The document provides information on performing Bier's block and fascia iliaca compartment block (FICB). It discusses the anatomy, equipment, approach, local anesthetics, and key teaching points for each procedure. Bier's block involves injecting local anesthetic intravenously to anesthetize nerves around blood vessels in the upper extremity. FICB involves injecting local anesthetic into the fascia iliaca compartment to anesthetize the femoral and lateral femoral cutaneous nerves of the thigh. Ultrasound guidance improves the success and safety of FICB compared to the landmark-based technique for Bier's block.

1. Extremity blocks
Bier’s Block &Facia
Iliaca block -FICB in ER
Dr.Venugopalan .P.P
DA,DNB,MNAMS,MEM[GWU]
Director ,Emergency Medicine
Aster DM Healthcare
India

2. Disclaimer
Every effort was made to ensure that material and
information contained in this presentation are correct and
up-to-date. The author can not accept liability/
responsibility from errors that may occur from the use of
this information. It is up to each clinician to ensure that
they provide safe anesthetic care to their patients.

3. Anaesthesia /EM
Intravenous Regional
Anaesthesia(Bier’s Block)
Introduced by August Bier in 1908
Bier block is a technique for
intravenous regional anesthesia
Produce total analgesia of either
the upper or lower extremity.
Best reserved for short procedures
(less than 60 minutes) of the distal
extremities.

4. Bier block
How does it work?
❖
The technique is based on the premise that if
circulation to the limb is blocked and local
anesthetic is injected into venous vessels
distal to the occlusion,
❖ The nerves that typically travel with blood
vessels will be anesthetized as the drug
diffuses into the ex- travascular space via
retrograde flow.
❖ The duration of the block depends on the
length of occlusion of the vessels.

5. Hypothesis on mechanism of action
Adapted from Rosenberg and Heavner, 1985

6. Why Bier block
Easy to administer
Rapid recovery
Rapid onset
Muscle relaxation

7. What procedures ?
Open procedures of the
hand or lower arm
Closed reductions of the
hand or lower arm

8. What limits you ?
Time!
Ideal for procedures lasting
40-60 minutes
Maximum time limit is 90
minutes
Tourniquet pain generally
starts after 20-30 minutes

9. IVRA
What are the
contraindications?
Reynaud’s disease
Homozygous sickle cell disease
Crush injuries
Young Children
Must have a reliable/operative
tourniquet!
If this can not be guaranteed then
this technique should not be used due
to risk of toxicity!

10. What are the equipment?
Operative and reliable double
tourniquet
Running IV in non-operative
arm
Resuscitation equipment
Eschmark bandage

11. What agents?
0.5% lidocaine or 0.5%
prilocaine
Dose is 3 mg/kg for either
NEVER USE EPI CONTAINING
SOLUTIONS
Complication of prilocaine is
methemoglobinemia in doses of
> 10 mg/kg

12. Caution !

14. Intravenous Regional Anaesthesia
How do you
perform?
Bier’s Block

15. IVRA - Bier’s Block
How do you do ?
IV catheter in
operative arm as
distally as possible

16. IVRA / Bier’s block
How do you do it?
Double
tourniquet on the
operative arm

17. IVRA /Bier’s Block
How do you do it?
Have patient hold arm
up.
Use Eschmark to
exsanguinate the arm
Exsanguinate the arm
from distal to proximal.

18. IVRA /Biers block
How do you do ?
Inflate the proximal
tourniquet to 150
mmHg over the
patients systolic
pressure
Proximal Cuff
Distal Cuff

19. Procedure
IVRA
Confirm the
absence of a
radial pulse

20. Procedure
IVRA
Inject your local
(0.5% Lidocaine or
Prilocaine in a dose
of 3 mg/kg)

21. Procedure
IVRA
• Remove IV catheter
• Hold pressure and have
OR staff prep arm.
• Onset of anesthesia
should occur in 5
minutes

22. Procedure
IVRA
When the patient
complains of pain you can
inflate the distal tourniquet
and then deflate the
proximal tourniquet
Proximal Cuff
2nd
Distal Cuff
1st

23. When & How to release tourniquet?
The tourniquet should be
up for at least 25
minutes…
Early release may result
in toxicity
Releasing the tourniquet in
cyclic deflations (10
second intervals) will
decrease peak levels of
local anesthetic

24. What are the complications ?
Tourniquet discomfort
Rapid return of sensation
after tourniquet release
and subsequent surgical
pain
Toxic reactions from
malfunctioning tourniquets
or deflating the tourniquet
prior to the 25 minute limit

25. How do you identify LA toxicity
Circum-oral parasthesia
Facial twitching
Tinnitus
Focal convulsions
Generalised convulsions
Respiratory arrest
Cardiac arrest

26. How do you manage it
A= airway. Maintain a
patent airway, administer
100% oxygen.
B= breathing. May need to
assist the patient with positive
pressure ventilation or
intubation.
C= circulation. Check for a
pulse. If no pulse, initiate
CPR.

27. How do you manage it?
Seizures. Diazepam in doses of 5 mg,
or alternatively sodium pentothal in
doses of 50-200 mg will decrease or
terminate seizures.
Hypotension. Treat with ephedrine
(typically 5 mg) IV, open up intravenous
fluids, place the patient in a head
down position (Trendelenburg).
If hypotension is refractory to
ephedrine, treat the patient with
epinephrine (5-10 mcg). Repeat and
escalate the dose as necessary.
The use of lipids in the treatment of
local anesthetic toxicity has shown
promise.

28. Prilocaine
Treat with 1-2 mg/kg of 1% methylene blue given over 5 minutes

29. Bier Block Study
10 patients were enrolled in this prospective study.
The aim was to study the onset, the order of sensory
anesthesia, and plasma serum levels of lidocaine were
measured at 1,5,10,15,20,25,30,45,60, and 90 minutes
after the tourniquet was released.
The tourniquet was elevated for a minimum of 30
minutes prior to release.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during
day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

30. Bier Block Study Results
Mean onset of action for lidocaine was 11.2 minutes (+/-
5.1 minutes).
No fixed sequence of anesthesia (radial, median, and
ulnar distributions).
No patient exhibited toxicity.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-
case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

31. Bier Block Study Results
8 of the 10 patients reached the maximum plasma
concentrations of lidocaine 1 minute after tourniquet
release.
2 of the 10 patients had a slow release and peak in
concentration of lidocaine.
Delayed release of lidocaine may be explained by a
greater degree of absorption into tissue of the arm.
Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during
day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

32. J Pediatr Orthop. 1991 Nov-Dec;11(6):717-20.
❖ J Pediatr Orthop. 1991 Nov-Dec;11(6):717-20.
❖ Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children.
❖ Barnes CL1, Blasier RD, Dodge BM.
❖ Author information
❖ 1Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock 72205.
❖ Abstract
❖ We reviewed our most recent 100 consecutive cases with respect to efficacy and safety of anesthesia in which Bier block anesthesia was used to
reduce upper extremity fractures. Records were reviewed to document diagnosis, number of reduction attempts, efficacy of anesthesia, and
incidence of complications and untoward effects. No adverse effects were noted from lidocaine injection or tourniquet release. The cost of
Bier block anesthesia administered in the emergency room (ER) was significantly less than
that of a general anesthetic in the operating room. We have found the Bier block to be a
safe, reliable, and cost-effective anesthetic in treatment of children's upper extremity
fractures in the ER.
❖ Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children. [J Pediatr
Orthop. 1992]

33. Teaching points
❖ Never deflate the tourniquet sooner than 20 minutes after injection,
even if the surgery is shorter than that time period
❖ The lidocaine has been injected intravenously and toxicity can occur
with early cuff deflation.
❖ Because of the possibility of intravenous injection, epinephrine is not
used in the local anesthetic solution
❖ Short-acting, less toxic local anesthetics are employed (lidocaine or
prilocaine).
❖ Do not use ropivacaine or bupivacaine

34. Lorem Ipsum Dolor
Fascia Iliaca Block FICB

35. Fascia Iliaca Compartment Block -FICB
★ Described by Dalens et al
★ It is a low-skill
★ Inexpensive
★ Provide peri-operative analgesia in
patients with painful conditions
★ Thigh, the hip joint and/or the femur
★ Use of ultrasound to aid
identification of the fascial planes
may lead to faster onset, denser
nerve blockade and an increased
rate of successful blocks

36. Fascia Iliaca Compartment Block
❖ Compartment block
❖ Volume is the key.
❖ Goal is not to place the local
solution next to nerve
❖ Local anesthetic into an
anatomical compartment
containing nerves
❖ Let the distribution of the local
solution within the compartment
take the local to the nerves.
❖ Adequate volume for the block.

37. Anatomy
Key points:
•Innervation of medial, anterior and lateral aspects of thigh comes from L2 to 4
•Fascia iliaca compartment contains three of four major nerves to the leg
•Local anaesthetic injected here reliably reaches the femoral and LFCN only

38. Lumbar Plexus
❖ Nerve roots from the T12
through L5 vertebrae.
❖ The largest branch of the
lumbar plexus is the Femoral
nerve is, arising from the L2,
L3, & L4 roots.

39. Femoral Nerve -FN
❖ Descends through the fibers of
the psoas major
❖ Exits at the lower portion of
the psoas' lateral border,
❖ Passing downward between
the psoas and iliacus muscle,
deep to the iliacus fascia.
❖ Exits the pelvis into the upper
thigh, lateral to the common
femoral artery and vein

40. Lateral Femoral Cutaneous Nerve-LFCN
❖ Purely sensory nerve arising from the
L2 & L3 nerve roots
❖ Provides sensation from the iliac crest
down the lateral portion of the thigh
to the area of the lateral femoral
condyle.
❖ Emerges from the lumbar plexus and
travels downward lateral to the psoas
muscle
❖ Crosses the iliacus muscle deep to the
iliacus fascia.

41. Obturator Nerves -A &P
❖ Innervate a portion of the
distal, medial thigh.
❖ L2, L3, & L4 nerve roots
❖ Cross the iliacus muscle, deep
to the fascia, to the medial
thigh.
❖ Involved in the FICB
❖ Probably plays little role in
post-operative pain relief of
hip and proximal femur.

42. Fascia Iliaca
Compartment Block
Approach

43. How do you do it ? Videos

44. Approach
Fascia Iliaca
Compartment Block
Ultrasound Guided approach

45. Equipment needed
• Ultrasound machine with linear
transducer (6-14 MHz)
• Sterile sleeve
• Gel
• Standard nerve block tray
• Two 20-mL syringes containing
local anesthetic
• 80- to 100-mm, 22-gauge
needle (short bevel aids in
feeling the fascial ‘pops')
• Tuohy needle is better
• Sterile gloves

46. Facia Iliaca Compartment
Block - USG guided
✤The transducer should be placed at the level of
the femoral crease and oriented parallel to the
crease.
Make sure you are
looking at iliacus
fascia.

47. FICB
❖ The sartorius muscle crosses the iliopsoas just after it passes
over the edge of the ilium .It passes under the inguinal
ligament.
❖ The simplest way to find the correct fascial layer is to clearly
identify the ilium (bone) on ultrasound.
USG -Guided

48. FICB
❖ The muscle lying in contact with the bone
and directly overlying it, is the iliacus muscle
❖ The fascial layer covering it is the iliacus
fascia.
USG Guided

49. Ultra sound anatomy
A panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. From lateral to
medial shown are tensor fascia lata muscle (TFLM), sartorius muscle (SaM), Iliac muscle, fascia
iliaca, femoral nerve (FN), and femoral artery (FA). The lateral, middle and medial 1/3s are derived
by dividing the line between the FA and anterior-superior iliac spine in three equal 1/3 sections.
Sartorius MuscleTensor Fascia Lata Muscle

50. Approach
FICB

51. Sonological Anatomy
FICB-USG Guided

52. FICB-UGG Guided
❖ Advance the needle In-Plane so
that you can see its passage in the
subcutaneous tissue moving
superiorly.
❖ Angle the needle to try to cross the
iliacus fascia about midway across
the bony edge of the ilium.
❖ You should feel a pop and see the
needle tip puncture the iliacus
fascia.

53. FICB -USG Guided
❖ Introduce the needle at the rim
of the ilium
❖ Nerves arise from the lumbar
plexus
❖ They are coming from the
superomedial edge of the
ilium.

54. FICB-USG Guided
❖ Watch for the local solution to
move superiorly as you inject.
❖ Local solution needs to travel
superiorly to encounter them
at the earliest opportunity

55. FICB-USG guided
❖ Ensure that the solution travels
superiorly, after inserting the
needle through the iliacus fascia
❖ Injecting a small amount of
solution, advance the needle tip
superiorly, under ultrasound, into
the space created by the injected
local solution
❖ Needle tip must remain beneath
the fascia and above most of the
iliacus muscle as it is advanced.

56. FICB -USG Guided
❖ Observe injected local solution
expanding or “running off”
towards the superior edge of
the iliacus muscle on the
ultrasound image.
❖ It is alright if your local
solution is injected within the
body of the iliacus muscle
❖ Try to keep it in the superficial
(anterior) portion if possible.

57. How much local Anaesthetics ?
❖ Total of 50 ml of local
anesthetic mixture injected
incrementally, 10 – 15 ml after
needle placement
❖ Advance the needle into the
space created by the volume,
then inject the remainder of the
local anesthetic mix.

58. What drug?
❖ Bupivacaine
❖ Ropivacaine
❖ Lignocaine with Epinephrine

59. Video

61. FICB-EBM

64. Bier’s Block FICB
Site Upper and Lower Limbs Lower Limb
Type Vascular route Compartment Route
Basis Volume Based Volume Based
USG No need of GSG
USG Guided is the best
option
Drugs
Can’t Use EPI,BUPI
&ROPI
Can Use it safely
Duration Duration 30mts Upto 2 hours
Tripple Nerves Radial,Ulnar,Median FN,LCNT,Obturator
Tourniquet Need tourniquet No role for tourniquet
Comparative Summary

65. www.drvenu.net , www.emergencymedicinemims.com

66. www.drvenu.net
EMS Asia 2014 ;Goa ; October17,18&19