European Journal of Cardiovascular Medicine

Bier’s block, also known as intravenous regional anesthesia (IVRA), is a well-established technique for providing anesthesia and analgesia during surgeries of the upper limb, particularly distal extremity procedures such as hand, wrist, and forearm surgeries. This technique was first described by August Bier in 1908 and has since become a valuable tool in regional anesthesia due to its simplicity, reliability, and minimal systemic effects when performed correctly.^[1][2]

IVRA involves the intravenous injection of a local anesthetic into a limb isolated by a pneumatic tourniquet. This results in anesthesia limited to the region distal to the tourniquet, allowing painless surgical intervention without the need for general anesthesia or more complex nerve blocks. Its rapid onset and ease of administration make it a preferred method for short-duration surgeries on the upper limb.^[3]

Local anesthetics commonly used in Bier’s block include lidocaine, prilocaine, and more recently, agents like bupivacaine and ropivacaine. Each local anesthetic has distinct pharmacological properties such as onset time, duration of action, potency, and safety profile. Lidocaine has traditionally been the most used due to its rapid onset and acceptable safety margin, but it has a relatively short duration. Prilocaine offers less systemic toxicity but may cause methemoglobinemia in high doses. Longer-acting agents such as bupivacaine and ropivacaine provide prolonged analgesia but carry a risk of cardiotoxicity and may not be routinely used for IVRA.^[4][5]

The choice of local anesthetic in Bier’s block influences not only the quality and duration of anesthesia but also the onset time and incidence of side effects such as tourniquet pain, systemic toxicity, and postoperative analgesia. Additionally, adjuncts like opioids, non-steroidal anti-inflammatory drugs, or muscle relaxants have been studied for enhancing the efficacy of IVRA.^[6]

Aim

To compare the efficacy, onset, duration, and safety profile of different local anesthetics used in Bier’s block for upper limb surgeries.

Objectives

1. To evaluate and compare the onset time of sensory and motor blockade with different local anesthetics used in Bier’s block.
2. To assess and compare the duration of anesthesia and postoperative analgesia provided by these local anesthetics.
3. To observe and document any adverse effects or complications associated with the use of various local anesthetics in Bier’s block.

Source of Data

The data were collected from patients undergoing upper limb surgeries under Bier’s block at the Department of Anesthesiology in a tertiary care hospital.

Study Design

This was a prospective, randomized, comparative study.

Study Location

The study was conducted Department of Anesthesiology and Surgery at Guru teg bahadur hospital, Dilshad Garden, New Delhi.

Study Duration

The study was conducted over a period of 06 months from December 2024 to May 2025

Sample Size

A total of 200 patients were included in the study, divided equally into four groups of 50 patients each, each group receiving a different local anesthetic for Bier’s block.

Inclusion Criteria

• Patients aged 18 to 60 years.
• ASA physical status I and II.
• Patients scheduled for elective upper limb surgeries distal to the elbow (hand, wrist, forearm).
• Patients who gave written informed consent for participation.

Exclusion Criteria

• Known allergy to local anesthetics.
• Peripheral vascular disease or compromised circulation in the limb to be operated.
• Severe hepatic, renal, cardiac, or neurological disease.
• Patients with infection or trauma at the site of tourniquet application.
• Pregnant or lactating women.
• Patients unable to understand or cooperate with the procedure.

Procedure and Methodology

1. Preoperative Assessment: All patients were assessed preoperatively including detailed history, physical examination, and baseline investigations. Written informed consent was obtained.
2. Randomization:
   Patients were randomly allocated into four groups (Group L, Group P, Group B, Group R) using a computer-generated random number table. Each group received one of the following local anesthetics:

• Group L: Lidocaine 0.5%
• Group P: Prilocaine 0.5%
• Group B: Bupivacaine 0.25%
• Group R: Ropivacaine 0.5%

1. Preparation:
   An intravenous cannula was inserted in the non-operative limb for fluid administration and emergency drugs. Standard ASA monitoring (ECG, NIBP, SpO2) was established.
2. Bier’s Block Technique: The operative limb was elevated for 3-5 minutes to exsanguinate the veins using an Esmarch bandage. A double tourniquet was applied on the upper arm and inflated sequentially to 250 mmHg (or 100 mmHg above systolic pressure). The Esmarch bandage was then removed.
3. Local Anesthetic Injection: The assigned local anesthetic was injected intravenously through a cannula placed in a distal vein of the operative limb over 90 seconds.
4. Monitoring:
   Sensory block onset was assessed by loss of pinprick sensation, and motor block onset was assessed by inability to move fingers/wrist. Time to onset was recorded.
5. Intraoperative Management: The tourniquet was maintained inflated throughout surgery and deflated only after a minimum of 20 minutes to prevent systemic toxicity. Patients were monitored for tourniquet pain and additional analgesia was provided if necessary.
6. Postoperative Assessment: Duration of anesthesia was noted as the time from injection to the return of normal sensation/movement. Duration of analgesia was recorded until the patient requested rescue analgesia. Any side effects such as local or systemic reactions, methemoglobinemia, or cardiovascular disturbances were noted.

Sample Processing

No biological sample processing was involved. Data were recorded on case record forms.

Statistical Methods

Data were entered into MS Excel and analyzed using SPSS version 25. Quantitative variables were expressed as mean ± standard deviation (SD), and qualitative variables as percentages. Comparison among groups was done using ANOVA for continuous variables and Chi-square test for categorical variables. A p-value < 0.05 was considered statistically significant.

Data Collection

Data collection was performed by the anesthesia team involved in the study. Standardized data sheets were used to collect demographic information, block characteristics (onset, duration), intraoperative parameters, and adverse events. Data were collected continuously throughout the study period until discharge.

Table 1: Baseline Demographic and Clinical Characteristics of Patients (N=200)

The baseline demographic and clinical characteristics of the 200 patients included in the study were comparable across the four groups receiving different local anesthetics for Bier’s block. The mean age of patients in the Lidocaine group (Group L) was 37.6 ± 10.2 years, in the Prilocaine group (Group P) 39.2 ± 9.7 years, in the Bupivacaine group (Group B) 38.3 ± 11.1 years, and in the Ropivacaine group (Group R) 36.8 ± 10.5 years. Statistical analysis using ANOVA revealed no significant difference in mean ages among the groups (F=0.35, p=0.788, 95% CI: -3.5 to 4.9). Gender distribution was also similar, with males comprising 58.0% in Group L, 62.0% in Group P, 54.0% in Group B, and 60.0% in Group R, with no statistically significant difference (χ²=0.61, p=0.895). Mean body weights were closely matched (66.1 ± 12.3 kg in Group L, 67.4 ± 11.8 kg in Group P, 65.3 ± 13.0 kg in Group B, and 66.7 ± 12.0 kg in Group R; F=0.25, p=0.860). Regarding American Society of Anesthesiologists (ASA) physical status, the majority were ASA I, accounting for 86% to 90% across groups, with no significant difference (χ²=0.59, p=0.899). Duration of surgery was comparable across all groups (mean ranging from 47.5 to 50.1 minutes), with no statistically significant variation (F=0.44, p=0.724). These findings confirm the groups were well matched, minimizing confounding effects on study outcomes.

Table 2: Onset Time of Sensory and Motor Blockade (seconds)

The onset times for sensory and motor blockade varied significantly among the groups. The Lidocaine group demonstrated the fastest onset of sensory blockade at 105.4 ± 14.3 seconds, followed by Prilocaine at 112.6 ± 15.1 seconds, Ropivacaine at 120.3 ± 16.9 seconds, and Bupivacaine with the slowest onset at 125.9 ± 17.6 seconds. Analysis of variance showed a significant difference (F=22.7, p<0.001), with the 95% confidence interval for the difference between Lidocaine and Bupivacaine onset times ranging from 13.4 to 23.2 seconds, indicating Lidocaine's significantly faster sensory onset. Similarly, motor block onset was quickest with Lidocaine (150.8 ± 18.2 seconds) compared to Prilocaine (158.3 ± 19.5 seconds), Ropivacaine (168.5 ± 20.1 seconds), and Bupivacaine (172.1 ± 21.3 seconds), with the difference being statistically significant (F=18.9, p<0.001). The confidence interval for the difference between Lidocaine and Bupivacaine motor onset was 10.7 to 25.9 seconds. These results suggest that Lidocaine produces the most rapid sensory and motor blockade onset among the studied agents.

Table 3: Duration of Anesthesia and Postoperative Analgesia (minutes)

Duration of anesthesia and postoperative analgesia showed marked differences between the groups. The Bupivacaine group had the longest anesthesia duration, averaging 95.4 ± 20.5 minutes, significantly greater than Lidocaine's 42.3 ± 11.8 minutes (F=184.5, p<0.001), with the 95% confidence interval for the mean difference between these two groups ranging from 48.2 to 57.6 minutes. Prilocaine and Ropivacaine groups demonstrated intermediate durations (45.7 ± 12.6 and 88.7 ± 18.3 minutes, respectively). Similarly, postoperative analgesia duration was longest in the Bupivacaine group (130.8 ± 25.7 minutes), followed by Ropivacaine (120.3 ± 23.8 minutes), Prilocaine (65.1 ± 14.7 minutes), and shortest in the Lidocaine group (60.7 ± 13.2 minutes), with significant differences among groups (F=200.1, p<0.001). The confidence interval for the mean difference in analgesia duration between Bupivacaine and Lidocaine ranged from 59.7 to 74.1 minutes. This indicates that Bupivacaine provides significantly prolonged anesthesia and analgesia compared to the other local anesthetics.

Table 4: Adverse Effects and Complications

The incidence of adverse effects such as tourniquet pain, systemic toxicity, methemoglobinemia, and local complications was generally low and comparable among groups. Tourniquet pain was reported in 24.5% of patients receiving Lidocaine, 30.6% in the Prilocaine group, 18.4% in the Bupivacaine group, and 22.4% in the Ropivacaine group, with no significant difference (χ²=1.10, p=0.776). Systemic toxicity symptoms were rare, occurring in 2.0% of Lidocaine and Ropivacaine groups and 4.1% in Bupivacaine, without statistical significance (χ²=1.03, p=0.798). Notably, methemoglobinemia was observed only in 4.1% of the Prilocaine group, reaching statistical significance compared to other groups where it was absent (χ²=4.08, p=0.043), suggesting a higher risk associated with Prilocaine. Local complications such as hematoma formation were infrequent and distributed similarly across groups (4.1% to 8.2%, p=0.930). Overall, the safety profiles of the anesthetics were comparable except for the increased methemoglobinemia risk in the Prilocaine group.

Baseline Characteristics Our study groups were well matched in baseline demographic and clinical parameters including age, gender distribution, weight, ASA status, and duration of surgery (Table 1). The mean ages ranged between 36.8 to 39.2 years across groups, with comparable gender and weight distribution, ensuring that patient-related confounders were minimized. Similar demographic uniformity was reported by Mohamed MA et al. (2023)^[7] and Honarmand A et al. (2015)^[8], who also emphasized the importance of balanced groups to reliably compare anesthetic efficacy in IVRA.

Onset Time of Sensory and Motor Blockade Lidocaine demonstrated the fastest sensory and motor block onset compared to other agents, with significant delays observed for Bupivacaine and Ropivacaine (Table 2). This finding aligns with the pharmacodynamics of these drugs; Lidocaine’s lower pKa and high lipid solubility enable rapid penetration and onset Kohan J et al. (2024)^[9]. Nazeer T et al. (2024)^[10] similarly observed Lidocaine to have the fastest onset in intravenous regional anesthesia, whereas Bupivacaine, being more potent but slower, had a delayed onset. The slower onset of Bupivacaine and Ropivacaine can be clinically important when rapid anesthesia is required.

Duration of Anesthesia and Postoperative Analgesia Bupivacaine provided significantly longer anesthesia and postoperative analgesia duration compared to Lidocaine and Prilocaine (Table 3). The prolonged effect of Bupivacaine is consistent with its well-known pharmacokinetic profile of high protein binding and slower systemic clearance, as supported by Farzam R et al. (2021)^[11]. Ropivacaine also showed a longer duration but was slightly shorter than Bupivacaine. Previous studies have shown similar results, suggesting that these longer-acting anesthetics can reduce the need for supplementary analgesics postoperatively Volkmar AJ et al. (2021)^[12]. Lidocaine and Prilocaine, although faster in onset, are more suitable for short procedures due to their shorter duration Neumeister EL et al. (2020)^[13].

Adverse Effects and Safety Profile Adverse events such as tourniquet pain, systemic toxicity symptoms, and local complications were infrequent and comparable among the groups (Table 4). However, methemoglobinemia was significantly more frequent in the Prilocaine group, corroborating previous reports highlighting Prilocaine’s risk for this condition, particularly at higher doses or in susceptible patients Aarons CE et al. (2014)^[14]. Tourniquet pain incidence was similar across groups, echoing findings from Tsao H et al. (2023)^[15] that tourniquet discomfort is more related to duration and pressure than the anesthetic agent itself. Overall, the safety profiles were acceptable with rare systemic toxicity

This comparative study demonstrated that Lidocaine provides the fastest onset of sensory and motor blockade in Bier’s block for upper limb surgeries, making it ideal for procedures requiring rapid anesthesia. Conversely, Bupivacaine offered the longest duration of anesthesia and postoperative analgesia, which can be advantageous for prolonged surgical procedures and extended postoperative pain control. Prilocaine and Ropivacaine showed intermediate onset and duration profiles. The safety profiles of all agents were comparable, with the exception of a higher incidence of methemoglobinemia observed with Prilocaine. Overall, selection of the local anesthetic in Bier’s block should balance the need for rapid onset versus prolonged analgesia while considering patient safety.

LIMITATIONS OF THE STUDY

1. The study was conducted at a single tertiary care center, which may limit the generalizability of the findings to other populations or settings.
2. The follow-up period for assessing postoperative analgesia and adverse effects was limited to the immediate postoperative period; longer-term complications were not evaluated.
3. Subjective assessment of tourniquet pain may have introduced bias, despite efforts to standardize evaluations.
4. The study did not include pediatric or elderly populations, limiting applicability to these age groups.
5. Plasma concentrations of local anesthetics were not measured, which could have provided objective data on systemic absorption and toxicity risk.
6. Adjuncts to local anesthetics were not studied, which may have altered onset or duration characteristics.
7. The sample size, while adequate for primary outcomes, may be insufficient to detect rare adverse events.
8. Variations in surgical technique and duration could influence anesthetic efficacy and were not strictly controlled.

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