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Original article
1
Emergency Department, Royal
United Hospital, Bath, UK
2
Bristol Medical School, Bristol,
UK
Correspondence to
Dr Nicola Jakeman, Emergency
Department, Royal United
Hospital, Bath BA1 3NG, UK;
nicola.jakeman@nhs.net
Accepted 3 March 2012
Published Online First
23 May 2012
214
Is lidocaine Bier’s block safe?
Nicola Jakeman,1 Philip Kaye,1 James Hayward,2 David P Watson,1 Stacy Turner1
ABSTRACT
Objectives To assess the safety profile of lidocaine Bier’s
block when compared with that of prilocaine.
Method A retrospective audit of patients undergoing
Bier’s block using 0.5% lidocaine during a 27-month
period (April 2008eJune 2010) at the Royal United
Hospital Bath emergency department.
Results 416 patients with sufficient data were included
in the study; 360 women and 56 men. The mean patient
age was 65 years. Complications were reported in 39
cases; transient hypotension/vasovagal episodes and
transient mild bradycardia were most frequent. No
patients required any medical intervention. There was no
occurrence of anaphylaxis, convulsion, hypotensive
episodes requiring medical intervention, collapse or
death.
Conclusion No clinically significant morbidity or
mortality as a consequence of lidocaine Bier’s block was
demonstrated in this audit.
Bier’s block is a useful technique for producing
regional anaesthesia within a limb and was initially
developed by Karl August Bier in 1908.1 While the
technique has been subject to various modifications
over time, it essentially entails the same principles;
the use of a tourniquet to occlude the arterial
supply to a limb and subsequent intravenous
administration of local anaesthetic to provide
regional anaesthesia, theoretically avoiding
systemic toxicity. Despite its debut in 1908 and
publication in several different journals, the tech-
nique went largely unnoticed for over 50 years.2 It
was not until 1963, thanks to its reintroduction in
a publication by Holmes in The Lancet,3 that the
procedure experienced renewed interest. Holmes
used 0.5% lidocaine and a sphygmomanometer cuff
to produce analgesia in the upper limbs of 30
patients, allowing for a number of procedures to be
performeddmost commonly the manipulation of
fractures. His modified technique entailed the
percutaneous administration of intravenous lido-
caine, eliminating the need for surgery to locate the
vein as initially described in Bier’s method of ‘vein
anaesthesia’.2 This created what was described by
Holmes as:
‘A safe simple method of producing analgesia of the
limbs, which does not require special training or
extensive experience’.3
Distal radial fractures may be treated using
several different methods of anaesthesia and there
is some evidence to suggest Bier’s block should be
considered a first-line treatment. Data from
a Cochrane review suggest intravenous regional
anaesthesia (IVRA) may be superior to haematoma
block.4 Other management options such as proce-
Emerg Med J 2013;30:214–217. doi:10.1136/emermed-2011-200999
dural sedation or general anaesthesia have signifi-
cant resource implications and carry their own
risks, especially in the population most likely to
experience distal radial fractures.5 6
Although the procedure for performing Bier’s
block is largely agreed, the choice of local anaes-
thetic is more controversial.2 The initial preference
for lidocaine in the 1960s was soon surpassed by
that for bupivacaine in the 1970s, with research by
Ware7 showing bupivacaine to provide better
anaesthesia and significant postoperative analgesia
and a better side-effect profile than lidocaine. This
was to be short-lived, however, with the advent of
a string of deaths from hypoxia related to
prolonged seizures and cardiac arrhythmias leading
to cardiac arrest between 1979 and 1983dall
associated with its use in IVRA.8 Since this time,
prilocaine has emerged as a safe and efficient
replacement agent. It has a theoretical advantage
over lidocaine with faster and greater tissue fixa-
tion, and greater extraction in the lungs, which
should reduce its toxic effects. The clinical effec-
tiveness committee of the College of Emergency
Medicine in the UK currently advocate the use of
prilocaine, specifically stating that lidocaine and
bupivacaine should not be used.9 While this is
justified in the case of bupivacaine, there is little
evidence in the literature with regard to lidocaine,
which continues to be used in many countries
outside of the UK, including North America where
prilocaine is unavailable.10
During a period of prilocaine shortage, the Royal
United Hospital emergency department (ED)
changed to using 0.5% lidocaine for Bier’s block.
This practice has continued. The current study is
a retrospective audit of the safety profile of lido-
caine Bier’s block when compared with that of
prilocaine. College of Emergency Medicine guide-
lines advocate the use of prilocaine, therefore gold
standards were derived from two large studies that
quantified the safety profile of prilocaine Bier’s
block. These included a retrospective review of
7110 patients undergoing prilocaine Bier’s block6
and a second case series of 45 000 patients under-
going prilocaine Bier’s block.11 (see table 1).
METHODS
Bier’s block procedure
The Bier’s block procedure is carried out using the
standard technique described in the College of
Emergency Medicine clinical effectiveness
committee guideline with cuff pressure
100 mm Hg above systolic blood pressure (SBP);9
0.5% plain lidocaine at a dose of 3 mg/kg up to
a maximum of 200 mg (40 ml) was used. The
patient has a cardiac monitoring, pulse oximetry
and blood pressure monitoring throughout the
procedure.
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Original article

Table 1 Audit standard

Standard Criteria Target (%) Exceptions Source of evidence
1 There should be no anaphylaxis 100 None Literature search6 12

2 There should be no arrythmia 100 None Literature search6 12

3 There should be no convulsions 100 None Literature search6 12

4 There should be no hypotensive episodes 100 None Literature search6 12

requiring medical intervention

5 There should be no collapse 100 None Literature search6 12

6 There should be no death 100 None Literature search6 12

Patient sample
Patients admitted to the ED for wrist trauma between April
2008 and June 2010 were identified using the electronic ‘patient
first’ database. The following search terms were used to identify
patients: Colles #; radius and ulna #; Smiths #; Colles #
compound; smiths # compound; wrist # compound; wrist
dislocation; carpal bone dislocation.
The electronic notes for patients identified were then
reviewed and those undergoing Bier’s block were identified.
Data collection
Sex, age, lidocaine dose, occurrence of complications and the
details of these complications were entered onto an Excel
spreadsheet. The occurrence of complications was determined
by review of the ‘adverse reactions’ box at the bottom of the
proforma, as well as the observation chart and hand-written
notes. It was assumed that the occurrence of any significant
complication(s) would be documented.
RESULTS
One thousand two hundred and twenty-nine patients were
identified. Four hundred and twenty-eight patients underwent
a Bier’s block procedure. Forty-one adult patients had their
initial manipulation in theatre. These patients generally had
compound fractures or required surgery for additional injuries.
Of the patients who underwent initial Bier’s block manipula-
tion, nine had a second manipulation while under Bier’s and
a further 10 required a second manipulation in theatre. Two
hundred and forty-three patients were under the age of 16 years.
One hundred and forty of these paediatric patient required
admission for reduction in theatre. No Bier’s blocks were
performed on patients under the age of 16 years. The age
distribution for the whole cohort is shown in figure 1.
There were insufficient data for 12 of the 428 individuals who
underwent Bier’s block. These patients were subsequently
excluded. Of the remaining 416, all data points could be
collected for 382 patients. For the remaining 34 patients
the lidocaine dose was not recorded; however, there was suffi-
cient information to assess the occurrence of complications.
Analysis was thus performed on a total of 416 individuals (see
figure 2).
Of the 12 patients excluded, the hospital tracking system was
used to determine the discharge destination. Eight were
discharged from the ED with fracture clinic follow-up. One was
a patient with multiple injuries who was transferred to another
hospital and three patients were admitted under the medical
team.
Of the 416 patients, there were 360 women (86.5%) and 56
men (13.5%). Ages ranged from 16 to 94 years, with a mean of
65 years (figure 3).
The dose of lidocaine used varied from 10 to 40 ml of 0.5%
lidocaine, with a mode of 30 ml 0.5% lidocaine (used in 224
patients).
Potential lidocaine-related complications occurred in 39 indi-
viduals (9%):
< Hypotension (SBP <90 mm Hg), 12 (3%)
< Feeling faint (without arrhythmia or hypotension), six (1.5%)
< Bradycardia, 17 (4%)
< Others (1%):
– Perioral paraesthesia, one
– Confusion and repetitive speech, one
– Post-procedure emesis, one
– Hypersensitivity in myasthenia gravis, one.
Seventeen of these complications occurred while the cuff was
fully inflated, the remaining 22 occurred shortly after the cuff
was deflated.
In addition there were four complications unrelated to the
choice of local anaesthetic agent, including three patients with
suboptimal anaesthesia and one patient who experienced cuff
failure at 13 min (interestingly entirely asymptomatic).

Figure 1 Age distribution of the whole cohort. Figure 2 Summary of data.

Emerg Med J 2013;30:214–217. doi:10.1136/emermed-2011-200999 215

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Original article
Figure 3 Age distribution of patients undergoing Bier’s block.
Hypotension
Twelve patients developed hypotensive episodes (SBP
<90 mm Hg), but all were transient and none required medical
intervention. These were not defined as true complications
according to the gold standards.
Feeling faint
Six patients felt dizzy or faint during the procedure but all had
normal vital sign observations. These were not defined as true
complications according to the gold standards.
Bradycardia
Seventeen patients developed sinus bradycardia. Fifteen had
a mild asymptomatic transient episode for which no interven-
tion was required. Two patients developed associated hypo-
tensiondan 87-year-old woman with a heart rate of 30 with no
altered level of consciousness for whom no intervention was
required and a 58-year-old man with a heart rate of 47 with no
symptoms who was treated with a head tilt with full rapid
recovery.
Others
The patient with perioral paraesthesia and the patient with
confusion and repetitive speech had no addition symptoms and
their symptoms rapidly resolved. Both had a SBP of more than
200 mm Hg during the procedure despite preprocedure SBP of
less than 200 mm Hg. Interestingly, both had preprocedure SBP
greater than 190 mm Hg suggesting an increased risk of local
anaesthetic leak.
The patient with post-procedural emesis showed no other
evidence to suggest local anaesthetic toxicity.
One patient with a history of myasthenia gravis exhibited
hypersensitivity, with myasthenic shaking and speech distur-
bance despite a half dose of lidocaine (10 ml 0.5%) and prolonged
tourniquet time. Symptoms improved spontaneously and
following a brief period of observation they were discharged
(approximately 4.5 h following admission).
DISCUSSION
There were no reports of anaphylaxis, convulsions, hypotensive
episodes requiring medical intervention, significant arrythmias,
collapse or death resulting from the use of lidocaine Bier’s block
in this retrospective study. A zero numerator analysis was
carried out to provide a risk estimate of the chance of having
missed any events within a finite series. This shows that the
interval estimate of 0/416 is consistent with a maximum risk of
one event per 139 patients (95% CI).12
216
Local anaesthetic toxicity in IVRA occurs due to cuff failure or
when the drug has not had sufficient time to become tissue
bound within the forearm before cuff deflation. This can result
in the delivery of a significant dose of a sodium channel antag-
onist to other electrically excitable tissues. In the central nervous
system excitatory phenomena occur first (a period characterised
by perioral paraesthesia then epileptiform activity) followed by
neuronal depression, whereas in the cardiovascular system
malignant arrhythmias, cardiac depression and peripheral vaso-
dilatation arise.13
A 15-year retrospective review by Pickering and Hunter6 of
7410 patients receiving IVRA with prilocaine (40 ml 0.5%)
reported no recorded incidents of convulsions, arrhythmia,
anaphylaxis or collapse. This confirms the essential safety of
prilocaine use for IVRA but the study’s limitations make it
difficult to compare our data. The authors failed to define what
comprises an arrhythmia. In addition, patient monitoring during
the procedure was limited to pulse oximetry, making it impos-
sible to be certain if any asymptomatic periods of hypotension
occurred. This, combined with the retrospective design of the
study, introduces the possibility that more subtle morbidity (eg,
transient hypotension) may have been missed. In a randomised
trial conducted by Kendall et al14 (1997) there were no reports of
significant complications secondary to prilocaine in IVRA.
However, there is no definition of a ‘significant complication’
and methods for monitoring the patient’s vital signs are not
mentioned. Similarly, in a retrospective review by Thamizhavell
and Shankar15 (1996) of 915 IVRA procedures using 0.5%
prilocaine no major complications were reported. Again the
definition of complication and the quality of monitoring was
not reported. A survey into the use of IVRA block conducted in
1990 revealed an absence of arrhythmia, convulsion or death
arising from any of 45 000 prilocaine Bier’s blocks performed in
45 UK ED.11 However, monitoring of vital signs was limited
with electrocardiography, pulse oximetry or both being used in
only 13%, 2% and 4% of departments, respectively.
The (initially enforced) use of lidocaine for IVRA in our study
population has been associated with no episodes of convulsion,
cardiovascular collapse or malignant arrhythmia. Ubiquitous
monitoring of vital signs appears to have allowed us to report
more non-significant ‘complications’. Using the same criteria for
complications as the previous studies of prilocaine would
exclude all but five of the reported complications, ie, the four
‘others’ and one patient with symptomatic bradycardia. Using
the principles of the Quebec criteria for sedation in which
complications are intervention orientated this latter one could
be excluded.16 It should be noted that all episodes of hypoten-
sion and/or bradycardia occurred transiently while the cuff was
fully inflated, suggesting the possibility of venous leakage
despite cuff inflation. Radiographic contrast studies have shown
such leakage can occur while the cuff is fully inflated despite
a cuff pressure 110 mm Hg above SBP. This may be due to the
high venous pressures generated during injection of the local
anaesthetic.17 Enhanced intraosseous circulation during fracture
manipulation has also been suggested to result in ‘leakage’.12 It is
also possible that the differential nerve block produced by local
anaesthetics results in analgesia without autonomic anaesthesia,
which would explain a vagal response during fracture manipu-
lation. These possibilities are procedure related and not drug
specific.
Our study confirms the findings from the North American
experience. Mohr18 has reported, in a retrospective review of
1816 IVRA procedures using lidocaine in Canada, no serious
morbiditydnamely no seizures, hypotension or any other
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Original article

complication requiring hospital admission. Another earlier
retrospective review from Canada, including 1906 patients
receiving IVRA with lidocaine, also demonstrated no major
morbidity. However, minor transient adverse effects were
reported in 1.6% of cases and these included tinnitus, dizziness
and mild bradycardia.19
There has been few published studies comparing lidocaine
with prilocaine and only one comparing the safety and efficacy
of lidocaine versus prilocaine for IVRA.20 Continuous electro-
cardiography and frequent blood pressure monitoring were
employed. The results revealed the two agents to have essen-
tially the same efficacy, with neither causing any significant
morbidity (there was one report of presyncope in the lidocaine
group). The study suggested a possible significant difference
between the agents in terms of whole blood concentration, with
that of prilocaine being lower than lignocaine, following tour-
niquet deflation, although with only 21 patients in total
conclusions are limited.
There are limitations with the retrospective design of this
study. Bier’s block proformas were partly/not complete for some
patients, raising the possibility that some complications may
not have been recorded. Treating clinicians were responsible for
documenting adverse outcomes and this may have been unreli-
able. Data collection was shared among investigators, which
may have resulted in inconsistent data collection.
CONCLUSION
This retrospective audit from a single centre failed to demon-
strate any clinically significant adverse events. This suggests
that lidocaine may be an acceptable alternative to prilocaine.
However, further work directly comparing lidocaine with
prilocaine in a non-inferiority trial with patient symptoms as
the primary outcome would help clarify the role of lidocaine
Bier’s block in UK practice.
Acknowledgements The authors would like to thank all the RUH emergency
medicine consultants and medical student James Hayward who shared the data
collection and supported the analysis of the results and review of the paper.
Contributors NJ: Developed the idea and led the project, guided data analysis and
interpretation, critically reviewed and rewrote large sections of the paper and gave
final approval to the published version. PK: Shared data collection, analysis and
interpretation, helped with revision of the article and approved final version. JH:
Shared data collection and analysis, wrote first draft of paper and approved final
version. DPW: Shared data collection, analysis and interpretation, critically analysed
article for intellectual content and approved final version. ST: Shared data collection,
reviewed and revised article and approved final version.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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Emerg Med J 2013;30:214–217. doi:10.1136/emermed-2011-200999 217

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Is lidocaine Bier's block safe?

Nicola Jakeman, Philip Kaye, James Hayward, David P Watson and

Stacy Turner

Emerg Med J 2013 30: 214-217 originally published online May 23, 2012
doi: 10.1136/emermed-2011-200999

Updated information and services can be found at:

http://emj.bmj.com/content/30/3/214

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References This article cites 17 articles, 3 of which you can access for free at:
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Topic Articles on similar topics can be found in the following collections

Collections Bradyarrhythmias and heart block (33)

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