The Indian Anaesthetists’ Forum

: 2022  |  Volume : 23  |  Issue : 1  |  Page : 75--76

Patchy or inadequate brachial plexus block: Bier block to our rescue!

Anju Gupta1, Amita Gupta2, Nishkarsh Gupta3,  
1 Department of Anaesthesiology, Pain medicine and Critical Care, AIIMS, Delhi, India
2 Department of Anaesthesiology, Pain Medicine and Critical Care, Delhi, India
3 Department of Onco-Anaesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India

Correspondence Address:
Dr. Nishkarsh Gupta
R. No 139, Brairch, AIIMS, New Delhi - 110 029

How to cite this article:
Gupta A, Gupta A, Gupta N. Patchy or inadequate brachial plexus block: Bier block to our rescue!.Indian Anaesth Forum 2022;23:75-76

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Gupta A, Gupta A, Gupta N. Patchy or inadequate brachial plexus block: Bier block to our rescue!. Indian Anaesth Forum [serial online] 2022 [cited 2023 Jan 31 ];23:75-76
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Full Text


Brachial plexus block (BPB) is well established as sole anesthesia technique for upper limb procedures. Ultrasound (US) has undoubtedly conferred major benefits, but even US-guided blocks can fail or have motor/sensory sparing.[1],[2] We describe the use of bier block (intravenous regional anesthesia [IVRA]) as a supplemental block in two patients when BPB was found inadequate.


A 22-year-old 92 kg male patient was posted for fixation of the fracture distal forearm. Supraclavicular BPB was performed by a trainee using US and 15 ml 0.5% bupivacaine was given. Motor and sensory blockade was seen within 15–20 min after which tourniquet was applied by surgeons, but when they checked the sensation at the site of incision, block was patchy and inadequate. The patient was not willing for general anesthesia. We thought of using IVRA as a rescue block as the tourniquet was in place and we were not adept at individual rescue nerve blocks. A 22G intravenous cannula was secured temporarily on the dorsum of the hand which was planned for surgery. After exsanguination and inflation of tourniquet to 220 mmHg, lignocaine 0.5%, 40 ml was injected slowly. By the time surgeons cleaned and draped the site, the dense sensory block had set in and the surgery could be started. Following completion of surgery (60 min), the tourniquet was cyclically deflated over 1–2 min. Postoperative pain was managed with nonopioid analgesics.


A 25-year-old patient weighing 82 kg was posted for hand contracture release. Axillary BPB was given in the procedure room using US with 20 ml 0.5% bupivacaine and 30 mcg clonidine. When the patient was taken up for surgery, motor and sensory block was inadequate. IVRA was similarly given to this patient also. Surgery could be started immediately and went uneventfully and the tourniquet was cyclically deflated after 40 min. Postoperatively, the patient remained pain-free on mild analgesics.

Bier block is a simple and very effective anesthetic technique with a reported success rate of 96%–100%.[3] The usual onset time using 0.5% lidocaine is very rapid (about 5 min).[3],[4]

The use of IVRA had many advantages over alternatives like individual nerve blocks as a rescue technique.[4] First, it provided immediate-onset block in a short time. It did not require any advanced skills or equipment like nerve stimulator or US (which require time to set up and for performing the procedure). Third, small dose of LA was needed (10 ml 2% lignocaine). Finally, the steps of Esmarch bandage use and tourniquet application are common to the surgery and IVRA. In addition, the sensory block due to BPB improved the tourniquet tolerance and contributed to postoperative analgesia. The limitation of IVRA over US-guided blocks is the possibility of LA systemic toxicity induced by its systemic absorption after tourniquet deflation.[4] We took precautions (cyclical deflation of the tourniquet and used body weight-guided permissible LA doses). Hence, we suggest the use of IVRA as a rescue technique for suitable upper limb procedures provided the maximum LA dose is not exceeded.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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2Honnannavar KA, Mudakanagoudar MS. Comparison between conventional and ultrasound-guided supraclavicular brachial plexus block in upper limb surgeries. Anesth Essays Res 2017;11:467-71.
3Song L, Wu C, Liu J, Zuo Y, Volinn E, Yao J. Potential advantages of an additional forearm rubber tourniquet in intravenous regional anesthesia: A randomized clinical trial. J Anesth 2015;29:551-6.
4Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma. CJEM 2006;8:247-50.