Bier's Block

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Background

• IntraVenous Regional Anaesthesia (IVRA) is better than haematoma block in forearm fracture reduction [BestBets].
• It is important to have two clincians present; one performing the Bier’s block and the other doing the procedure.
• This block would be used typically for the manipulation of a forearm fracture.
• If the patient attends late at night with a forearm fracture and you plan a manipulation the following morning it is best to contact the anaesthetist on-call at the time of presentation of the patient to plan the MUA and NOT when the patient returns the following morning.

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Please make use of the Bier's Block Documentation Sheet.

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Preparation / Procedure

1. Perform procedure on a tipping trolley, with resuscitation equipment nearby.
2. Explain the procedure and gain consent (preferably written).
   1. Side-effect of procedure - cuff discomfort
   2. Risk - fracture may require re-manipulation, block may fail, skin may tear.
   3. Very low risk of toxicity from local anaesthetic.
   4. If this occurs the main problems are seizures and dysrhythmias
3. Attach the tourniquet machine to the wall supply of piped oxygen. The red “supply” indicator should turn from red to green. Ensure that all the tubes are tightly secured at all their connections, and correctly attached. Test both cuffs to ensure that they are fully functional with no leaks, and make certain that both cuffs are empty of air before the tourniquet is applied.
4. Obtain bilateral venous access: A 22G venflon (blue) is adequate
5. Apply and document results of monitoring in the Bier's Block Documentation Sheet
   1. Automated blood pressure. 2. Pulse oximetry. 3. ECG lead II
6. Apply wool to humerus of affected limb.
7. Apply the cuff over the wool. Note that the cuff must be closely applied to the arm throughout its entire circumference, and that the dark red lining of the cuff should overlap by at least 5cm.
8. Write down in the Bier's Block Documentation Sheet notes your calculation of volume of prilocaine, and prepare the drug. Dose (3 mg / kg of prilocaine).
9. Elevate the arm for one to two minutes.
10. Then inflate the proximal (blue) cuff to at least 100mmHg above the systolic BP.
    1. Palpate the brachial or radial pulse and feel it disappear during cuff inflation.
    2. Ensure that the cuff is indeed inflated (by manually checking it) and then lower the arm, which should remain white with poor capillary refill and flat veins.
    3. If there is any doubt as to the effectiveness of the tourniquet do not inject the prilocaine and seek senior medical advice.
11. Warn the patient that the local anaesthetic may sting and that their arm will become mottled.
12. Inject the required volume of prilocaine SLOWLY into fractured limb. Then remove the cannula on the injured side.
13. Manipulate fracture when wrist is non-tender to deep pressure, ( circa 8 minutes)
14. Apply POP - ideally backslab or a split complete plaster.
15. The cuff must remain inflated for a minimum of 30 minutes(max of 60 min)
16. Monitor the patient for signs of toxicity for 30 minutes post-procedure

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Can I use lignocaine?

• Lignocaine can be used if prilocaine is not available.
• Use 3 mg/kg of 0.5% lignocaine.
• To make up 0.5% lignocaine dilute 1% lignocaine with an equal volume of normal saline.

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Contents by Dr Íomhar O' Sullivan 02/03/2003. Reviewed by Dr ÍOS 20/05/2005, 27/03/2007.   Next review 27/03/2008.