Pain and regional anaesthesia13 / 13
Bier block and early cuff deflation24-year-old man, 75 kg, healthy and very anxious
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Know this first
- Lidocaine about 3 mg/kg (40 mL of 0.5% for 65–70 kg); never bupivacaine.
- Cuff at 300 mmHg or 2.5 times systolic; at least 20 minutes up.
- 20–40 min: deflate, reinflate at once, final deflation after 1 minute; after 40 min, single deflation.
- Seizures have occurred after only 1.4 mg/kg of lidocaine.
The patient
24-year-old man, 75 kg, healthy and very anxious, for excision of a ganglion on his left hand under IV regional anaesthesia.
Plan: double-cuff tourniquet and 40 mL of preservative-free 0.5% lidocaine without adrenaline.
Vitals: BP 132/78, HR 96, SpO2 99% on air, RR 16.
The examiner asks
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Consider
What are your considerations?
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- A healthy, anxious 24-year-old for short hand surgery under IV regional anaesthesia. Patient
- The danger is lidocaine reaching his circulation if the cuff fails or is released early. Disease
- Lidocaine or prilocaine only; bupivacaine's cardiotoxicity rules it out.
Prepare
How do you prepare?
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- A cannula on the back of his left hand, and a second in the other arm for drugs. Surgery
- Full monitoring, resuscitation kit, lipid emulsion and midazolam ready. Crisis
- I test both cuffs and agree the inflation and deflation order before starting. Surgery
- Midazolam 1–2 mg for his anxiety, so he can still tell me how he feels. Patient
Plan
Take me through the block.
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- Elevate his arm and exsanguinate it with an Esmarch bandage. Surgery
- I set the cuff at 300 mmHg, or 2.5 × his systolic, and confirm the radial pulse has gone.
- 0.5% lidocaine, about 3 mg/kg, slowly into a hand vein, never the antecubital fossa.
- The cuff stays up at least 20 minutes, even if surgery ends sooner.
- Between 20 and 40 minutes: deflate, reinflate at once, then deflate after a minute.
- His blood level rises with time after release, so monitoring continues through and after it. After surgery
Crisis
Eight minutes after injection the cuff suddenly deflates. He reports ringing in his ears, then has a seizure; HR 42, BP 88/50. What do you do?
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- LAST algorithm: tinnitus, then seizure and bradycardia after early cuff deflation. Crisis
- Call for help and the LAST kit; airway, 100% oxygen, support his breathing.
- Midazolam 1–5 mg IV through the cannula in his other arm.
- Lipid 20% early: over 70 kg, 100 mL over 2–3 minutes, then 250 mL over 15–20 minutes.
- Bradycardia with low pressure: small adrenaline doses below 1 mcg/kg; vasopressin is avoided.
- If he stays unstable, give the bolus again and run the infusion at twice the rate; lipid ceiling 12 mL/kg.
- Observe him 4–6 hours after cardiovascular instability. After surgery
Fatal mistakes
- Bupivacaine for IV regional anaesthesia.
- No cannula in the other arm.
- Releasing the cuff before 20 minutes.
- Adding adrenaline to the IVRA solution.
Checked against: Barash 9e · Miller 10e · ASRA Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version
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