Intravenous Regonal Anaesthesia Biers Block

Update in Anaesthesia
28
INTRAVENOUS REGIONAL ANAESTHESIA - BIERS BLOCK

Dr Natasha Clark, Royal Devon & Exeter Healthcare NHS Trust, Barrack Road, Exeter, Devon EX2 5DW.
Intravenous regional anaesthesia (IRVA) was first described by

Augustus Bier in 1908; his technique was repopularised by
Holmes in 1963. The administration of intravenous local
anaesthetic in an isolated limb by means of an ischaemic cuff is a
simple and effective technique, with a low incidence of failure
and high degree of safety.
Clinical Application
IVRA is ideally suited to operations of the distal arm or leg (i.e.
below the elbow or knee), such as reduction of a radial or ulna
fracture. IVRA is useful for only short surgical procedures;
performed in 40 minutes or less (the length of operating time is
limited by tourniquet pain, which usually develops after 40 to 60
minutes.
IVRA is often a safer option than general anaesthesia, particularly
if the patient is elderly, or has cardiovascular or respiratory disease.
Of particular importance in hypertensive patients, the tourniquet
cuff used must be sealed and inflated to the correct pressure (see
below).
Contraindications to IVRA
Severe Raynauds Disease (intermittent arteriolar
vasospasm of the distal limbs after cold or emotional stimuli).
Sickle Cell Disease (IVRA is relatively contraindicated,

unless meticulous exsanguination of the limb takes place prior to
cuff inflation).
Crush injury to the limb, IVRA may provoke further tissue

damage secondary to hypoxia.
Drugs Required For IVRA

Prilocaine is the local anaesthetic agent of preference because
of its high margin of safety (it has a high therapeutic index).
40ml of 0.5% prilocaine is recommended, although larger
volumes will be required for lower limb IVRA (60ml). The
maximum dose is 400mg for a 70kg adult (approximately 6mg/
kg) which equates to 80ml of 0.5% solution.
Lignocaine is a useful alternative agent. On average 40ml 0.5%
lignocaine is required. The maximum dose is 250mg for a 70kg
adult (approximately 3mg/kg), which equates to 50ml of a 0.5%
solution. Only plain solutions of prilocaine or lignocaine should
be used (without adrenaline).
Bupivacaine is unsuitable for IVRA and should never be used
due to its cardiotoxic profile (leading to ventricular arrhythmias
and death).
IVRA Technique (Figure 1)
Attach patient to ECG monitor and measure the blood
pressure.
Insert a cannula as distal as possible in the limb to be

operated upon.
Insert a second cannula into the opposite arm for

intravenous access (in case of emergency).
Exsanguinate the limb either with an Esmarch rubber

bandage of by simply elevating the limb for several minutes,
with brachial / popliteal artery occlusion.
Age - young children are generally not amenable to IVRA

alone, however in combination with sedation and additional
analgesia it can be used successfully.
Patients should be starved, as there may be a possibility of

conversion to a general anaesthetic, alternatively the patient may
require sedation in addition to IVRA to improve co-operation.
Equipment Required For IVRA
A single or double tourniquet cuff that that has been checked

to ensure that it does not leak, and can be inflated 50 to 100mmHg
above the patients systolic blood pressure.
Two intravenous cannulae, one for venous cannulation distal

to the tourniquet and one for cannulation in the opposite arm to
allow access to the circulation if required in the event of
complications.
Full resuscitation equipment and ECG monitoring at all

times including immediately after tourniquet deflation.
Figure 1: Biers Block
Update in Anaesthesia
Protect the upper part of the limb with wadding before

placing and inflating the tourniquet to 50 - 100mmHg above their
systolic blood pressure (typically 200 to 250mmHg). Check for
an absent distal pulse on the limb (radial or dorsalis pedis). During
the operation the tourniquet should be observed continuously to
check for unintentional slow deflation.
29
Management of Systemic Toxicity of

Local Anaesthetics
Airway - Maintain the patients airway, administer

100% oxygen and call for help. Turn the patient
onto their side; lower their head if possible to prevent
aspiration.
Breathing - start ventilation if breathing inadequate.

Intubate if indicated.
Circulation - pulse check. If in cardiac arrest start

CPR. Assistant to start monitoring ECG, pulse
oximetry, and blood pressure.
The tourniquet must remain inflated for a minimum of 20

minutes from the time of local anaesthetic injection.
Convulsions - IV 5mg diazepam or 50mg - 200mg

thiopentone. Muscle relaxation if required.
Surgical procedures lasting longer than 40 minutes may

result in the patient complaining of tourniquet pain, this can be
reduced by the use of a double cuffed tourniquet - initially the
uppermost cuff is inflated and this can be switched to the lower
cuff. The addition of 150mcg clonidine to the local anaesthetic
solution may reduce tourniquet discomfort and thus improve
conditions. Alternatively, intravenous analgesia such as fentanyl,
or ketorolac can be administered (via the emergency IV cannula
in the other hand).
Hypotension - IV ephedrine 3-6mg increments,

elevate legs, IV fluid bolus
Inject the local anaesthetic solution slowly via the IV

cannula and inform the patient that the limb will feel a little strange
and become mottled in appearance. An assistant gripping the
forearm during local anaesthetic injection will ensure the most
of the anaesthetic solution is retained distally.
Surgical preparation and draping may proceed about 5

minutes after local anaesthetic injection.
At the end of the procedure the IVRA cannula is removed

and the cuff deflated - close observation of the patient is crucial
at this point, as this may result in systemic release of local
anaesthetic. The patients blood pressure should be measured and
ECG monitoring continued for at least 10 minutes following cuff
deflation.
Complications
IVRA is generally a safe technique. The most important
complication to recognise is a leaking or accidentally deflated
tourniquet cuff - this will result in a large volume of local
anaesthetic being rapidly introduced into the circulation. The
patient may develop dizziness, nausea, vomiting, tinnitus, perioral
tingling, muscle twitching, loss of consciousness, and
convulsions. Avoidable deaths have occurred.
Summary
IVRA is a simple and effective regional anaesthetic technique to
perform, provided that the cuff is checked, and its pressure
monitored.
Resuscitation and monitoring equipment should be readily
available when conducting IVRA.
References
1. Gentili M Bonnet F Bernard JM. Adding clonidine to lidocaine
for IVRA prevents tourniquet pain. Anesthesia Analgesia
1999;88:1327-30.
2. Haasio J Hippala S Rosenberg PH. Intravenous regional
anaesthesia of the arm. Anaesthesia 1989;44:19 -21.
LETTER TO THE EDITOR

Dear Sir,
Recently we have been following the procedure that after spinal
anaesthesia we position the patient with a pillow to prevent postoperative headache. Why is this useful?
Staff nurse, Bhutan
Comment by Dr Michael Dobson
There is a tradition that patients should lie flat after a spinal
anaesthetic to prevent headache. Spinal headaches (after spinal
anaesthesia and lumbar puncture) are caused by CSF leaking out
of the hole in the meninges caused by the spinal needle. The
bigger the leak, the worse the headache. If a headache occurs it

is often relieved by lying down flat, but there is no evidence to
suggest that lying down actually prevents the headache.
In general, the bigger the hole in the meninges, the worse the
headache. I use only 27 or 25 gauge needles for spinals - with
these, the chance of a headache is only 1%, and it makes no
difference whether the patient lies flat or not. So the message is,
if you use a careful technique and use a fine needle, lying flat is
not necessary and patients can sit up after the block has worn off.

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Update in Anaesthesia

INTRAVENOUS REGIONAL ANAESTHESIA - BIERS BLOCK

Intravenous regional anaesthesia (IRVA) was first described by

Sickle Cell Disease (IVRA is relatively contraindicated,

Crush injury to the limb, IVRA may provoke further tissue

Drugs Required For IVRA

Insert a cannula as distal as possible in the limb to be

Insert a second cannula into the opposite arm for

Exsanguinate the limb either with an Esmarch rubber

Age - young children are generally not amenable to IVRA

Patients should be starved, as there may be a possibility of

Equipment Required For IVRA

A single or double tourniquet cuff that that has been checked

Two intravenous cannulae, one for venous cannulation distal

Full resuscitation equipment and ECG monitoring at all

Figure 1: Biers Block

Protect the upper part of the limb with wadding before

Management of Systemic Toxicity of

Airway - Maintain the patients airway, administer

Breathing - start ventilation if breathing inadequate.

Circulation - pulse check. If in cardiac arrest start

The tourniquet must remain inflated for a minimum of 20

Convulsions - IV 5mg diazepam or 50mg - 200mg

Surgical procedures lasting longer than 40 minutes may

Hypotension - IV ephedrine 3-6mg increments,

Inject the local anaesthetic solution slowly via the IV

Surgical preparation and draping may proceed about 5

At the end of the procedure the IVRA cannula is removed

LETTER TO THE EDITOR

bigger the leak, the worse the headache. If a headache occurs it

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