American Society of Regional Anesthesia and Pain Medicine February 2018 - 34

Intravenous Regional Anesthesia: A New Look at an Old Technique
BACKGROUND
More than a century has passed since Dr August Bier first
described vein anesthesia as a rapid-onset anesthetic technique
for extremity surgery. The process required exsanguination of
the extremity, application of a tourniquet, vascular cutdown for
access, and administration of local anesthetic. The technique was
considered cumbersome, and with the introduction of brachial
plexus blockade, it was largely forgotten. However, in 1963, C.
Holmes published a case series in Lancet using dilute lidocaine
for intravenous anesthesia, thus reviving interest in the anesthetic
technique.1
Today, the technique is commonly referred to as a Bier block or
intravenous regional anesthesia (IVRA). It has been refined over
the years and remains a core skill for anesthesiologists worldwide.
Although IVRA has been used for lower-extremity surgery, it is
most commonly performed on upper extremities for planned
surgical procedures 60 minutes or shorter in duration. Indications,
contraindications, advantages, and disadvantages as well as
potential adverse outcomes must be considered when selecting
IVRA as an anesthetic plan (see Table 1).
TECHNIQUE
IVRA is a simple, effective anesthetic technique with a reported
success rate of 96-100%.2 Preparation for the block should
ensure standard American Society of Anesthesiologists monitors
application, adequate nil per os status, and immediate access to
resuscitation equipment, including lipid emulsion. The technique
requires reliable intravenous access in the operative extremity
near the surgical site. Following Esmarch bandage exsanguination,
the tourniquet is inflated. Tourniquet use has several accepted

Cody Rowan, MD
Assistant Professor
Department of Anesthesiology
University of North Carolina
Chapel Hill, North Carolina

Elizabeth Wilson, MD
Assistant Professor
Department of Anesthesiology
University of Wisconsin
Madison, Wisconsin

Section Editor: Kristopher Schroeder, MD

approaches, including single or double tourniquet and proximal
(upper arm) or distal (forearm) tourniquet. Recently, use of a
forearm tourniquet has increased because of diminished tourniquet
pain and potentially improved safety with the use of decreased
local anesthetic volumes.3-5
Although optimal inflation pressure has not been determined, the
tourniquet is typically inflated to 100 mm Hg over systolic blood
pressure or to a minimum of 250 mm Hg.6,7 After the bandage
is removed, local anesthetic is injected into the cannulated
vein distal to the tourniquet. Dilute lidocaine (0.5%) is the most
commonly used local anesthetic, and the total dose should not

Table 1: Considerations for IVRA.
Indications
Extremity surgery
shorter than 60 min in
duration
Examples:
Carpal tunnel release
Dupuytren release
Neuroma excision
Fracture reduction

Contraindications
Absolute:
Sickle cell disease
Raynaud disease
Berger disease
A/V shunt
Local anesthetic allergy
Patient refusal
Relative:
Local Infection
Paget disease
PVD
Uncontrolled HTN
Crush injury

Advantages
Simple, reliable
Cost-effective
Rapid recovery of
function

Disadvantages
Limited to short
surgical procedures
Minimal postoperative
analgesic benefits

Bloodless field

Potential adverse events
LAST
Compartment syndrome
Nerve injury
Skin discoloration
Thrombophlebitis

Avoidance of general
anesthesia

Abbreviations: A/V, arteriovenous; LAST, local anesthetic systemic toxicity; HTN, hypertension; IVRA, intravenous regional anesthesia; PVD, peripheral
vascular disease.

34

American Society of Regional Anesthesia and Pain Medicine
2018



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