Bier block

Background

The Bier block was described by German surgeon Dr. August Bier in 1908. (1) An intravenous (I.V.) regional anesthesia, the Bier block involves complete anesthesia and motor paralysis of an exsanguinated limb, many times an arm. An anesthetic, commonly lidocaine, is injected into the exsanguinated limb through a small catheter in the hand. The anesthetic directly diffuses from the venous system into the soft tissues. The benefits of this procedure are its simplicity and dependability. However, the rapid dispersal of anesthetic after tourniquet release means that there is no postoperative analgesia.

Indications for Use

Minor and brief surgery of the forearm, wrist, hand, or fingers.

Contraindications

The Bier block is not appropriate for surgeries lasting longer than 1 hour as the tourniquet becomes painful past this point. Allergies to lidocaine, any condition that makes it difficult to achieve an effective tourniquet seal (such as severe obesity), and an injury under or outside of the tourniquet area would make this procedure inappropriate.

Consider the addition of systemic pain and anxiolytic medications in the opposite arm I.V. to complement the Bier block, particularly in an apprehensive patient. Very young, apprehensive, or combative patients may be better served by other types of anesthesia.

Technique

• Insert a small I.V. catheter (22 gauge) in the dorsum of the hand of the arm to the blocked.

• Place the patient in the supine position, with the arm to be blocked raised for about 2 minutes for passive exsanguination.

• Place a tourniquet around the proximal arm to be blocked. It is imperative to the check the tourniquet’s functionality as a leak will negatively affect the patient. Use a double cuff tourniquet to lessen the risk of the anesthetic escaping from the blocked area and to decrease patient discomfort.

• An Esmarch bandage may be applied from the distal to proximal arm to further exsanguinate the limb, which may increase the effectiveness of the anesthetic.

• After exsanguination, inflate the tourniquet and slowly inject lidocaine into the I.V. catheter in the patient’s hand. Monitor for systemic signs of lidocaine toxicity, such as numbness of the tongue, lightheadedness, and vision problems, during the injection, stopping the injection if they occur. Discoloration of the skin distal to the tourniquet is common. 

• Remove the I.V. catheter and apply pressure with a folded 4×4 gauze over the I.V. site.  Allow 5-10 minutes for anesthesia.

• Inflate the proximal cuff and then deflate the distal cuff. (For longer procedures, you may inflate the distal cuff of the tourniquet first to ensure that no leaking occurs.) After about 45 minutes, the patient may report pain at the tourniquet site. (2)  At this point, inflate the distal cuff and deflate the proximal cuff. This will allow for about 15 to 30 minutes to complete the procedure. The tourniquet should be inflated for a minimum of 20-25 minutes to prevent a large systemic dose of lidocaine when the tourniquet is released. (3) 

• At the end of the procedure, release the tourniquet slowly to prevent a high concentration of lidocaine from flooding the patient’s system. A step wise procedure has been described where the tourniquet is temporarily deflated for 10 seconds, inflated for 1 minute, and then deflated. (2)

Dosage

The recommended dosage of preservative-free lidocaine is generally 0.5 mg/kg and should not exceed 3 mg/kg. Most authors recommend using a diluted 0.5% lidocaine or 0.33% lidocaine (1% diluted in normal saline 3:1). However 12-15 mL of 2% preservative-free lidocaine has been described by some authors. (2) Other drugs such as bupivacaine, ropivacaine, and tramadol have also been used, but their potential to increase the length of anesthesia may not outweigh the added complexity and adverse effects.

Complications/Risks

Sudden tourniquet deflation can lead to toxicity of local anesthetic, which can lead to severe cardiac problems and seizure. Lidocaine toxicity can first be recognized through numbness of the tongue, metallic taste, lightheadedness, tinnitus, headache, and vision problems. Further toxicity leads to seizures, unconsciousness, and coma. This can be avoided by carefully checking the tourniquet for leaks prior to the injection of the anesthetic and by slowly and gradually releasing the tourniquet at the end of the procedure.

Local complications associated with tourniquet use include:

• Postoperative swelling and stiffness
• Delay in recovery of muscle power
• Compression neurapraxia
• Wound hematoma
• Wound infection
• Direct vascular injury
• Skin abrasions
• Bone and soft-tissue necrosis
• Deep vein thrombosis
• Compartment syndrome(4-9) 

Systemic complications associated with tourniquet use include

• Increased central venous pressure
• Arterial hypertension
• Cardiorespiratory decompensation
• Cerebral infarction
• Alterations in acid-base balance
• Rhabdomyolysis(4-9)

References

1. Bier A. A new method for local anaesthesia in extremities. Annal Surg 1908;48:780 –781

2. http://www.nysora.com/peripheral_nerve_blocks/intravenous_regional_blocks/3009-bier_block.html  June 20, 2011.

3. http://www.ifna-int.org/ifna/e107_files/downloads/lectures/H16BierBlock.pdf  June 20, 2011

4. Abel Wakai, MB, Desmond C. Winter, MD, John T. Street, MB, and Paul H. Redmond, MCh. Pneumatic Tourniquets in Extremity Surgery J. Am. Acad. Orthop. Surg., September/October 2001; 9: 345 – 351.

5. Ward CM: Oedema of the hand after fasciectomy with or without tourniquet. Hand 1976;8:179-185.

Greene TL, Louis DS: Compartment syndrome of the arm: A complication of the pneumatic tourniquet—A case report. J Bone Joint Surg Am 1983;65: 270-273.

6. Shenton DW, Spitzer SA, Mulrennan BM: Tourniquet-induced rhabdomyolysis: A case report. J Bone Joint SurgAm 1990;72:1405-1406.

7. O’Leary AM, Veall G, Butler P, Anderson GH: Acute pulmonary oedema after tourniquet release [letter]. Can JAnaesth 1990;37:826-827.

8. Ogino Y, Tatsuoka Y, Matsuoka R, et al: Cerebral infarction after deflation of a pneumatic tourniquet during total knee replacement. Anesthesiology 1999; 90:297-298.

9 Gielen M: Cardiac arrest after tourniquet release [letter]. Can J Anaesth 1991;38(4 pt 1):541.