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Bier block uses
- -short (60 mins) procedures
- -superficial wrist and hand surgeries (ex: carpal tunnel)
- -rapid onset and recovery
What type of anesthesia is a bier block considered?
Bier block IV placement and gauge
- -IV as distal as possible on affected side
- -small gauge IV (22)
How high should the cuff be inflated?
- -150 mmHg greater than SBP
- -usually to 300 mmHg
How do we check the double tourniquet cuffs are working?
Absence of a pulse
What cuffs should be up / down when injecting the LA?
- Distal cuff down (so LA get get there)
- Proximal cuff up
General sequence of events for a Bier block
- -place 22g IV
- -check cuffs are working (no pulse)
- -elevate extremity and wrap with esmarch distal to proximal all the way up to distal cuff
- -inflate distal then proximal cuffs to 300 mmHg
- -unwrap esmarch
- -deflate distal cuff
- -inject LA over 5 mins
- -once patient c/o pain the distal cuff is inflated and the proximal cuff is deflated
What LA is used? How much?
50 ml of 0.5% lidocaine
Why does the LA need to be injected slowly?
So as not to overcome the tourniquet pressure (otherwise the medication would not be localized to the surgical site)
What s/sx could indicate lido toxicity?
Perioral numbness, metallic taste in the mouth
Other SE include: dizziness, tinnitus, bradycardia, seizures
Why is lido 0.5 % the LA of choice?
- -high therapeutic index
- -always plain lido (NO epi)
How long does the tourniquet need to stay inflated for to prevent toxicity?
- -At least 20-30 mins (sources vary)
- -This gives the tissues time to take up the LA
What size syringe should be used to inject the lido? Why?
- 50 cc
- Reduces the pressure in the syringe when the barrel is pushed
How should the cuff be deflated?
- -Cyclically so LA is leaked into the systemic circulation slowly
- -deflated in 10 second intervals with 1 min reinflation x 3
Bier block complications
- -Engorgement of the pt's extremity (pt with arteriosclerosis)
- -Hematoma (hence we use a small gauge IV)
- -Inadequate block
Bier block contraindications
- -sickle cell
- -ischemic vascular disease
- -traumatic lacerations, crush injuries
- -severe pain
- -severe post-op pain issues
- -extremity fx (pain limits exsanguination)
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