BIER BLOCK (INTRAVENOUS

REGIONAL ANESTHESIA)

By: Komal Haleem

(Pharm-D)

Huda Hamid

Amna Tahir

Yoanna David

HISTORY

August Bier introduced this block in 1908.

In 1963, Holmes popularized the Bier Block.

Completed within 40-60 minutes.

Onset of anesthesia is rapid and reasonable

muscle relaxation.

CONDITIONS

1.Surgical procedures involving the arm below the

elbow.

2.Surgical procedures involving the leg below the knee.

Ensure that the patient has been fasting for an

appropriate period of time.

INDICATIONS:

Closed fractures

Burn debridement

Removal of ground-in debris

Abscess I&D

Laceration repair

Foreign body removal

Limited surgical procedures

There appears to be multiple and complementary

mechanisms for producing analgesia and anesthesia.

FACTORS RESPONSIBLE:

A large volume of dilute anesthetic

Ischemia

Asphyxia

Hypothermia

Acidosis

HYPOTHERMIA&ACIDOSIS

Hypothermia and acidosis results in enhanced local anesthetic activity.

ASPHYXIA

Asphyxia occurs at 20-30 mins complementing local anesthetic action.

Local anesthetic molecules transverse venous walls into surrounding tissue.

INJECTION OF LOCAL ANESTHETIC

Initial analgesia produced by local anesthetic action on major nerve trunks, small nerves, and nerve endings.

SEQUENCE EVENTS RESULTING IN ANESTHESIA &

ANALGESIA:

EQUIPMENTS

A standard regional anesthesia tray is prepared with the

following equipment:

22-gauge intravenous catheter

Flexible extension tubing

5" Esmarch bandage

Double cuff tourniquet

20 mL syringes with local anesthetic

Pressure source

A double-cuff tourniquet

PROCEDURE:

1. A small IV intravenous catheter (e.g, 22-gauge) is

introduced in the dorsum of the patient's hand of the

arm to be anesthetized. The patient is in the supine

position.

2. A tourniquet is

placed on the proximal

arm of the extremity to

be blocked. We use a

"double cuff" to increase

the reliability of the

technique and help reduce

the tourniquet pressure pain.

3. Palpate radial and ulnar arteries to establish

baseline.

4. Apply wide Esmarch rubber

bandage to complete the

exsanguination of the

extremity.

5.Elevate arm to promote

venous drainage. The

Esmarch is then unwrapped

and the extremity is checked

for color (pale skin) and

arterial occlusion

(absence of the radial pulse).

6.The extremity is then lowered

and the local anesthetic is

slowly injected through the

previously inserted IV

catheter.

POST PROCEDURE

Analgesia will occur within 3-4 minutes.

Even if the surgery is completed within a few minutes,

on no account should the tourniquet be deflated until at

least 15 minutes has passed.

The pressure in the tourniquet must be constantly

observed and maintained at least 50mm Hg above the

patient's systolic blood pressure.

If the operation is prolonged, the patient may

complain of pain due to pressure from the

tourniquet. This may be reduced either by the

subcutaneous infiltration of a few mls of local

anesthetic above the tourniquet or by the use of a

"double tourniquet technique”.

At the end of the procedure, the tourniquet is

deflated and normal sensation quickly returns.

The tourniquet is reinflated again 20-30 seconds.

ADVANTAGES OF THE BIER BLOCK

Easy to administer

Low incidence of block failure

Safe technique when used appropriately

Rapid onset and recovery

Patient is awake during procedure.

Controllable extent of anesthesia.

DISADVANTAGES OF THE BIER BLOCK

Should be used for only short procedures

Patient may experience tourniquet pain after

20-30 minutes

Sudden cardiovascular collapse or seizures

may occur if local anesthetic is released into

the circulation too early.

Lose pulse

Rapid recovery may lead to postoperative

pain

Difficulty in providing a bloodless field

CONTRAINDICATIONS

Reynaud’s disease

Homozygous sickle cell disease

Young children

Unreliable or inadequate tourniquets.

Shock

Multiple trauma (crush injuries of relevant

limb)

Hypersensitivity to Prilocaine or lidocaine

Seizure disorder

DRUGS

1.PRILOCAINE

The drug of choice as it is least toxic

largest therapeutic index.

One complication is methemoglobinemia . Prilocaine is metabolized to o-toluidine derivatives, which converts hemoglobin to methemoglobin.

onset 2 - 15minute and duration 1 – 4hours.

2.BUPIVACAINE

not suitable

it is too toxic, particularly to the myocardium.

Slower onset .

3.LIGNOCAINE

acceptable alternative.

onset 1.5 - 5minute and duration 1 – 4hours

DOSAGE

the arm dosage can be: 30-40 ml of 0.5%

prilocaine or 0.5 % lidocaine.

In leg, larger volumes 50-60 ml.

COMPLICATIONS

1. Tourniquet pain

2. At IV site: blotchy erythema, flushing, urticaria

3. Tourniquet fails Lidocaine bolus:

Headache, lethargy, slurred speech, seizure

Hypotension, bradycardia

4. Toxicity of local anesthetics

Signs and symptoms may include nausea,

vomiting, dizziness, tinnitus, funny sensation

around the mouth, loss of consciousness.

Local Anesthetic Toxicity Management

Use the A, B, C’s for the management of local

anesthetic toxicity.

A= airway. administer 100% oxygen.

B= breathing. May need to assist the patient with

positive pressure ventilation or intubation.

C= circulation. Check for a pulse..

CONCLUSION

IVRA is a simple and valuable technique that is

easy to learn and perform. It is very safe

provided excessive doses of local anesthetic are

avoided, if the tourniquet pressure is carefully

monitored and if resuscitation equipment is

always immediately available.