Bier block (intravenous regional anesthesia)
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The Bier block, introduced by August Bier in 1908, is a technique for intravenous regional anesthesia primarily used for surgical procedures on the arms and legs below the elbow and knee, respectively. It offers rapid onset of anesthesia with relatively low risks when performed correctly, though it is limited to short procedures and carries potential complications such as tourniquet pain and local anesthetic toxicity. The technique involves the use of a tourniquet and local anesthetic, with careful monitoring of dosage and duration to ensure patient safety.
Bier block (intravenous regional anesthesia)
- 1. BIER BLOCK (INTRAVENOUS REGIONAL ANESTHESIA) By: Komal Haleem (Pharm-D) Huda Hamid Amna Tahir Yoanna David
- 2. 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.
- 3. 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.
- 4. INDICATIONS: Closed fractures Burn debridement Removal of ground-in debris Abscess I&D Laceration repair Foreign body removal Limited surgical procedures
- 5. 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
- 6. 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:
- 7. 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
- 8. 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.
- 9. 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.
- 10. 3. Palpate radial and ulnar arteries to establish baseline.
- 11. 4. Apply wide Esmarch rubber bandage to complete the exsanguination of the extremity.
- 12. 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).
- 13. 6.The extremity is then lowered and the local anesthetic is slowly injected through the previously inserted IV catheter.
- 14. 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.
- 15. 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.
- 16. 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.
- 17. 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
- 18. 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
- 19. 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 .
- 20. 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.
- 21. COMPLICATIONS 1. Tourniquet pain 2. At IV site: blotchy erythema, flushing, urticaria 3. Tourniquet fails Lidocaine bolus: Headache, lethargy, slurred speech, seizure Hypotension, bradycardia
- 22. 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..
- 23. 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.