Bier Block Flashcards
While performing a Bier block, you exsanguinate the
arm, inflate the tourniquet to 300 mmHg, and inject
50 mL of 0.5% lidocaine. Three minutes later, the
patient complains of a ‘pins and needles’ sensation
in his arm. What should you tell the patient?
On injecting the local anesthetic for a Bier block, the arm
discolors and the patient experiences a ‘pins and needles’
sensation over the next five minutes. You should reassure the
patient that this is normal and proceed as planned.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1026.
With what pre-existing conditions is a Bier block
contraindicated?
The performance of a Bier block is contraindicated in patient’s
with severe crush injuries to the arm as hypoxia may worsen the
potential outcome, uncontrolled hypertension because it would
increase the risk that arterial flow may not be occluded
sufficiently, and Raynaud’s disease or other forms of peripheral
vascular disease affecting the surgical limb. Homozygous sickle
cell is also a contraindication to the procedure.
Lee CY. Manual of Anesthesiology. Singapore: McGraw-Hill;
2006: 425-526.
What local anesthetic is most suitable for a Bier
block? Least suitable?
Lidocaine 0.5% is suitable for Bier blocks because of the low
risk of toxicity at the doses used at a minimum tourniquet time
of 20 minutes. Because of its high risk for prolonged
cardiotoxicity, bupivacaine is absolutely contraindicated for this
procedure.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 970.
What concentration and volume of lidocaine should
be used when performing a Bier block?
50 mLs of 0.5% lidocaine
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 970.
Most clinicians limit the use of a Bier block to
procedures lasting less than one hour. Why is this?
The pain from the tourniquet becomes intolerable to most
patients by about 45 minutes to an hour.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 1116.
To what pressure should you inflate the tourniquet
for a Bier block?
300 torr or 2.5 times the patient’s systolic blood pressure.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 970.
What is the minimum time the tourniquet should be
inflated when performing a Bier block? What is the
recommended technique for deflating the tourniquet?
To avoid a rapid bolus of intravenous local anesthetic that could
result in local anesthetic toxicity, the tourniquet should remain
inflated for a minimum of 15 to 20 minutes. Waiting an
additional 25-40 minutes as recommended in some sources
would prolong the surgical turnover time unnecessarily while
deflating the proximal tourniquet and then inflating the distal
tourniquet would not be an appropriate action in any situation.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1000-1001
What is the dual-tourniquet technique used in Bier
blocks and how is it performed?
Patients can tolerate a procedure under Bier block for a longer
period of time if a double-tourniquet is used. The distal cuff is
inflated first followed by the proximal cuff. The distal cuff is then
deflated to allow the area under it to become anesthetized. If
the proximal cuff of the tourniquet becomes too painful for the
patient to tolerate, the distal cuff can be inflated and then the
proximal cuff deflated to allow the surgeon more time to
complete the procedure.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 970.
