Chapter 107

The technique of intravenous regional anesthesia (IVRA) was first introduced by August Bier in 1908.1 IVRA essentially consists of injecting local anesthetic solution into the venous system of an extremity (upper or lower) that has been exsanguinated by compression and/or gravity and isolated from the central circulation by means of a tourniquet. Procaine in concentrations of 0.25% to 0.5% was injected through an intravenous cannula placed between two Esmarch bandages utilized as tourniquets to divide the arm into proximal and distal compartments in Bier’s original technique.2–4 He noted two distinct types of anesthesia. The first was an almost immediate onset of “direct” anesthesia between the two tourniquets. An “indirect” anesthesia distal to the distally placed tourniquet was noted after a delay of 5 to 7 minutes. This technique was eventually renamed the Bier block.

Bier performed dissections of the venous system of the upper extremity in cadavers after injecting methylene blue. He was able to determine that the “direct” anesthesia was the result of the local anesthetic agent bathing bare nerve endings in the tissues. The “indirect” anesthesia was most probably due to the local anesthetic agent being transported into the substance of the nerves via the vasa nervorum, where a typical conduction block is affected. Bier’s conclusion was that there were two mechanisms of anesthesia associated with his technique: peripheral infiltration block and conduction block.

The only major modification of Bier’s technique in the past 90 years has been the development of the double tourniquet technique in current clinical practice.5–7 The Bier block is appropriate for brief surgical procedures of the upper or lower extremity. However, the technique has certainly gained its greatest acceptance for use in the former case as tourniquet problems and safety issues seem to arise more frequently when IVRA is undertaken in the leg. The Bier block is a procedure that has found utility as a treatment adjunct for patients suffering from complex regional pain syndromes (CRPS, formerly reflex sympathetic dystrophy or sympathetically maintained pain) as an alternative to repeated sympathetic blocks. Chemical sympathectomy using IVRA with agents such as guanethidine or bretylium may last up to five days, as compared to local anesthetic blocks that typically provide analgesia lasting only hours.

Intravenous regional anesthesia is appropriate for procedures, surgeries, and manipulations of the extremities requiring anesthesia of up to one hour in duration. It is most suited for laceration repair, reduction of fractures and dislocations, burn care, and minor soft tissue procedures in the Emergency Department. The necessity of exsanguinating the extremity is a potentially painful maneuver that may preclude certain procedures from being undertaken with this technique. The Bier block is acceptable in the anticoagulated patient, a feature that distinguishes this technique from other regional anesthesia procedures (spinal block, epidural block, or plexus blocks).

The only absolute contraindication for IVRA is patient refusal. Relative contraindications include crush injuries of an extremity, the inability to obtain ...

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