Anesth Analg 2006;103:257
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215220.95927.3F
LETTER TO THE EDITOR
A Useful Modification of the Bier’s Block
Ling Ye,
Jin Liu, MD, and
Tao Zhu, MD
Department of Anesthesiology; West China Hospital; Sichuan University; Chengdu, P.R. China; wuliujin{at}china.com
To the Editor:
The Bier block is a method of IV regional anesthesia (IVRA) that can adequately block nerves to the distal arm or leg (1). The Bier block is disadvantageous under several conditions. In short procedures, if the tourniquet is deflated soon after the injection of local anesthetics, potential local-anesthetic toxicity may develop. In long cases, the tourniquet may become painful. Furthermore, Reuben et al.’s study (2), comparing conventional, upper-arm and forearm IVRA, found that forearm IVRA was safe and effective for patients undergoing ambulatory hand surgery. Compared with upper-arm IVRA, forearm IVRA provided perioperative analgesia, longer-lasting sensory block, and prolonged postoperative analgesia. Because the dose of local anesthetics was reduced by 50%, forearm IVRA may also be safer.
We present an ultra-short day surgery case in which we used a novel technique to overcome potential risks of local anesthetic toxicity. A 43-yr-old, healthy male patient, 170-cm tall, weighing 60 kg, was scheduled for elective surgery on his right forefinger. We inserted an IV cannula into the dorsum of the right hand and applied the usual IVRA tourniquet on the patient’s upper arm. In addition, before slowly injecting 7-mL 0.5% lidocaine into the indwelling cannula, we applied the 2-cm-wide rubber tourniquet (used to insert the cannula) to the wrist. After 10 min surgery was completed. We deflated the arm tourniquet and removed the rubber tourniquet. The patient reported feeling well, without any pain, tinnitus, dizziness, or transient drowsiness. Ten minutes later, he was discharged.
The rubber tourniquet confined the local anesthetic to the hand, permitting us to decrease the dose and the possibility of toxicity. The total amount of lidocaine was just 35 mg, less than used to treat arrhythmia in awake subjects. As a result, the tourniquet could be safely released as soon as surgery concluded, without waiting the recommended 25 min after block placement (3).
In our view, selective IVRA may be a faster and safer method of regional anesthesia for very brief hand procedures, although this requires confirmation in clinical trials.
REFERENCES
- Bier A. A new method for anaesthesia in the extremities. Ann Surg 1908;48:780.
- Reuben SS, Steinberg RB, Maciolek H, et al. An evaluation of the analgesic efficacy of intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm tourniquet Anesth Analg 2002;95:457–60.[Abstract/Free Full Text]
- Miller RD. ed. Miller’s aesthesia. 6th ed. Philadelphia: Churchill Livingstone, 2005:587.
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