針刺；醫者在針刺過程中，發現患者面色蒼白，出汗或訴說頭暈等暈針先兆時，應及時采取處理措施。

Prevention:Forpatientsbeingtreatedbyacupunctureforthefirsttime,orthoseofsensitiveindividuals,abriefaccountofneedlingshouldbegiventothempriortothetreatmenttorelievetheirnervousness,andsupinepostureisadopted.Themanipulationshouldnotbetooforceful.Needlesarenotretainedforlongtime.Duringthetreatment,ifthereappearsomeprodromalsymptomssuchaspallor,sweatingordizziness,managementshouldbetakenpromptly.二、滯針（Stuckneedle）：原因：患者精神緊張，針刺入后，局部肌肉強烈收縮；或行針時向同一方向連續捻轉，而致肌纖維纏繞針身；或因針身刺入肌腱；或針刺后體位改變，都可引起滯針。

Cause:Thismayresultfromnervousness,strongspasmofthelocalmuscleaftertheinsertionoftheneedle,twirlingtheneedlewithtoolargeamplitudeorinonedirectiononlycausingmusclefiberstobind,orfromachangeofthepositionofthepatientaftertheinsertionoftheneedles.

現象：進針后針下異常緊澀，出現提插、捻轉及出針困難。Manifestations:Aftertheneedleisinserted,itisfounddifficultorimpossibletorotate,liftandthrusttheneedles.

處理：囑患者消除緊張情緒，使局部肌肉放松，因單向捻轉而致者，則須反向捻轉。如屬肌肉一時性緊張，可留針一段時間，然后再行捻轉出針，也可輕輕按揉針刺周圍的皮膚肌肉，或在附近部位加刺一針，以宣散氣血，緩解痙攣，因體位改變者，應恢復體位后隨之將針取出。

Management:Askthepatienttorelax.Iftheneedleisstuckduetoexcessiverotationinonedirection,theconditionwillreleasewhentheneedleistwirledintheoppositedirection.Ifstuckneedleiscausedbytemporarymusclespasm,leavetheneedleinplaceforawhile,thenwithdrawitbyrotating,orbyinsertinganotherneedlenearbytodispersetheQiandblood,andtorelievethespasm.Ifthestuckneedleiscausedbythechangingofthepositionofthepatient,theoriginalpostureshouldberesumedandthenwithdrawtheneedle.

預防：對精神緊張者，下做好解釋工作，消除緊張心理。行針時不可用力過猛，避免單向捻針及將針刺入肌腱，留針過程中不宜隨意改變體位。Prevention:Nervouspatientsshouldbeencouragedtorelaxtheirtension.Manipulationshouldnotbetooforceful.Avoidpuncturingthemusculartendonduringinsertion.Twirlingtheneedleinonlyonedirectionshallnotbeallowed.Duringretentionoftheneedles,thepostureofthepatientshouldremainunchanged.

三、彎針（Bentneedle）原因：醫者手法不熟練，進針時用力過猛，或針下碰到堅硬組織；或留針時患者體位移動；針柄受到外物的壓迫和碰撞，以及滯針沒有及時處理。Cause:Thismayarisefromunskillfulmanipulationortooforcefulmanipulation,ortheneedlestrikingonthehardtissue,orasuddenchangeofthepatient'sposture,orthehandleofneedlebeingtouchedorpressedbysomething,orfromanimpropermanagementofthestuckneedle.

現象：針身彎曲，針柄改變了進針時刺入的方向，提插、捻轉及出針均感困難，患者感覺疼痛。

Manifestations:Itisdifficulttolift,thrust,rotateandwithdrawtheneedle,andthepatientfeelspainful.

處理：發現彎針后，不可再行提插、捻轉等手法。應順勢慢慢退出；如因患者體位改變所致，應使患者慢慢恢復體位，使局部肌肉放松后，再將針慢慢退出，切記強行拔針，以免將針斷入體位。Management:Whentheneedleisbent,lifting,thrustingandrotatingshallbenolongerconducted.Theneedlemayberemovedslowlyandwithdrawnbyfollowingthecourseofbent.Ifthebentneedleiscausedbythechangeofthepatient'sposture,helphimtoresumetheoriginal,relaxthelocalmuscleandremovetheneedle.Nevertrytowithdrawtheneedlewithforcesoastobreaktheneedleinsidethebody.

預防：醫者進針手法要熟練，指力要均勻輕巧；針刺前應選擇舒適的體位，留針期間不能隨意變動體位。Prevention:Skillfulinsertionandevenmanipulationarerequired.Priortotreatment,thepatientshouldhaveacomfortableposition.Duringtheretentionoftheneedle,apatientisnotallowedtochangethepositionashepleases.

四、斷針（Brokenneedle）原因：針具質量欠佳，針根或針身有剝蝕損壞；行針時手法過重，肌肉強烈收縮；或患者體位改變，滯針和彎針現象未能及時正確處理等，均可造成斷針。Cause:Thismayresultfromthepoorqualityoftheneedleorerodedbaseoftheneedle,fromtoostrongmusclespasm,orasuddenmovementofthepatientwhentheneedleisinplace,orfromwithdrawingastuckneedle.

現象：針身折斷，或部分針身尚露于皮膚之外，或針身殘端全部沒入皮膚之下。Manifestations:Theneedlebodyisbrokenduringmanipulationandthebrokenpartisbelowtheskinsurfaceoralittlebitoutoftheskinsurface.

處理（Management）：囑患者不要緊張、亂動，以防斷針繼續向肌肉深層陷入，如殘斷部分針身尚露于體外，可立即用手指或鑷子取出；如殘斷與皮膚相平，可按壓針孔兩旁，使斷針暴露于體外，用鑷子取出；如斷針完全深入皮下或肌肉時，應在x線下定位，手術取出。

Management:Whenithappens,thepatientshouldbetoldtokeepcalmtopreventthebrokenneedlefromgoingdeeperintothebody.Ifthebrokenpartprotrudesfromtheskin,removeitwithforcepsorfingers.Ifthebrokenpartisatthesameleveloftheskin,pressthetissuearoundthesiteuntilthebrokenendisexposed,thenremoveitwithforceps.Ifitiscompletelyundertheskin,surgeryshouldberesortedwiththehelpofx-