A Modern Approach to the Bier Block Technique

We describe our preferred technique of administering a Bier block for hand and upper extremity surgery using Lidocaine as the typical local anesthetic. The Bier block, also known as intravenous regional anesthesia (IVRA), can be used for various surgeries on the upper and lower limbs and involves the placement of a double tourniquet around an extremity followed by injection of a local anesthetic into the venous system of that extremity. The traditional Bier block technique offers the advantage of anesthesia in the operative extremity without the need to inject local anesthetic directly into the soft tissue (which tends to distort soft tissue planes and does not wear off as quickly) and without the need for general anesthesia. Our described technique aims to enhance the safety of this method of regional anesthesia and improve patient comfort. We can extend the indications for using a Bier block to include patients with large, short, or conical shaped arms and describe how to protect frail skin and exsanguinate the arm for best surgical outcomes.