Bier Block

Question 1

How does the bier block work?

Answer 1

Exsanguinate extremity by compression and occlude with pneumatic tourniquet

Question 2

What types of cases is the bier blocked used in?

Answer 2

Hand/forearm

Can use in lower extremity in leg/foot

Question 3

What is the limiting factor of the bier block?

Answer 3

Duration: 90-120m

Question 4

At what point might the tourniquet become very painful to the patient?

Answer 4

After 30-45 minutes

Question 5

What type of tourniquet must be used for a bier block?

Answer 5

Double wide cuff, two ports that are capable of having two different pressures

Question 6

What type of IV should be placed in a patient receiving a bier block and where should it be placed?

Answer 6

IV 22g or less with the cannula as distal as possible on operative extremity

Question 7

How can the provider aid in promoting venous drainage from the extremity?

Answer 7

Elevate the extremity

Question 8

What is the purpose of the esmarch elastic bandage?

Answer 8

To exsanguinate all of the vascular tree of the extremity

Question 9

What can occur if the esmarch bandage it wrapped too tightly around a ganglion cyst?

Answer 9

Could rupture the cyst

Question 10

When placing the tourniquet on the patient, why is it important to know the difference between the two port sites?

Answer 10

One is proximal and one is distal, need to know this for inflation

Question 11

In what order should the tourniquet be inflated when performing a bier block?

Answer 11

Distal cuff first then the proximal and then deflate the distal

Question 12

What is an appropriate pressure to inflate the tourniquet to?

Answer 12

50-100mmHg greater than the systolic

Question 13

What is the maximum amount to inflate the tourniquet in the upper and lower extremity?

Answer 13

Max 300 in arm

Max 400 in leg

Question 14

Why do we deflate the distal cuff once the proximal has been inflated?

Answer 14

So LA can get under the distal cuff to anesthetize the area

Question 15

What is the importance of tourniquet bounce?

Answer 15

Bounce indicates that the cuff is inflated

Question 16

What type of LA should be used when performing a bier block?

Answer 16

Lidocaine 0.5% preservative free, WITHOUT vasoconstrictor

Question 17

How much volume should be injected for a bier block?

Answer 17

30-50mL

Question 18

What is the onset of a bier block?

Answer 18

About five minutes, may complain of hot, burning, pins and needles sensation

Question 19

What should be done to the catheter once LA is injected?

Answer 19

Should be taken out and firm pressure should be held on the site to prevent LA from bleeding out

Question 20

What is the goal of a bier block?

Answer 20

To exsanguinate all of the vascular system in the extremity and fill it with LA

Question 21

Why might the provider hold the wrist tightly while injecting the LA in a bier block?

Answer 21

Acts as a tourniquet to keep LA in area for longer period of time

Question 22

If a patient begins to complain about tourniquet pain, what can the provider do to relieve this?

Answer 22

Inflate the distal tourniquet where LA has anesthetized the area and then deflate the proximal cuff after confirming the distal is inflated

Question 23

Why must tourniquet time be greater than 20-30m?

Answer 23

Gives time for the LA to be metabolized, otherwise they will receive a large bolus IV and may experience LAST

Question 24

How should the provider proceed if the tourniquet is 20-40m long?

Answer 24

Release briefly then immediately reinflate, observe 1m for LAST
Repeat the process if no signs of LAST, deflate and remove

Question 25

How should the provider proceed if the tourniquet time is greater than 40m?

Answer 25

Deflate slowly and observe for signs of toxicity

Question 26

What are complication associated with a bier block?

Answer 26

Premature release of LA often associated with tourniquet failure –> May result in LAST
Hematoma
Engorgement of extremity
Eccymoses and subcutaneous hemorrhage

Question 27

How should the provider treat a patient that may be experiencing LAST?

Answer 27

Quickly isolate the extremity and support ventilation/circulation