Bier block gone... terrible

[narcotics999]

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I wonder if you could flush out the arm? Drain as much blood as humanly possible, then infuse as much amount of pRBCs back? Rinse and repeat?

Why pRBC? You have turniquet on and the pRBC will go nowhere. In addition pRBC is too sticky.

I am wondering if you can Rinse and repeat with intralipid?

 

[deleted87051]

Even in patients receiving no block, IV dexamethasone in moderate (>0.1mg/kg) and large doses will reduce postop pain scores and opioid consumption.

 

[anbuitachi]

Even in patients receiving no block, IV dexamethasone in moderate (>0.1mg/kg) and large doses will reduce postop pain scores and opioid consumption.

i usually dont go over 10 mg.. i usually give 8mg... .1mg/kg is a lot in some of our patients

 

[gcc322]

In defense of the beir block - at my PP job, two surgeons prefer them. Don’t like using local because it “alters their view of the surgical field.” 🤔
They get an extra IV in their operative hand by the nurse before OR. Esmarch, tourniquet, inject your ****, and then to pacu 2 in 30 minutes. I am not proficient in wrist blocks but I find it hard to imagine being an efficient technique for such a quick surgery especially for a lineup of 5-6 cases. The other option being a general LMA, which is way overkill IMO.

 

[Urzuz]

In defense of the beir block - at my PP job, two surgeons prefer them. Don’t like using local because it “alters their view of the surgical field.” 🤔
They get an extra IV in their operative hand by the nurse before OR. Esmarch, tourniquet, inject your ****, and then to pacu 2 in 30 minutes. I am not proficient in wrist blocks but I find it hard to imagine being an efficient technique for such a quick surgery especially for a lineup of 5-6 cases. The other option being a general LMA, which is way overkill IMO.

If you think general with an LMA is overkill you’re doing it wrong.

 

[GassYous]

If you think general with an LMA is overkill you’re doing it wrong.

Patients leave the pacu faster with a cleaner wakeup after a bier block than lma. Minimal sedation is needed. But I agree with you, placing an lma is nbd.

 

[deleted162650]

Patients leave the pacu faster with a cleaner wakeup after a bier block than lma. Minimal sedation is needed. But I agree with you, placing an lma is nbd.

I would argue if your patients “wake up” after a Bier block you’re doing it wrong.

 

[GassYous]

I would argue if your patients “wake up” after a Bier block you’re doing it wrong.

True they're awake and chatting when we're rolling out. That's why they leave pacu so fast.

 

[deleted875186]

I too don’t mind the beir block. I think it’s incredibly efficient, is very reliable, and is great for cases under one hour. When you get tourniquet pain it starts to be not a great technique. Seems very safe, never had an adverse event from a beir block, although I’ve only done about a dozen or so.

 

[Iso4ane]

Question. So 3mg/kg of bupiv was given? In some older text that's right at the limit of toxicity. Leave the tourniquet up for the case and then maybe a controlled release if you are really worried. All of that local should have diffused into tissues. Or am I missing something.

 

[Arch Guillotti]

True they're awake and chatting when we're rolling out. That's why they leave pacu so fast.

Why are they going there in the first place?

 

[Arch Guillotti]

Seems very safe

Seems like an accident waiting to happen to me.

 

[DocMcCoy]

Question. So 3mg/kg of bupiv was given? In some older text that's right at the limit of toxicity. Leave the tourniquet up for the case and then maybe a controlled release if you are really worried. All of that local should have diffused into tissues. Or am I missing something.

Not totally disagreeing with you but what ever isn’t tissue bound is going right to the heart when the TQ drops. That’s ballsy to me.

 

[epidural man]

Beir Blocks still have utility I think. I disagree they are not worth it.

However, with all things, the technology must evolve.

IF you are going to do a BEIR block, it should be with a forearm tourniquet. you can use a third of the dose. The tourniquet is tolerated a lot better. The amount of medicine is minimal and the tourniquet could be dropped at any time without much risk.

 

[Mman]

Bier blocks are useful and we still do them occasionally. Their safety profile is likely even better than peripheral nerve blocks although most complications from a peripheral block are going to be relatively minor.

In this situation from OP (which I have never heard of or encountered) I would probably start patient on lipid infusion and then have small brief tourniquet releases over 2-3 hours to hopefully minimize massive release into systemic circulation at once.

 

[Iso4ane]

Not totally disagreeing with you but what ever isn’t tissue bound is going right to the heart when the TQ drops. That’s ballsy to me.

We expect lidocaine to diffuse through plastic into tissue, are we saying it doesn’t diffuse through vasculature in tissue?

Also, can you fill the Beir Block with Intralipid.

 

[MDanesth]

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.

we routinely do 15-20ml of 0.25% bupivacaine with some decadron for such blocks

 

[BLADEMDA]

I haven't done a Bier block in years and think it is an antiquated technique. I'd rather do a TIVA, MAC, LMA or even a Brachial Plexus block for a short procedure on the hand than a Bier block.

 

[jthedestroyr]

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.

In residencyb we did both, although I got "too dense of a block" including hitting Phrenic(of course to be expected), but freaked the patient out. That was using 0.5% bupi 20ml. Now in private I use 0.25% bupi 10mL and 10mL 1% lidocaine. Seems to work sufficiently, normally can get away with as little as 10mL if good anatomy.