1. BIER BLOCK Developing Countries Regional Anesthesia Lecture Series Daniel D. Moos CRNA, Ed.D. U.S.A. moosd@charter.netmoosd@charter.net Lecture 16 Soli Deo Gloria

2. 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.

3. Advantages  Easy to administer  Rapid recovery  Rapid onset  Muscle relaxation

4. Type of surgery  Open procedures of the hand or lower arm  Closed reductions of the hand or lower arm

5. Limitation  Time!  Ideal for procedures lasting 40-60 minutes  Maximum time limit is 90 minutes  Tourniquet pain generally starts after 20-30 minutes

6. 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!

7. Mechanism of Action  Not clearly understood.  Local anesthetics, ischemia, asphyxia, hypothermia, and acidosis all may play a role.

8. Mechanism of Action Adapted from Rosenberg and Heavner, 1985

9. Equipment  Operative and reliable double toruniquet  Running IV in non-operative arm  Resuscitation equipment  Eschmark bandage

10. 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

12. Technique

13.  IV catheter in operative arm as distally as possible

14. Technique  Double tourniquet on the operative arm. Proximal Cuff Distal Cuff

15. Technique  Have patient hold arm up.  Use Eschmark to exsanguinate the arm  Exsanguinate the arm from distal to proximal.

16. Inflate the proximal tourniquet to 150 mmHg over the patients systolic pressure Proximal Cuff Distal Cuff

17. Confirm the absence of a radial pulse

18. Inject your local (0.5% lidocaine or prilocaine in a dose of 3 mg/kg)

19. Remove IV catheter, hold pressure and have OR staff prep arm. Onset of anesthesia should occur in 5 minutes

20. When the patient complains of pain you can inflate the distal tourniquet and then deflate the proximal tourniquet Proximal Cuff Distal Cuff1st 2nd

21. 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

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. References  Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3 rd 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, 4 th 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, 4 th edition. New York: Lange Medical Books.  Wedel, D.J. & Horlocker, T.T. Nerve blocks. In Miller’s Anesthesia 6 th 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.