Intravenous regional anesthesia (IVRA) or Bier's block anesthesia is an anesthetic technique on the body's extremities where a local anesthetic is injected intravenously and isolated from

circulation Circulation may refer to: Science and technology * Atmospheric circulation, the large-scale movement of air * Circulation (physics), the path integral of the fluid velocity around a closed curve in a fluid flow field * Circulatory system, a bio ...

in a target area. The technique usually involves exsanguination of the target region, which forces blood out of the extremity, followed by the application of

pneumatic Pneumatics (from Greek ‘wind, breath’) is a branch of engineering that makes use of gas or pressurized air. Pneumatic systems used in Industrial sector, industry are commonly powered by compressed air or compressed inert gases. A central ...

tourniquets to safely stop blood flow. The anesthetic agent is intravenously introduced into the limb and allowed to diffuse into the surrounding tissue while tourniquets retain the agent within the desired area.

History

The use of tourniquets and injected anesthesia to induce localized anesthesia was first introduced by

August Bier August Karl Gustav Bier (24 November 1861 – 12 March 1949) was a German surgeon. He was the first to perform spinal anesthesia and intravenous regional anesthesia. Early medical career Bier began his medical education at the Charité – Uni ...

in 1908. He used an

Esmarch bandage Esmarch bandage (also known as Esmarch's bandage for surgical haemostasis or Esmarch's tourniquet) in its modern form is a narrow (5 to 10 cm wide) soft rubber bandage that is used to expel venous blood from a limb (exsanguinate) that has ...

to exsanguinate the arm and injected procaine between two tourniquets to rapidly induce anesthetic and

analgesic An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...

effects in the site. Though it proved effective, IVRA remained relatively unpopular until C. McK. Holmes reintroduced it in 1963. Today, the technique is common due to its economy, rapid recovery, reliability, and simplicity.

Methods

Protocols vary depending on local standard procedures and the extremity being operated on. A vast majority of practitioners begin by exsanguinating the limb as Bier did with an elastic bandage (

), squeezing blood

proximal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position ...

ly toward the heart, then pneumatic tourniquets are applied to the limb and inflated 30mmHg above arterial pressure to occlude all blood vessels and then the elastic bandage is removed. A high dose of local anesthetic, typically

lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...

or prilocaine without adrenaline, is slowly injected as

distal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

ly as possible into the exsanguinated limb. The veins are filled with the anesthetic, with the anesthetic setting into local tissue after approximately 6–8 minutes, after which the surgery, reduction, or manipulation of the region may begin. It is important that the region is isolated from active blood flow at this time. Analgesic effect typically remains for up to two hours depending on the dosage and type of anesthetic agent being used. The wait time and isolation of blood flow from the region is important for avoiding an overdose of the anesthetic agent in the blood which can lead to hypotension, convulsions,

arrhythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

and death. Cardiotoxic local anesthetic agents like bupivacaine and etidocaine are strictly contraindicated.

Safety

The safety and effectiveness of IVRA is well established in clinical literature. However, cardiotoxic local anesthetic agents like bupivacaine and etidocaine are contraindicated. Shorter procedure times (for up to 2 hours) are preferred when IVRA is applied on the distal limb, especially on the forearm, except when the patient has contraindications to tourniquet use (such as in sickle cell anemia, where there is a risk of massive hemolysis due to low oxygen tension or hemolytic crisis due to restricted blood flow). A systematic review of IVRA-related complications found 64 cases reported between 1964 and 2005, which compares favorably against other techniques. The type of anesthetic agent, improper equipment use or selection, and technical error are prominent factors in most cases of morbidity related to IVRA. Modern practice now includes various safeguards to improve patient safety.

Equipment

Reports from anesthesiologists and surgeons cite proper selection, inspection, and maintenance of equipment as important safety measures. The safest tourniquet equipment should have IVRA-specific features such as independent limb occlusion pressure measurements for each channel, as well as dual-bladder tourniquet cuffs combined with dedicated safety lockouts that reduce human error. Additionally, IVRA protocols should include procedures for regular preventative maintenance of the equipment and performance testing, whether manual or automated, prior to surgery.

Drug additives

Adjuvants improve the safety of IVRA by promoting anesthetic action and minimizing side effects. For example, benzodiazepine and fentanyl are often added to prevent seizures and to improve nerve blockage, respectively.

Procedural safeguards

Improved protocols, including adherence to standardized practice, may also help ameliorate the chance and the effect of complications. For example, limb protection padding and a snug tourniquet application prevents tissue damage, while sufficient but not excessive tourniquet pressure ensures that anesthetics remain within the limb without risking injury. Care should be taken to avoid the premature release or a lack of inflation in the cuff. Should complications occur, constant physiological monitoring and ready access to resuscitative drugs and equipment facilitates a speedy response.

References

{{Reflist, 1

External links

Advances in IVRA Instrumentation
Regional anesthesia