Local Anesthetics: Clinical Application as Intravenous Regional Anesthesia

The Bier block technique, or intravenous regional anesthesia, uses exsanguinated or blood-drained vessels to transport local anesthetics to peripheral nerve trunks. An IV cannula is placed near the surgery site, the arm is raised and bandaged to drain blood, then a tourniquet is inflated around the proximal arm to isolate veins from systemic circulation. Local anesthetic is injected through the cannula, achieving complete anesthesia within 10 minutes.

The tourniquet must stay inflated for at least 30 minutes to prevent local anesthetics from entering the systemic circulation. Premature deflation causes pain to return quickly and releases toxic levels of anesthetic into circulation, risking systemic toxicity and adverse effects on the patient's health and safety.

Lidocaine without vasoconstrictors like epinephrine is most commonly used for intravenous regional anesthesia. Other suitable agents include prilocaine, ropivacaine, and chloroprocaine. Bupivacaine is not recommended due to its high cardiac toxicity, making it unsafe for this technique and limiting its clinical use.

Intravenous regional anesthesia offers rapid onset of action, achieving anesthesia within five minutes after injection for efficient pain control during procedures. The procedure can be performed on an outpatient basis, avoiding general anesthesia risks. It requires minimal additional equipment and can be done in a simple clinical environment.

The Bier block technique is limited to certain areas like the arm and has disadvantages including quick pain return after tourniquet deflation and high systemic toxicity risk. Contraindications include hypersensitivity to local anesthetics, deep vein thrombosis, impaired limb perfusion, hypertension, open wounds, and significant limb injuries.

Exsanguination removes blood from the arm to create a clear pathway for local anesthetic distribution to peripheral nerve trunks. The arm is raised to drain blood passively, then tightly bandaged starting from the cannula insertion site to obstruct blood flow. This blood-drained state allows the injected anesthetic to reach target nerves effectively.

Complete anesthesia of the extremity is achieved within 10 minutes after local anesthetic injection. However, the tourniquet must remain inflated for at least 30 minutes to maintain anesthetic effect and prevent systemic toxicity. Pain returns quickly once the tourniquet is deflated and anesthetic enters systemic circulation.