Bier Block

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  • Surgery of appropriate duration on the hands, wrist, fingers, and forearm
  • Manipulation of forearm, wrist, and finger fractures
  • Surgery on the foot and ankle
  • Manipulation of fractures of the foot
  • Allergies to local anesthetics
  • Patient refusal
  • Disease processes in which a tourniquet is contraindicated
    • Raynaud’s disease
    • Sickle cell disease or trait
    • Seizure disorders
  • Presence of heart block
  • Presence of severe hypotension
  • Patient monitors
  • Resuscitation equipment
  • Sterile gloves
  • Intravenous access in a nonoperative site or limb
  • Sterile prep equipment: alcohol, Betadine, or noniodine (for patients with iodine allergy) scrub
  • 22-gauge or 20-gauge intravenous cannula in addition to intravenous access in nonoperative limb
  • Flexible extension tubing of short length to reduce dead space in tubing
  • 5-inch Esmarch bandage
  • Local anesthetic for infiltration of the skin
  • Small (30-gauge) needle and 3-mL syringe for local anesthetic skin infiltration
  • 20-mL syringes (2)
  • Intravenous local anesthetic solution
  • Sodium bicarbonate 8.4% for intravenous anesthetic solution adjunct
  • Double-cuff tourniquet with inline valves and pressure source
  • Kerlix or other soft wrap to be placed underneath the tourniquet

The distribution of the block is the area of the limb distal to the tourniquet.

Sample excerpt does not include step-by-step text instructions for performing this procedure
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  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures


Troubleshooting Problems

  • Tourniquet pain: Inflate the distal tourniquet cuff, and confirm it is inflated by palpating the cuff. Then deflate the proximal cuff.
  • Oozing at the surgical site: Reexsanguination of the limb before surgery may provide a drier surgical field but may also increase risk of local anesthetic systemic toxicity.
  • Inadequate analgesia: Augment the block with local injection of concentrated anesthetic by the surgeon or by administration of a sedative or general anesthesia.

Deflation of the Tourniquet

  • Do not deflate the tourniquet for at least 20-30 minutes following injection of the limb.
  • Rapidly releasing and reinflating the tourniquet several times in succession appears to allow only fractional doses of local anesthetic into the systemic circulation and may reduce toxicity.
  • Close monitoring of the patient’s ECG, blood pressure, and heart rate should be maintained for 5-10 minutes following deflation of the cuff.
  • Warn the patient that dizziness, tinnitus, and/or a metallic taste in the mouth may occur.
  • Delayed aftereffects do not appear to be a problem.

Postsurgical Care

The length of time for postsurgical recovery is largely dependent on the dose and effects of adjuvant sedation given during the procedure.


Early Complications

  • Systemic local anesthetic toxicity
    • Central nervous system signs and symptoms
      • Dizziness, tinnitus, metallic taste; usually transient
      • Loss of consciousness or seizures: treatment is airway control, administration of 100% oxygen, and administration of a barbiturate to control seizures.
    • Methemoglobinemia
      • Can cause cyanosis
    • Cardiovascular toxicity
      • Usually mild and transient
      • Includes a slight drop in blood pressure and heart rate upon release of the tourniquet
      • Can be exacerbated in patients with preexisting heart block

Late Complications

  • Few and generally transient
    • Thrombophlebitis
    • Complications related to tourniquet use: peripheral nerve damage, generally transient and rare
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