Bier block gone... terrible

Started by Propofool123
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Propofool123

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50 kg female coming in for carpal tunnel release in the OR and surgeon prefers Bier blocks. Our typical practice is to inject 3 mg/kg of 0.5% Lidocaine. Let’s say someone accidentally injects 0.5% Bupivicaine instead and realized after injecting the medication but prior to tourniquet release. You try aspirating the medication back out of that IV but you can’t. What would you do?
 
Propofool123 said:
50 kg female coming in for carpal tunnel release in the OR and surgeon prefers Bier blocks. Our typical practice is to inject 3 mg/kg of 0.5% Lidocaine. Let’s say someone accidentally injects 0.5% Bupivicaine instead and realized after injecting the medication but prior to tourniquet release. You try aspirating the medication back out of that IV but you can’t. What would you do?
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That is a bad situation. We have multiple safety checks in place to prevent exactly this from happening. Stuff like this does happen from lack of vigilance (there was a case several years ago where 8.4% sodium bicarbonate was injected and that led to limb loss). As for bupi, I dont know if giving intralipid through that tourniquet arm would help? Be prepared for all sorts of badness when the tourniquet is released
 
Propofool123 said:
50 kg female coming in for carpal tunnel release in the OR and surgeon prefers Bier blocks. Our typical practice is to inject 3 mg/kg of 0.5% Lidocaine. Let’s say someone accidentally injects 0.5% Bupivicaine instead and realized after injecting the medication but prior to tourniquet release. You try aspirating the medication back out of that IV but you can’t. What would you do?
Click to expand...

This actually happened to a world famous hand surgeon at one of the name brand hospitals in the 1980s. He was delayed and didn't want to wait. So he did the block himself. patient had some neurologic damage post arrest.
 
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I think the intralipid is a good idea, followed by slow, controlled release of the tourniquet over an hour (or more?). Alert bypass team and ICU, get other help for the OR, pause and huddle with the rest of the room staff so they know what to expect as the tourniquet comes down. It’s plausible that with slow release, nothing happens.
 
Intralipid..art line..central line. Slow intermittent tourniquet release

Maybe put in brachial arterial line..and flush saline into the arm while draining via an IV.
 
Happened at my place but the tourniquet was up. We started an intralipid drip, then added an elastic tourniquet proximal to the larger one. Over the course of about 90 minutes we would lower the measured tourniquet pressure very briefly then reinflate and then quickly lower the elastic tourniquet, hoping that the bupiv would get released from the arm little by little. Fortunately, they did fine and never showed any arrhythmia. We also injected some saline into the veins to hopefully dilute the bup.
 
New anesthetist. Had not done a Bier block in training. Asked my partner what he wanted for the block and he replied "half marcaine" thinking they were talking about an adductor canal for a different patient. MD did not check the vial before injecting the 50cc syringe. Swiss cheese model. Got lucky there was no harm.
 
camkiss said:
New anesthetist. Had not done a Bier block in training. Asked my partner what he wanted for the block and he replied "half marcaine" thinking they were talking about an adductor canal for a different patient. MD did not check the vial before injecting the 50cc syringe. Swiss cheese model. Got lucky there was no harm.
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You don't need that much for a bier block. I do 20-30
 
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The risk/benefit ratio of a Bier block should not be worth it for anybody. I refuse to do them. Even one complication is too many. And if I get fired for not doing a Bier block, good for me.

One of my former highly-experienced colleagues had a cuff leak, patient seized on the table. This is the kind of thing that will happen even to the best of anesthesiologists. It's just a bad archaic technique, from an era when the only alternative was GETA. Another friend of a friend had a U/S-guided preop interscalene block with bupi leak asymptomatically into a vessel over 20-30 minutes; patient seized, arrested and died, despite intralipid. Local anesthetics are bad drugs (and lido is no exception, just the toxic dose differs).

Learn the anatomic blocks for the wrist, or have the surgeons learn/do them. Most good hand surgeons do carpal tunnels under local.
 
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My mafat is about 5 minutes in the room to ready. Total or time is about 20-25 minutes per case. 20 cc of lido 0.5% is no different from 5 cc of lido 2% which I push on induction regularly.
 
FFP said:
The risk/benefit ratio of a Bier block should not be worth it for anybody. I refuse to do them. Even one complication is too many. And if I get fired for not doing a Bier block, good for me.

One of my former highly-experienced colleagues had a cuff leak, patient seized on the table. This is the kind of thing that will happen even to the best of anesthesiologists. It's just a bad archaic technique, from an era when the only alternative was GETA. Another friend of a friend had a U/S-guided preop interscalene block with bupi leak asymptomatically into a vessel over 20-30 minutes; patient seized, arrested and died, despite intralipid. Local anesthetics are bad drugs (and lido is no exception, just the toxic dose differs).

Learn the anatomic blocks for the wrist, or have the surgeons learn/do them. Most good hand surgeons do carpal tunnels under local.
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I don’t understand the ISB story. How could it leak in over 20 min?
 
caligas said:
I don’t understand the ISB story. How could it leak in over 20 min?
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The guess was that the anesthesiologist punctured a vessel and did not notice (although aspiration was negative), so part of it leaked into the vessel while injecting, with some more continuing to leak slowly until it reached a toxic level.

I don't know the details/comorbidities. It may have been less than 20 minutes, because it was preop, but it was definitely a longer time than one would expect.
 
Propofool123 said:
50 kg female coming in for carpal tunnel release in the OR and surgeon prefers Bier blocks. Our typical practice is to inject 3 mg/kg of 0.5% Lidocaine. Let’s say someone accidentally injects 0.5% Bupivicaine instead and realized after injecting the medication but prior to tourniquet release. You try aspirating the medication back out of that IV but you can’t. What would you do?
Click to expand...

Consult vascular to amputate the extremity. Problem solved.
 
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Fyi, for brachial plexus blocks I’ve decreased my maximum allowed Bupivacaine to a max of 2 mg/kg with no drop off in post op analgesia. The concept that we Need 30 ml of 0.5 percent Bup for a block is simply false. Post op analgesia is still Excellent with 100 mg of Bup combined with Decadron. On tiny patients I even use 0.25 Bup with excellent Results. I encourage everyone on this board to give it a try and you will be pleasantly surprised how effective postop analgesia is with a reduced dosage of Bup.

This post is meant to encourage those who are the fence to give it a try. 2 mg/kg maximum dosage. For most patients I’m well under that dosage.
 
BLADEMDA said:
Fyi, for brachial plexus blocks I’ve decreased my maximum allowed Bupivacaine to a max of 2 mg/kg with no drop off in post op analgesia. The concept that we Need 30 ml of 0.5 percent Bup for a block is simply false. Post op analgesia is still Excellent with 100 mg of Bup combined with Decadron. On tiny patients I even use 0.25 Bup with excellent Results. I encourage everyone on this board to give it a try and you will be pleasantly surprised how effective postop analgesia is with a reduced dosage of Bup.

This post is meant to encourage those who are the fence to give it a try. 2 mg/kg maximum dosage. For most patients I’m well under that dosage.
Click to expand...
Any significant difference if the decadron is IV?
 
BLADEMDA said:
Fyi, for brachial plexus blocks I’ve decreased my maximum allowed Bupivacaine to a max of 2 mg/kg with no drop off in post op analgesia. The concept that we Need 30 ml of 0.5 percent Bup for a block is simply false. Post op analgesia is still Excellent with 100 mg of Bup combined with Decadron. On tiny patients I even use 0.25 Bup with excellent Results. I encourage everyone on this board to give it a try and you will be pleasantly surprised how effective postop analgesia is with a reduced dosage of Bup.

This post is meant to encourage those who are the fence to give it a try. 2 mg/kg maximum dosage. For most patients I’m well under that dosage.
Click to expand...

Right but it lasts longer with the higher mg of bupivicaine, and isnt that the goal? why is it important to see how little it takes to acheive post op analgesia? because in my mind thats not the goal, the goal is how dense is the block and how long does it last..

I dont see the need to move to less than the current max dose, since we know that is already very safe and probably a conservative number already
 
BLADEMDA said:
Fyi, for brachial plexus blocks I’ve decreased my maximum allowed Bupivacaine to a max of 2 mg/kg with no drop off in post op analgesia. The concept that we Need 30 ml of 0.5 percent Bup for a block is simply false. Post op analgesia is still Excellent with 100 mg of Bup combined with Decadron. On tiny patients I even use 0.25 Bup with excellent Results. I encourage everyone on this board to give it a try and you will be pleasantly surprised how effective postop analgesia is with a reduced dosage of Bup.

This post is meant to encourage those who are the fence to give it a try. 2 mg/kg maximum dosage. For most patients I’m well under that dosage.
Click to expand...

standard in my residency was 20mL of 0.25%, blocks typically in the 12-24 hour range for upper extremity with decadron and epi.
 
FFP said:
The guess was that the anesthesiologist punctured a vessel and did not notice (although aspiration was negative), so part of it leaked into the vessel while injecting, with some more continuing to leak slowly until it reached a toxic level.

I don't know the details/comorbidities. It may have been less than 20 minutes, because it was preop, but it was definitely a longer time than one would expect.
Click to expand...

thats insane. how did they even come up with that.. autopsy? found a hole in the vessel? as opposed to just systemic absorption...
 
Propofool123 said:
50 kg female coming in for carpal tunnel release in the OR and surgeon prefers Bier blocks. Our typical practice is to inject 3 mg/kg of 0.5% Lidocaine. Let’s say someone accidentally injects 0.5% Bupivicaine instead and realized after injecting the medication but prior to tourniquet release. You try aspirating the medication back out of that IV but you can’t. What would you do?
Click to expand...

intralipid
put in IV in hand and force the blood out proximally to distally.
can replace lost blood by lowering tourniquet to allow arterial to go in but not venous .. or just dump in a ton of LR and repeat
 
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Back in the day, as they like to say, some people were intentionally using bupiv for Bier blocks. Not sure what the dose was. The one study I found used 1.5mg/kg. I would probably leave the tourniquet up for a long time and give some intralipid too. But there's a decent chance she will do just fine.

Edit to add a rant: With all the BS I have to do to get credentialed how the hell does someone who never did one get credentialed for a Bier block? And how do they not have the brains to just casually mention, "Oh by the way I have never done one of these."
 
Had a colleague tell me a surgeon in the middle of Dingo Woop Woop demands Bier block or GA for all carpal tunnels. Apparently, that's a thing.

I'd plumb brachial artery and a proximal vein and circulate CSL to wash as much of it out as possible. Then partially lift tourniquet to allow re-perfusion and fill it up with intralipid and wait. Rinse and repeat blood letting/intralipid until happy.
 
dr doze said:
This actually happened to a world famous hand surgeon at one of the name brand hospitals in the 1980s. He was delayed and didn't want to wait. So he did the block himself. patient had some neurologic damage post arrest.
Click to expand...
If this was on the East coast, I believe the patient announced the tourniquet was going down as he was washing his hands at the sink. Heard this from a friend.
 
We still do occasional Bier blocks (for teaching purposes). But it's honestly an archaic form of anesthesia that should be retired. Just quickly learn distal blocks (super easy median, ulnar, radial) or better yet have the surgeons inject their own local. Or LMA em. If I were in PP, definitely would never be doing Bier blocks.
 
Velefunt said:
We've got one or two hand surgeons who love Bier blocks; So I do 'em in PP.

As far as "injecting the wrong stuff" goes, what about those two case reports of TXA being injected for SAB? That's absolutely nuts.
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Agree, or the digoxin SAB.
 
FFP said:
Any significant difference if the decadron is IV?
Click to expand...


Decadron IV has an effect at 8-10 mg IV. At lower doses IV I don't see any prolongation of the block. Dexamethasone when added directly to the local has a small increase in duration of analgesia at lower doses (2-4 mg) and a much more obvious increase in duration of analgesia at 8-10 mg. The issue is that dexamethasone may be neurotoxic at higher doses (IMHO) so you need to choose carefully which patients get the higher dose vs the lower dose of dexamethasone. If I am particularly concerned I don't add any decadron to the local at all.

As I get older and practice longer I find myself becoming more conservative with the use of adjuvants which are added to the local anesthetic. So, while I'm willing to add 8 mg of decadron to the 0.5% Bup for one subset of patients, I am also adding only 2 mg of decadron for the typical medicare patient with type 2 diabetes.
 
BLADEMDA said:
Decadron IV has an effect at 8-10 mg IV. At lower doses IV I don't see any prolongation of the block. Dexamethasone when added directly to the local has a small increase in duration of analgesia at lower doses (2-4 mg) and a much more obvious increase in duration of analgesia at 8-10 mg. The issue is that dexamethasone may be neurotoxic at higher doses (IMHO) so you need to choose carefully which patients get the higher dose vs the lower dose of dexamethasone. If I am particularly concerned I don't add any decadron to the local at all.

As I get older and practice longer I find myself becoming more conservative with the use of adjuvants which are added to the local anesthetic. So, while I'm willing to add 8 mg of decadron to the 0.5% Bup for one subset of patients, I am also adding only 2 mg of decadron for the typical medicare patient with type 2 diabetes.
Click to expand...

i just do IV dex
 
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