Bier Block + Local Question

[ProPropofol]

In the OR today, had a hand surgeon ask for a Bier block and while doing the case asked how much 0.25 Bupivicaine he could give. I told him I'd prefer if he didn't since I can give fentanyl before/after tourniquet release to help with pain control once the block wears off. Settled for max of 1.25mg/kg instead of the normal 2.5mg/kg (so half dose). Case was a trigger finger release if I remember correctly so done right at the 30min mark.

Don't really do Bier blocks and I think he is the only person in our institution who does them. I did a search in the literature and couldn't find anything regarding acceptable local anesthetic doses after a Bier block. Curious if anyone has any articles/text/suggested wisdom in regards this.

Thank you!

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[anesthesiadoc]

Don’t do one with Bupivicaine.

 

[ProPropofol]

Don’t do one with Bupivicaine.

The Bier block was performed with 25cc of 0.5% Lidocaine. Question is in regards to infiltrating tissue with 0.25 bupivicaine on top of the IV lidocaine given with the Bier block.

 

[anesthesiadoc]

Sorry I was being a bit snarky there. Had a feeling you did it the right way. But I think surgeons should pick their poison. If they want a bier block, then they should let that be their local anesthetic contribution to the case. Reminds me of Ortho pods who still want to inject the knee after we already did iPACK and adductor canal. At a certain point folks need to understand that that sodium channel blockade box has been appropriately checked.

 

[GassYous]

Just have them put in 10 ccs and call it a day
Patients do better with local on top of ipack and adductor canal imo. It's not like the blocks cover the entire knee

 

[Airway]

Just have them put in 10 ccs and call it a day
Patients do better with local on top of ipack and adductor canal imo. It's not like the blocks cover the entire knee

Agree but my orthopod wants to put (not joking) 48.5ml of 0.5 rop. In everyone. Most of it splashes on to the ground but it's still really obnoxious, malpractice.

 

[ProPropofol]

Sorry I was being a bit snarky there. Had a feeling you did it the right way. But I think surgeons should pick their poison. If they want a bier block, then they should let that be their local anesthetic contribution to the case. Reminds me of Ortho pods who still want to inject the knee after we already did iPACK and adductor canal. At a certain point folks need to understand that that sodium channel blockade box has been appropriately checked.

I agree with that. Perhaps just tell them that their local is already used up for the case. TY

 

[GassYous]

Agree but my orthopod wants to put (not joking) 48.5ml of 0.5 rop. In everyone. Most of it splashes on to the ground but it's still really obnoxious, malpractice.

That is quite a lot
But the old school guys tell me they used to put like 100 cc in the joint before blocks were a thing
The absorption in the knee is so crappy so I don't think it's really that big of a deal

 

[jwk]

In the OR today, had a hand surgeon ask for a Bier block and while doing the case asked how much 0.25 Bupivicaine he could give. I told him I'd prefer if he didn't since I can give fentanyl before/after tourniquet release to help with pain control once the block wears off. Settled for max of 1.25mg/kg instead of the normal 2.5mg/kg (so half dose). Case was a trigger finger release if I remember correctly so done right at the 30min mark.

Don't really do Bier blocks and I think he is the only person in our institution who does them. I did a search in the literature and couldn't find anything regarding acceptable local anesthetic doses after a Bier block. Curious if anyone has any articles/text/suggested wisdom in regards this.

Thank you!

So much easier to give a little versed/prop/fent and let the surgeon do their block. We haven't done Bier blocks in years. Tell them that's the way the podiatrists do all their bunions. 🙂

 

[coffeebythelake]

That is quite a lot
But the old school guys tell me they used to put like 100 cc in the joint before blocks were a thing
The absorption in the knee is so crappy so I don't think it's really that big of a deal

The only reason why the surgeon is asking is to absolve themselves of any blame if the patient gets LAST. They know the patient is getting a ton of local with the bier block.

 

[patriot6]

The only reason why the surgeon is asking is to absolve themselves of any blame if the patient gets LAST. They know the patient is getting a ton of local with the bier block.

Plot twist: maybe the surgeon is actually trying to be a doctor and be conscientious about toxic levels of LA. I’d always welcome such a question.

Sorry I was being a bit snarky there. Had a feeling you did it the right way. But I think surgeons should pick their poison. If they want a bier block, then they should let that be their local anesthetic contribution to the case. Reminds me of Ortho pods who still want to inject the knee after we already did iPACK and adductor canal. At a certain point folks need to understand that that sodium channel blockade box has been appropriately checked.

I don’t see anything wrong with site infiltration as a practice by the surgeon for patients receiving bier blocks. That 1.5% lido IV won’t be doing any analgesic lifting in an hour.

 

[Simba1711]

That is quite a lot
But the old school guys tell me they used to put like 100 cc in the joint before blocks were a thing
The absorption in the knee is so crappy so I don't think it's really that big of a deal

I had one surgeon tell me most of it gets washed out during the knee scope. I haven’t done any research to see how much of that is true.

 

[Gasworks]

Agree but my orthopod wants to put (not joking) 48.5ml of 0.5 rop. In everyone. Most of it splashes on to the ground but it's still really obnoxious, malpractice.

Worked with an orthopod that would fill the joint capsule with as much bupi as he could find. Pts looked so toxic in pacu and wouldn’t be ready to leave for hours. I’d prefer a surgeon that asks over a surgeon that just scoops up whatever is left in the bowl and dumps it into the patient.

The “professor” would also piss all over the toilet seat in the only staff bathroom and drank the shared milk straight from the carton.

 

[nimbus]

I had one surgeon tell me most of it gets washed out during the knee scope. I haven’t done any research to see how much of that is true.

“Most of it is sucked out” is the same reasoning that is used when toxic doses of lidocaine are given for tumescent liposuction. 30-50mg/kg was common.

Estimated Maximal Safe Dosages of Tumescent Lidocaine - PMC

Supplemental Digital Content is available in the text. Published ahead of print February 18, 2016

www.ncbi.nlm.nih.gov

“The removal of a significant volume of tumescent subcutaneous fat by liposuction removes a significant portion of the tumescent lidocaine before it is absorbed into the systemic circulation.”

 

[Orin]

In the OR today, had a hand surgeon ask for a Bier block and while doing the case asked how much 0.25 Bupivacaine he could give. I told him I'd prefer if he didn't since I can give fentanyl before/after tourniquet release to help with pain control once the block wears off. Settled for max of 1.25mg/kg instead of the normal 2.5mg/kg (so half dose). Case was a trigger finger release if I remember correctly so done right at the 30min mark.

Don't really do Bier blocks and I think he is the only person in our institution who does them. I did a search in the literature and couldn't find anything regarding acceptable local anesthetic doses after a Bier block. Curious if anyone has any articles/text/suggested wisdom in regards this.

Thank you!

Treat this as the simpler question of total local anesthetic dose instead of making it hard for yourself. What percentage of their max dose of lidocaine did you give for the Bier block? The remaining percentage can be given as percent dose of the max dose of bupivacaine you find acceptable for the patient.

Truth of the matter is that most of that lidocaine is tissue bound and of minimal concern after the tourniquet goes down, as long as you've waited enough time.

 

[Maz777]

In the OR today, had a hand surgeon ask for a Bier block and while doing the case asked how much 0.25 Bupivicaine he could give. I told him I'd prefer if he didn't since I can give fentanyl before/after tourniquet release to help with pain control once the block wears off. Settled for max of 1.25mg/kg instead of the normal 2.5mg/kg (so half dose). Case was a trigger finger release if I remember correctly so done right at the 30min mark.

Don't really do Bier blocks and I think he is the only person in our institution who does them. I did a search in the literature and couldn't find anything regarding acceptable local anesthetic doses after a Bier block. Curious if anyone has any articles/text/suggested wisdom in regards this.

Thank you!

You'll never find an evidence-based answer for this. It's likely safe (although unnecessary) to give 5-10cc of 0.25% bupi at the end of case. Assuming a 70kg patient, you said it was okay to give 35cc of 0.25% bupi. For a trigger finger (small incision; minimal postop pain), that amount is unnecessary. I don't even know how you would fit 35cc of local into a 1-2cm incision without massively disrupting your tissue planes for closure. That's talent right there.

The comment about TKAs is interesting. People are giving ungodly amounts of local anesthetic to these patients (adductors + iPACKs + periarticulars) and getting away with it. Be careful in anyone with altered metabolism (CKD/ESRD, liver disease, etc.).

 

[Airway]

The comment about TKAs is interesting. People are giving ungodly amounts of local anesthetic to these patients (adductors + iPACKs + periarticulars) and getting away with it. Be careful in anyone with altered metabolism (CKD/ESRD, liver disease, etc.).

Getting away with stuff is what dummies do. I'm not willing to exceed standard doses of LAs in healthy people.