Bier Block - Indications, Contraindications, Procedure and Complications

Introduction

The Bier block is a technique where local anesthesia is injected into a limb after making it bloodless with a tourniquet (a device used to put pressure on the limb or other extremities to stop the blood flow). It was introduced by August Bier in 1908 but gained popularity when reintroduced by Holmes in 1963. It is used for short surgeries on the arms or legs, like carpal tunnel release or fracture reduction. The procedure involves:

• Removing blood from the limb.

• Applying a tourniquet.

• Injecting anesthesia into the veins.

The Bier block is reliable and easy to administer but requires precautions to avoid complications. It is a well established method for regional anesthesia in limb surgeries.

What Is a Bier Block?

Intravenous regional anesthesia, also called Bier Block, involves injecting numbing medication into the veins of an arm or leg made bloodless using a tourniquet. This technique is commonly used for surgeries or arm or leg procedures. This method was a natural outgrowth of Bier's work with tourniquets and local anesthetics, which was known for his work with spinal anesthetics. During the Bier block, the blood is temporarily removed from the limb, and the medication is injected into the veins. This numbs the area and allows the surgery to be performed without pain. Bier discovered that there are two types of anesthesia produced by this technique:

• One that occurs immediately between the tourniquets.

• Another that happens a few minutes later beyond the lower tourniquet.

The Bier block has been used successfully for various procedures, especially those on the upper extremities, as it can be more challenging and riskier to use on the lower extremities. It has also been found helpful in treating conditions like complex regional pain syndromes (CRPS) by reducing inflammation and providing pain relief. In some cases, chemicals can be used instead of traditional anesthetics to relieve longer-lasting pain. This is particularly useful for patients who have experienced traumatic injuries or undergone surgery. Although the Bier block is generally considered safe and effective, a survey found that many anesthesia residents have needed more experience with this technique during their training.

What Are the Indications for Bier Block?

• The Bier block, called intravenous regional anesthesia (IVRA), is a quick and efficient method for minor forearm, wrist, hand, or finger surgery.

• Complete anesthesia is provided by IVRA, eliminating the requirement for general anesthesia and creating a bloodless surgical field.

• The procedure involves draining the blood in the extremity by elevating it, applying a tourniquet, and injecting a local anesthetic through an intravenous catheter.

• Lidocaine is a common local anesthetic often injected in 30 to 50 mL doses.

• Various tourniquet techniques, including an Esmarch bandage or a distal forearm tourniquet, can be used.

• Additional drugs can increase the IVRA's analgesic impact, including opioids, dexamethasone, clonidine, dexmedetomidine, ketamine, muscle relaxants, anti-emetics, benzodiazepines, and NSAIDs.

• IVRA is suitable for upper and lower extremity surgeries lasting up to one hour, such as carpal tunnel release, fracture reduction, and excision of masses.

• IVRA can be considered an alternative to general anesthesia or other regional anesthesia procedures in patients who might not tolerate them or in environments with limited resources.

• IVRA may not be appropriate for procedures requiring longer anesthesia or when the blood-draining process is not feasible or contraindicated.

• The technique has been used in pediatric patients to reduce forearm fractures safely and effectively.

• IVRA may help with Complex Regional Pain Syndrome (CRPS), but its long-term effectiveness remains unknown.

What Are the Contraindications for Bier Block?

Absolute Contraindications:

• Patient refusal.

• Hypersensitivity or allergy to local anesthetics.

• Impaired limb perfusion.

• Deep vein thrombosis or thrombophlebitis in the limb.

• Uncontrolled hypertension.

• Surgical procedures in a limb that cannot be wholly exsanguinated.

• Open wounds or significant injuries in the limb.

Relative Contraindications:

• Uncooperative patient.

• Morbid obesity impacting blood pressure cuff reliability.

• Neuropathies.

• Arrhythmias.

• Surgical procedures lasting over two hours.

• Sickle cell disease.

• Paget's disease.

• Severe Raynaud's disease.

• Crush injuries to the limb.

• Young children or patients who may require sedation for cooperation.

What Is the Procedure for Doing Bier Block?

Equipment Used:

• Lidocaine HCl (0.25 percent to 0.1 percent) or prilocaine (0.5 percent) are two choices for local anesthesia.

• Before inserting the IV, a rubber tourniquet (Penrose drain) about 12 to18 inches long and 7or 8 inches broad is used.

• A thin IV catheter (20 or 22 gauge) that goes through a needle.

• A bag of intravenous solution (500 mL or 1 L) is connected to a tube to keep the IV open until the anesthetic is injected into the affected limb.

• Anesthesiologists typically use ECG, blood pressure, and pulse oximeters as monitoring tools.

• A fluid solution, an IV catheter, and a tube for the opposing arm in case of upper extremity anesthesia are all included in the emergency resuscitation equipment.

• Two inflatable tourniquets of appropriate size are needed for the affected limb.

• A long bandage (Esmarch bandage) measuring 60 inches long and 4 inches wide squeezes blood out of the arm.

• A set of sterile materials for cleaning the skin.

• A syringe with a 30 or 50 mL capacity that locks securely.

• A measuring cup, preferably with a 100 mL capacity, is used to mix the solution.

• Various sizes of adhesive tape for securing the equipment.

Things to Consider:

• Before using the tourniquet, make sure it functions properly.

• Blood from the arm can be squeezed out using a bandage or rubber band.

• Place the IV catheter in the back of the hand or foot if feasible.

• Keep an IV line running to administer sedatives, painkillers, or emergency drugs in the other arm.

• Maintain ongoing ECG monitoring and have resuscitation supplies on hand in case of crises, especially after loosening the tourniquet.

Technique of Placement:

Preparation:

• Inserting a small IV catheter (22 gauge) in the dorsum of the hand of the blocked arm.

• Placing the patient supine position with the blocked arm raised for 2 minutes for passive exsanguination.

• Applying a tourniquet around the proximal arm, ensuring proper functionality, and using a double cuff tourniquet for better effectiveness and patient comfort.

• Optionally an Esmarch bandage can be used to exsanguinate the limb from distal to proximal.

Procedure:

• After draining blood, inflate the tourniquet and slowly inject lidocaine into the IV catheter while monitoring for signs of lidocaine toxicity.

• Remove the IV catheter and apply pressure on the site with folded gauze for 5 to 10 minutes to allow anesthesia to take effect.

• Deflate the distal cuff before inflating the proximal cuff (the order may be reversed for lengthier procedures to prevent leaks).

• If the patient still feels tourniquet pain after 45 minutes, inflate the distal cuff and deflate the proximal cuff to finish the treatment.

• Inflate the tourniquet for at least 20 to 25 minutes to prevent excessive systemic lidocaine dose upon release.

• Slowly release the tourniquet at the end of the procedure to avoid a sudden concentration of lidocaine.

• Prepare the required materials, ensuring preservative-free anesthesia without epinephrine.

• Verify the tourniquet's proper operation and the patient's suitable fasting.

• ECG, blood pressure, and pulse oximetry monitors should be connected, and an IV catheter should be positioned distally on the operative limb.

• On the surgical limb, apply a double tourniquet and ask the patient to support it.

• Blood drained on the extremity using an Eschmark or rubber bandage from distal to proximal.

• Inflate the proximal tourniquet to a pressure approximately 100 mmHg higher than the patient's systolic blood pressure.

• Remove the Eschmark or rubber bandage and confirm the absence of an arterial pulse.

• Slowly inject the local anesthetic, being careful not to use more than the recommended dosage.

• Apply pressure to the area after removing the IV catheter.

• Proceed with arm preparation while informing the patient about the expected numbness or tingling sensation and mottled appearance.

• Deflate the proximal cuff and inflate the distal tourniquet if the patient experience tourniquet pain.

• Give analgesics as needed to relieve pain.

What Are the Complications of Bier Block?

• Rapid tourniquet deflation during IVRA can result in high anesthetic levels in the blood, which can cause life-threatening heart problems and seizures.

• Tongue numbness, dizziness, ringing in the ears, headaches, and visual issues are symptoms of lidocaine poisoning.

• Swelling, stiffness, delayed muscle recovery, nerve compression, wound problems, blood vessel injury, skin damage, tissue necrosis, blood clot development, and compartment syndrome are all risks of using a tourniquet during IVRA.

• Increased blood pressure, heart issues, breathing issues, stroke, modifications to the acid-base balance, and muscle disintegration are just a few examples of systemic consequences.

• The bier block technique is generally safe, but there can be rare but serious complications such as systemic toxicity, seizures, and cardiac arrest.

• Nerve injury, compartment syndrome, skin pigmentation, and vein irritation are examples of less severe IVRA side effects.

• Tourniquet pain is a common issue during IVRA, but it can usually be managed by adjusting the tourniquet or using additional pain relief methods.

• Care should be taken to ensure the tourniquet functions appropriately and does not leak.

• Early tourniquet leakage or deflation can result in a substantial amount of anesthetic being released abruptly, which can cause seizures, loss of consciousness, nausea, vomiting, ringing in the ears, tingling around the mouth, and other symptoms.

Complications can be avoided with careful monitoring and a tourniquet release done gradually.

Conclusion

The Bier block is a safe and effective anesthesia and pain relief method during short surgeries. It requires minimal equipment and can be used in different settings. Serious complications are rare but should be prepared for. Additional medications can improve pain control. Intravenous regional anesthesia is a useful option for acute injuries. It is a straightforward technique that does not require advanced equipment or specialized skills. The anesthesia effect may only last for a while, so alternative methods may be considered. In conclusion, the Bier block is a safe and cost-effective option for short surgeries, but proper equipment and monitoring are essential.