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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Bier Block Anesthesia



- Discussion:
    - indicated for fractures of the forearm, wrist, and hand;
    - bier block is not appropriate for fractures about the elbow, and may not be appropriate in patients with excessive obesity (w/ a large fatty arm);

- Precautions:
    - prior to performing the Bier block, be sure that the tourniquet is working properly;
           - if the tourniquet malfunctions and deflates during the case, the patient will likely have a siezure due to lidocaine toxicity;
    - in obese patients, consider use of a wide single tournique in order to ensure that there will not be leakage of the lidocaine into the systemic circulation;

- Technique:
    - first IV line is place in non injured forearm for administration of sedation and fluids;
    - in injured limb, a butterfly needle is placed in a dorsal vein in hand, distal to the fracture site;
    - 0.33% lidocaine solution is given in a dose of 0.5 mg/kg;
    - 1% lidocaine solution is diluted threefold with normal saline to produce a 0.33% lidocaine solution;
           - some authors feel that the addition of fentanyl to the lidocaine adds to patient comfort and extends the patient's tolerance to the tourniquet;
           - never use marcaine or any similar long acting anesthetic, since the medication will still be active when the tourniquet is deflated at the end of the case (causing a seizure);
    - double pneumatic touriquet is placed on arm;  (see tourniquets)
    - arm is exsanguinated either by elevating the extremity for 4 min or by wrapping it carefully iwth an elastic bandage;
           - it is essential that the esmarch is applied as tightly as possible inorder to achieve best results;
           - in the prospective study by Tham and Lim, the authors assessed a modification to Bier's IV regional anaesthesia which introduced a third temporary distal forearm tourniquet;
                   - this confined the injected lignocaine to the hand, resulting in a higher local lignocaine concentration;
                   - subsequent exsanguination of the limb then channels the remaining intravascular lignocaine under the distal cuff of a double tourniquet;
                   - of the 18 patients, none experienced pain during operation and all tolerated the tourniquet without significant discomfort;
                   - no other anaesthetic complications were encountered;
    - more proximal of the two cuffs is inflated to 250-300 mm Hg;
    - lidocaine is injected;
    - if tournequet pain develops, the distal tournequet is inflatted & then proximal tournequet is released;
    - after 30-45 min, most of the lidocaine has been bound to tissues in forearm, therefored, removing the tourniquet at this time does not release a large dose of lidocaine into the general circulation

- steven schwam



Evaluation of the myotoxicity of bupivacaine in bier blocks--a biochemical and electron microscopic study.

A modification of the technique for intravenous regional blockade for hand surgery.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, August 3, 2012 11:15 am