Bier Block (BB) or Intravenous Regional Anesthesia (IVRA) was first introduced by the German surgeon August Bier in 1908 (Bier also the one who reported postspinal headache after trial of spinal block to himself) by injecting 0.25 % -0.5 % Procaine directly to the vein.
The mechanism of action is explained by diffusion of the local anesthetic retrogradely from the injected vein to capillaries (those supplying the nerves) and then epineurium and endoneurium. Another possible component is the ischemia which may be a major determinant from the fact that the complete pinprick analgesia and motor block can be achieved in 20-25 min when saline is administered as in IVRA.

The advantages of this block include rapid onset and offset, ease of performing and control -ling the extent of anesthesia and a bloodless surgical field. The BB is ideally suited for soft tissue surgery less than 90 min. Unfortunately, the BB lost it’s popularity because the brachial plexus block becomes more reliable. Equipments Double tourniquet, local anesthetics without epi. (virtually any LA except for Bupivacaine ) , Esmarch, 2 IV setups with long extusion tubing. Technique First, establish 2 IVs - one in the distal aspect of the operative limb and one in the other limbs. Then, apply the double tourniquet (if not available, may use regular tourniquet or put 2 of regular tourniquets together if space allows) at the most proximal part of the limb.

Exsanquinate blood from the operative limb by way of gravity or Esmarch (may not applicable for fractured limbs).
Inflate the proximal cuff of double tourniquet to 300 mmHg or 2.5 times of the SBP. Then slowly inject the LA through the IV (diluted & large volume, no Epi). The total dose of LA is based on patient’s wt, i.e. 0.5 % lidocaine 40-50 ml for upper extremities.

If the surgery is short, the IV in the operative arm may be removed at this point or may be left in placed for dosing if longer operation is anticipated. The onset of analgesia is quick, however, after 30-45 min the pt may report discomfort secondary to tourniquet pain. In this case, inflate the distal cuff (which is numbed) and release the proximal cuff.

For procedure < than 20 min, release the tourniquet very slowly as the LA will enter the systemic circulation. After 40 min, the single cuff deflation is possible. Between 20-40 min, deflate & reinflate the cuff at 10 sec intervals to minimize the sudden release of LA into the systemic circulation.

Phlebography (performed instead of IVRA) of the arm of a female volunteer. The Tourniquet cuff pressure was 250 mmHg, and 50 ml of contrast medium was injected at a rate of 1 ml/s. Note the filling of axillary veins with contrast medium already in the first (15 s) roentgenogram (curved arrow). The straight arrows indicate narrow contrast medium streaks under the inflated cuff.

Limitation & Side effects.

The LA toxicity is the main concern with a Bier’s Block. Deaths have been reported with bupivacaine. The rapid offset requires planning for control of postop pain. In addition to tourniquet discomfort in long procedures, other rare complications include tourniquet induced n. injury, compartment syndrome and loss of limb.

References
1. Barash PG, Cullen BF, Stoelting RK : Clinical Anesthesia 3rd ed, pp 892-893, 1997
2. Miller RD, Cucchiara RF, Miller ED, Jr, et al. Anesthesia. 5th ed. Philadelphia: Churchil Livingstone;2000