Bier’s block (intravenous regional anaesthesia, IVRA)
Bier’s block (IVRA) is a regional anaesthesia technique in which a bolus of local anaesthetic is injected into a limb rendered temporarily bloodless by a tourniquet.
In the emergency department it is most commonly used for short procedures on the distal upper limb - classically reduction and manipulation of dorsally displaced distal radius fractures. NICE recommends considering IVRA for selected distal radius fracture reductions when performed by clinicians trained in the technique (NICE NG38).
Local governance, documented competency and readiness to manage complications are mandatory before offering IVRA in the ED (RCEM NAP8).
Why it works
Isolating limb circulation with a tourniquet confines the injected local anaesthetic to the venous plexus of the limb. The drug diffuses into nerves and surrounding tissues providing rapid, reliable anaesthesia distal to the cuff. When the tourniquet is released the local anaesthetic is released into the systemic circulation - hence the need for strict timing, monitoring and rescue readiness.
Indications and evidence
- Main ED indication: closed reduction and minor procedures of the distal upper limb (eg, distal radius manipulations).
- NICE NG38 cites randomised trials using prilocaine 0.5% and supports IVRA as an option in adults for appropriate fractures when staff are trained (NICE NG38).
- Always confirm local policy and the SPC for choice and dosing of agent.
Contraindications
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