Bier block

  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also    

    Acute pain management
    Local anaesthetic poisoning
    Communicating procedures to families

    Key points

    1. Bier block can provide safe and effective anaesthesia in select children with forearm injuries requiring manipulation or repair in the emergency department
    2. Tourniquet must not be deflated before 20 minutes to minimise risk of local anaesthetic poisoning


    • A Bier block is a form of regional anaesthesia, where local anaesthetic is given intravenously with a tourniquet applied to stop it from spreading systemically
    • Limb neurovascular observations must be documented prior to performing regional anaesthesia
    • Clinicians would benefit from supervision if they do not have prior experience with the procedure, and must be able to provide resuscitation if local anaesthetic poisoning occurs


    • Cooperative child with forearm fracture requiring manipulation or laceration needing repair


    • Local anaesthetic allergy/anaphylaxis
    • Open fracture
    • Severe hypertension (reconsider if systolic blood pressure >175 mmHg)
    • Severe crush injury or compromised circulation
    • Sickle cell disease

    Potential Complications

    • Cuff discomfort (common)
    • Allergy/anaphylaxis to lidocaine (lignocaine)
    • Systemic lidocaine toxicity (rare): agitation, headache or dizziness, tinnitus, blurred vision and tongue numbness or metallic taste can be early signs. Severe toxicity may cause seizures, methaemoglobinaemia, cardiovascular and respiratory compromise
      • In case of suspected lidocaine (lignocaine) toxicity: stop injection, confirm tourniquet inflation and provide resuscitation


    • Pneumatic tourniquet
    • Soft wrap to place under tourniquet for comfort
    • Two IV cannulas and associated set-up
    • Lidocaine (lignocaine) 1%
    • Equipment (eg plaster or suture material) needed once block is complete

    Analgesia, Anaesthesia, Sedation

    • Ensure adequate analgesia of underlying injury (see acute pain management)
    • Topical anaesthetic cream for insertion of IV cannulas
    • Local anaesthetic for the block:
      • Dilute lidocaine (lignocaine) 1% with an equal quantity of normal saline to make a 0.5% solution
      • Lidocaine (lignocaine) dose: 3 mg/kg (0.6 mL/kg of 0.5%; max 200 mg or 40 mL) 

    Procedure – step by step

    • Obtain blood pressure, apply cardiac leads and oxygen saturation
    • Provide clinical monitoring for signs and symptoms of systemic lidocaine (lignocaine) toxicity
    • Insert an IV cannula into a distal vein of the affected arm. The insertion of a second IV cannula in the unaffected arm is recommended
    • Apply pneumatic tourniquet to the affected arm (a soft wrap under the cuff may improve comfort)
      • If available use the recommended tourniquet pressure (RTP) feature
      • When not using the RTP feature, set the tourniquet pressure to 75 mmHg above the patient’s systolic blood pressure (max tourniquet pressure of 250 mmHg)
    • Before inflating cuff, perform limb exsanguination by elevating the affected arm for at least 1 minute
    • With the arm still elevated, inflate the tourniquet cuff to the RTP or previously established tourniquet pressure
    • Start a timer
    • Squeeze the cuff to observe pressure oscillations
    • Confirm absence of radial pulse
    • Inject 0.5% lidocaine (lignocaine) into IV on the affected side
    • Remove IV cannula from affected arm and apply prolonged direct pressure to avoid bleeding
    • Commence procedure, for which the block is required, only after adequate anaesthesia has been obtained (usually 5-10 minutes after infiltration)
    • Do not deflate the tourniquet before 20 minutes or later than 45 minutes after lidocaine infusion  

    Post-Procedure Care and Discharge instructions

    Check limb circulation and ensure no signs of local anaesthetic poisoning after tourniquet deflation

    Alternatives if the block is not successful

    In block failure or for children with severe distress, agitation or difficult positioning, additional sedation (see Acute pain management) or general anaesthesia may be required.

    Consider transfer when

    • Staff unable to safely perform the procedure
    • Uncontrollable pain
    • Fracture requiring surgical treatment not able to be performed at presenting hospital
    • Signs of local anaesthetic poisoning – will need discussion with retrieval team

    Consider discharge when

    Follow-up plan for injury in place and adequate ongoing pain relief provided 

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services. 

    Parent information

    Not available 

    Last updated November 2020

  • Reference List

    1. Candido K et al. Intravenous Regional Block for Upper and Lower Extremity Surgery.  New York School of Regional Anesthesia (viewed November 2020)