BIER BLOCK Developing Countries Regional Anesthesia Lecture Series Daniel D. Moos CRNA, Ed.D. U.S.A. Lecture 16 Soli Deo Gloria

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.

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

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

Limitation  Time!  Ideal for procedures lasting minutes  Maximum time limit is 90 minutes  Tourniquet pain generally starts after minutes

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!

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

Mechanism of Action Adapted from Rosenberg and Heavner, 1985

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

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

Technique

 IV catheter in operative arm as distally as possible

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

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

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

Confirm the absence of a radial pulse

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

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

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

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

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

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 (1), 2006.

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 (1), 2006.

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 (1), 2006.

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.

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 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

References  Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3 rd edition. Nagelhout, JJ & Zaglaniczny KL ed. Pages  Rosenberg, P.H., Heavner, J.E. (1985). Multiple and complementary mechanisms produce analgesia during intravenous regional anesthesia. Anesthesiology, 62,  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 Elsevier, Philadelphia, Penn  Wedel, D.J. & Horlocker, T.T. (2008). Peripheral nerve blocks. In D.E. Longnecker et al (eds) Anesthesiology. New York: McGraw-Hill Medical.