Bier Block

CHAPTER 1 Bier Block



Peter W. Grigg


Intravenous (IV) regional anesthesia, also known as a Bier block, is a useful method of providing operative anesthesia to wide areas of the distal portion of an extremity. When executed with proper technique, the Bier block is a safe alternative to local or hematoma infiltration, and provides anesthesia superior to these other methods. At the same time, it has the advantage of being technically simpler to perform than other regional alternatives (e.g., axillary or brachial plexus block).



Indications


Although the technique of IV regional anesthesia has been used on the lower extremity, it is most often used in applications involving the upper extremity. Bier blocks are useful for (1) surgery of the wrist, hand, and fingers (e.g., carpal tunnel release, foreign body removal, laceration repair, incision and drainage, and tendon release and repair); and (2) reduction of fractures or dislocation below the elbow. Bier blocks are also used in the treatment of complex regional pain syndromes.



Contraindications


Documented sensitivity to local anesthesia is an absolute contraindication. Relative contraindications include the following:


• Injuries to the proximal extremity that would be adversely affected by application of a tourniquet (e.g., crush injury)

• Conditions predisposing to arterial thrombosis (e.g., Raynaud’s phenomenon, homozygous sickle cell disease)

• Fractures about and above the elbow

• Infection at or near the intended IV cannula insertion site

• Preexisting cardiac disorders affected by IV local anesthetic (e.g., untreated third-degree heart block)

• Difficulty in maintaining arterial occlusion with a tourniquet (e.g., inadequate cuff size in a massively obese patient)


Equipment



• Standard monitoring equipment (cardiac monitor, pulse oximeter, continuous blood pressure monitor)

• Standard Advanced Cardiac Life Support (ACLS) airway supplies and drugs, as well as drugs used for sedation (e.g., midazolam [Versed], fentanyl, and propofol [Diprivan])

• Double-cuff automatic pneumatic tourniquet that can individually or simultaneously inflate or deflate both cuffs to preset pressures (as an alternative, ordinary blood pressure cuffs can be used if the dimensions of the arm can accommodate two appropriately sized cuffs between the axilla and the elbow without overlap)

• Lidocaine (without epinephrine), 1 mL/kg of 0.5% solution for upper extremity blocks, 2 mL/kg of the 0.25% solution for lower extremity blocks

• Two IV catheters, a 22-gauge line for the operative side and a 20-gauge line for the arm on the nonoperative side, which can be used for sedation and administration of emergency drugs if needed

• Sterile skin preparation solution (e.g., povidone-iodine)

• Tape

• Elastic bandage of sufficient size to wrap the entire extremity distal to the tourniquet

Although the risk of serious adverse reaction is very small when the procedure is followed correctly, it should be conducted only in facilities capable of managing serious local anesthetic toxicities (see the Complications section, later).


American Society of Anesthesiologists standards require an anesthesiologist (or a similarly qualified practitioner other than the surgeon) to manage the patient during a Bier block. This person should not be the operating surgeon because the surgeon is busy doing the procedure and cannot effectively manage complications of the local anesthetic.



Preprocedure Patient Preparation


Advise the patient that 95% of patients experience good or complete anesthesia with a Bier block; the remainder require additional analgesics or sedatives. Explain the risks, alternatives, and potential complications to the patient and answer any questions. Note that anesthesia will resolve in 30 minutes or less after tourniquet release. See patient education and patient consent forms available online.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bier Block

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