BIER BLOCK
Developing Countries Regional Anesthesia Lecture Series
Daniel D. Moos CRNA, Ed.D. U.S.A. [email protected] Lecture 16
Soli Deo Gloria
Disclaimer
Every effort was made to ensure that material and information contained in this presentation are correct and up-to-date. The author can not accept liability/responsibility from errors that may occur from the use of this information. It is up to each clinician to ensure that they provide safe anesthetic care to their patients.
Advantages
Easy to administer Rapid recovery Rapid onset Muscle relaxation
Type of surgery
Open procedures of the hand or lower arm
Closed reductions of the hand or lower arm
Limitation
Time! Ideal for procedures lasting 40-60
minutes Maximum time limit is 90 minutes Tourniquet pain generally starts after 20-
30 minutes
Contraindications
Reynaud’s disease Homozygous sickle cell disease Crush injuries Young Children Must have a reliable/operative
tourniquet! If this can not be guaranteed then this technique should not be used due to risk of toxicity!
Mechanism of Action
Not clearly understood. Local anesthetics, ischemia, asphyxia,
hypothermia, and acidosis all may play a role.
Mechanism of Action
Adapted from Rosenberg and Heavner, 1985
Equipment
Operative and reliable double toruniquet Running IV in non-operative arm Resuscitation equipment Eschmark bandage
Local Anesthetic Choice
0.5% lidocaine or 0.5% prilocaine Dose is 3 mg/kg for either NEVER USE EPI CONTAINING SOLUTIONS Complication of prilocaine is
methemoglobinemia in doses of > 10 mg/kg
Treat with 1-2 mg/kg of 1% methylene blue given over 5 minutes
Technique
Technique
IV catheter in operative arm as distally as possible
Technique Double tourniquet on the operative arm.
Proximal Cuff
Distal Cuff
Technique
Have patient hold arm up.
Use Eschmark to exsanguinate the arm
Exsanguinate the arm from distal to proximal.
Inflate the proximal tourniquet to 150 mmHg over the patients systolic pressure
Proximal Cuff
Distal Cuff
Confirm the absence of a radial pulse
Inject your local (0.5% lidocaine or prilocaine in a dose of 3 mg/kg)
Remove IV catheter, hold pressure and have OR staff prep arm. Onset of anesthesia should occur in 5 minutes
When the patient complains of pain you can inflate the distal tourniquet and then deflate the proximal tourniquet
Proximal Cuff
Distal Cuff 1st
2nd
Minimum time for tourniquet inflation
The tourniquet should be up for at least 25 minutes…releasing it before this may result in toxicity
Releasing the tourniquet in cyclic deflations (10 second intervals) will decrease peak levels of local anesthetic
Complications
Tourniquet discomfort Rapid return of sensation after
tourniquet release and subsequent surgical pain
Toxic reactions from malfunctioning tourniquets or deflating the tourniquet prior to the 25 minute limit
Bier Block Study
10 patients were enrolled in this prospective study.
The aim was to study the onset, the order of sensory anesthesia, and plasma serum levels of lidocaine were measured at 1,5,10,15,20,25,30,45,60, and 90 minutes after the tourniquet was released.
The tourniquet was elevated for a minimum of 30 minutes prior to release.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.
Bier Block Study Results
Mean onset of action for lidocaine was 11.2 minutes (+/- 5.1 minutes).
No fixed sequence of anesthesia (radial, median, and ulnar distributions).
No patient exhibited toxicity.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.
Bier Block Study Results
8 of the 10 patients reached the maximum plasma concentrations of lidocaine 1 minute after tourniquet release.
2 of the 10 patients had a slow release and peak in concentration of lidocaine.
Delayed release of lidocaine may be explained by a greater degree of absorption into tissue of the arm.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.
Local Anesthetic Toxicity
Signs and symptoms may include nausea, vomiting, dizziness, ringing of the ears (tinnitus), funny sensation around the mouth, loss of consciousness, and seizures.
Local Anesthetic Toxicity
Use the A, B, C’s for the management of local anesthetic toxicity. A= airway. Maintain a patent airway, administer 100% oxygen. B= breathing. May need to assist the patient with positive
pressure ventilation or intubation. C= circulation. Check for a pulse. If no pulse, initiate CPR. Seizures. Diazepam in doses of 5 mg, or alternatively sodium
pentothal in doses of 50-200 mg will decrease or terminate seizures.
Hypotension. Treat with ephedrine (typically 5 mg) IV, open up intravenous fluids, place the patient in a head down position (Trendelenburg). If hypotension is refractory to ephedrine, treat the patient with epinephrine (5-10 mcg). Repeat and escalate the dose as necessary.
The use of lipids in the treatment of local anesthetic toxicity has shown promise. There are currently no established methods and research continues. For updates please refer to http://lipidrescue.squarespace.com.
References Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3rd
edition. Nagelhout, JJ & Zaglaniczny KL ed. Pages 977-1030.
Rosenberg, P.H., Heavner, J.E. (1985). Multiple and complementary mechanisms
produce analgesia during intravenous regional anesthesia. Anesthesiology, 62, 840-842.
Morgan, G.E., Mikhail, M.S., Murray, M.J. (2006). The practice of anesthesiology. In
G.E. Morgan, M.S. Mikhail, M.J. Murray (editors) Clinical Anesthesiology, 4th edition. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division.
Morgan, G.E. & Mikhail, M. (2006). Peripheral nerve blocks. In G.E. Morgan et al
Clinical Anesthesiology, 4th edition. New York: Lange Medical Books.
Wedel, D.J. & Horlocker, T.T. Nerve blocks. In Miller’s Anesthesia 6th edtion. Miller,
RD ed. Pages 1685-1715. Elsevier, Philadelphia, Penn. 2005.
Wedel, D.J. & Horlocker, T.T. (2008). Peripheral nerve blocks. In D.E. Longnecker et al (eds) Anesthesiology. New York: McGraw-Hill Medical.
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