Improving Quality of Bier Block

Two Intravenous lines will be inserted one at a distal point on the arm to be blocked and other one in the other arm for fluids infusion. The block will be executed by injecting the target medicine in 10 ml increments in a blinded manner of total of 40 ml (study drugs diluted in normal saline 0.9% solution.

1. Group (L): will receive lidocaine 3 mg/kg total of 40 ml (control group)

2. Group (M): will receive lidocaine 3 mg/kg total of 40 ml plus Magnesium sulphate 30 mg/kg maximum 1.5 gm, mixed with the second 20 ml of block solution.

3. Group (F): will receive lidocaine 3 mg/kg total of 40 ml plus fentanyl 1 mcg/kg, mixed with lidocaine given after the first 20 ml of block solution.

Equipment: Local anesthetic agent: lidocaine HCl (2%), Rubber tourniquet, IV catheters (20- or 24-gauge), 500-mL or 1-L bag of IV solution (crystalloid), Infusion set, Pneumatic tourniquet, ideally with a double cuff, One Esmarch bandage (about 150 cm in length, 10 cm in width), Syringes.

Preparation: The patient lies in the supine position with the vein selected for block placement is readily accessible. Baseline vital signs are assessed; blood pressure, oxygen saturation, and ECG monitoring. Intravenous access in the non-operated extremity is obtained. Small doses of benzodiazepine for anxiolysis or small aliquots of opioids in case of discomfort will be available if needed. For safety and securing success, pneumatic cuffs will always be checked for air leaks prior to each IVRA procedure. Clinical staff performing the technique should have ready access to intra-lipid in case it is needed.

Technique:

1. Secure IV cannula in the extremity opposite to the block side.

2. A double pneumatic tourniquet is fixed on a padding layer of soft cloth or cotton with the proximal cuff high on the upper arm.

3. An IV cannula is inserted and secured into a peripheral vein of the operative limb, as far distally as possible.

4. The entire limb is elevated for 1 to 2 minutes to allow for passive exsanguination. Afterwards, while still keeping the limb high, a rubber (Esmarch) bandage is wrapped around it spirally from distal end proximally till the distal cuff of the double tourniquet.

5. The artery is digitally occluded by inflating the proximal cuff 100 mm Hg above systolic arterial blood pressure.

6. After reaching the correct pressure, the Esmarch bandage is removed.

7. A total of 40 mL of the study medicine according to the protocol is injected slowly in 10 ml increments via the IV catheter.

8. After the injection, the arm is lowered to the level of the table. The used IV cannula is removed, and in a sterile manner, pressure is quickly applied over the puncture site.

The onset of anesthesia is + 5 minutes after injection. When the patient reports the tourniquet pain, the distal cuff should be inflated and the proximal cuff is deflated about 20 to 30 minutes after the beginning of anesthesia