Intravenous Regional Anesthesia Bier Block

This block can be used for surgery involving the hand, forearm, or elbow. Examples include manipulation of forearm fractures, excision of wrist ganglia, and palmar fasciotomy. Local anesthetics diffuse from blood vessels to the surrounding soft tissues and nerves and provide anesthesia to the extremities when the circulation of the extremity is occluded with the aid of a tourniquet.

Technique Preparation

Arrange sterile towels, sterile gloves, gauze pads, Esmarch bandage, antiseptic solution, syringes, and needles for local infiltration and nerve block placement.


20 ml syringes oflocal anesthetic.


25 g 1.5 in. needle for skin infiltration.


3% chloroprocaine, 0.5% lidocaine, 0.5% ropivacaine.

Surface Anatomy and Landmarks Landmarks

The extremity to be anesthetized is elevated to drain blood as much as possible (gravity effect) subsequent to inserting an intravenous catheter as far distal in the extremity as possible. The intravenous catheter will later be used for injection of local anesthesia of the extremity to be anesthetized. A double bladder tourniquet is applied over a cotton padding that has been wrapped around the arm as far proximal as possible. The Esmarch bandage is used to exsanguinate the extremity of blood by circumferentially wrapping around the entire extremity beginning from the most distal portion up to the previously placed double bladder tourniquet while the extremity remains elevated. The most proximal bladder of the double tourniquet is then inflated to 100 mm Hg above the systolic blood pressure of the patient. The Esmarch bangade is then removed and preservative-free lidocaine, 0.5% up to a total of 30-50 cc, is injected into the previously placed intravenous catheter for surgical anesthesia.

For chronic pain conditions, drugs such as bretylium, reserpine, and methylprednisolone with lower concentrations of lidocaine may be injected for pain relief. For surgeries requiring longer periods of time (greater than 40-60 min) and to reduce tourniquet pain, the distal cuff can be inflated over the anesthetized area and the proximal cuff then deflated following confirmation of inflation of the distal bladder on the double tourniquet. It is recommended that at least 30 min elapse following the initial injection of lidocaine prior to slowly releasing the double bladder tourniquet. Release of the tourniquet can be done safely by deflating the tourniquet to just below the patient's systolic pressure for a few seconds, followed by quick reinflation. This is done repeatedly to permit slow wash out of the local anesthetic while constantly observing the patient for any signs of local anesthetic toxicity. Bier block is most commonly performed for surgery involving the upper extremity, but may also be used for surgeries of the lower extremity.

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