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A box of sand! How wonderful.

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+A box of sand! How wonderful.
-{{Interventions infobox |
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-'''Intravenous regional anesthesia (IVRA)''' or '''Bier block anesthesia''' is a common [[anesthesia|anesthetic]] technique for [[surgery|surgical procedures]] on the body's extremities where a [[local anesthetic]] is injected [[intravenous therapy|intravenously]]. The technique usually involves exsanguination, which forces blood out of the extremity, followed by the application of [[pneumatic]] [[surgical tourniquet|tourniquets]] to safely stop blood flow. The [[anesthetic agent]] is introduced into the limb and allowed to set in while tourniquets retain the agent within the desired area. After some time, the tourniquet is depressurized to restore circulation.<ref name=Matt2007>{{cite journal |last1=Matt |first1=Corinna |year=2007 |title=Intravenous regional anaesthesia |journal=Anaesthesia and Intensive Care Medicine |volume=8 |issue=4 |pages=137-9 |publisher=Elsevier}}</ref><ref name=Clark2002>{{cite web |url=http://www.nda.ox.ac.uk/wfsa/html/u15/u1511_01.htm |title=Intravenous Regional Anaesthesia - Bier’s Block |author=Clark, Natasha |date=2002 |accessdate=23 September 2011}}</ref>
-==History==
-[[Image:August Bier.jpg|thumb|August Bier]]
-The use of tourniquets and injected agents to induce localized anesthesia was first introduced by [[August Bier]] in 1908. He used an [[Esmarch bandage]] to exsanguinate the arm and injected [[procaine]] between two tourniquets to quickly produce anesthetic and [[analgesic]] effects in the site.<ref name=Holmes1969>{{cite journal |last1=Holmes |first1=C. McK. |year=1969 |title=The history and development of intravenous regional anaesthesia |journal=Acta Anaesthesiologica Scandinavica |volume=Supplementum XXXVI |pages=11-18 |publisher=Wiley |doi=10.1111/j.1399-6576.1969.tb00473.x}}</ref> Though it proved effective, IVRA remained relatively unpopular until C. McK. Holmes reintroduced it in 1963.<ref name=Brown1989>{{cite journal |last1=Brown |first1=Eli M. |last2=McGriff |first2=James T. |last3=Malinowski |first3=Robert W. |year=1989 |title=Intravenous regional anaesthesia (Bier block): review of 20 years' experience |journal=Canadian Journal of Anesthesia |volume=36 |issue=3 |pages=307-10 |publisher=Springer |doi=10.1007/BF03010770}}</ref> Today, the technique is common due to its economy, rapid recovery, reliability, and simplicity.<ref name=Matt2007/><ref name=Mariano2009>{{cite journal |last1=Mariano |first1=Edward R. |last2=Chu |first2=Larry F. |last3=Peinado |first3=Christopher R. |last4=Mazzei |first4=William J. |year=2009 |title=Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia  |journal=Journal of Clinical Anesthesia |volume=21 |pages=253-7 |publisher=Elsevier |doi=10.1016/j.jclinane.2008.08.019}}</ref>
-==Methods==
-[[Image:LimbProtectionSleeve.jpg|thumb|left|A single-bladder pneumatic tourniquet cuff with limb protection applied to the upper arm. Dual-bladder cuffs are far more common and generally safer for IVRA.]]
-Protocols vary depending on local standard procedures and the extremity being operated on. A vast majority of practicioners begin by exsanguinating the limb as Bier did with an elastic bandage, squeezing blood [[proximal|proximally]] toward the heart. Pneumatic tourniquets are then applied to the limb and inflated to occlude all blood vessels. The local anesthetic, typically [[lidocaine]] or [[prilocaine]], is slowly injected as [[distal|distally]] as possible into the exsanguinated limb. The anesthetic sets in after approximately 20 minutes, at which point the tourniquets can be deflated and the surgery may begin. The wait time is important for avoiding toxic levels of anesthetics in the systemic bloodstream. Alternatively, the tourniquets may remain inflated to maintain a bloodless field.<ref name=Matt2007/><ref name=Clark2002/><ref name=Henderson1997>{{cite journal |last1=Henderson |first1=Cynthia L. |last2=Warriner |first2=C. Brian |last3=McEwen |first3= James A. |last4=Merrick |first4=Pamela M. |year=1997 |title=A North American survey of intravenous regional anesthesia |journal=Anesthesia & Analgesia |volume=85 |pages=858-63 |publisher=International Anesthesia Research Society}}</ref>
-==Safety==
-The safety and effectiveness of IVRA is well established in clinical literature. It is often preferred for shorter procedures on the distal limb, especially on the forearm, except when the patient was advised against tourniquet use.<ref name=Matt2007/><ref name=Brown1989/><ref name=Henderson1997/> A systematic review of IVRA-related complications found 64 cases reported between 1964 and 2005, which compares favorably against other techniques.<ref name=Guay2009>{{cite journal |last1=Guay |first1=Joanne |year=2009 |title=Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications |journal=Journal of Clinical Anesthesia |volume=21 |pages=585-94 |publisher=Elsevier |doi=10.1016/j.jclinane.2009.01.015}}</ref> The type of anesthetic agent, improper equipment, and technical error are prominent factors in most instances of [[morbidity]] related to IVRA.<ref name=Brown1989/><ref name=Henderson1997/><ref name=Guay2009/><ref name=McEwen2011>{{cite web |url=http://tourniquets.wordpress.com/2011/06/21/ivra_whats_new_and_why/ |title=Tourniquet Safety and Intravenous Regional Anesthesia (IVRA, also called Bier Block Anesthesia): What’s New and Why? |author=McEwen, James |date=21 June 2011 |accessdate=22 September 2011}}</ref> Modern practice now includes various safeguards for improving safety.
-===Equipment===
-Reports from anesthesiologists and surgeons cite proper selection, inspection, and maintenance of equipment as important safety measures.<ref name=Brown1989/><ref name=Henderson1997/><ref name=Guay2009/> The safest tourniquet equipment should have IVRA-specific features such as independent [[tourniquet#Limb occlusion pressure|limb occlusion pressure]] measurements for each channel, as well as dual-bladder tourniquet cuffs combined with dedicated safety lockouts that reduce human error.<ref name=McEwen2011/> Additionally, IVRA protocols should include procedures for regular preventative maintenance of the equipment and performance testing, whether manual or automated, prior to surgery.<ref name=Brown1989/><ref name=Henderson1997/><ref name=Guay2009/><ref name=McEwen2011/>
-===Drug additives===
-[[Adjuvants]] improve the safety of IVRA by promoting anesthetic action and minimizing side effects. For example, benzodiazepine and fentanyl are often added to prevent seizures and to improve nerve blockage, respectively.<ref name=Matt2007/><ref name=Henderson1997/>
-===Procedural safeguards===
-Improved protocols, including adherence to standardized practice, may also help ameliorate the chance and the effect of complications.<ref name=Henderson1997/> For example, limb protection padding and a snug tourniquet application prevents tissue damage, while sufficient but not excessive tourniquet pressure ensures that anesthetics remain within the limb without risking injury. Should complications occur, constant [[medical monitoring|physiological monitoring]] and ready access to resuscitative drugs and equipment facilitates a speedy response.<ref name=Brown1989/><ref name=Henderson1997/><ref name=Guay2009/><ref name=McEwen2011/>
-<!-- List of references in order of appearance.
-<ref name=Matt2007/>
-<ref name=Clark2002/>
-<ref name=Holmes1969/>
-<ref name=Brown1989/>
-<ref name=Mariano2009/>
-<ref name=Henderson1997/>
-<ref name=Guay2009/>
-<ref name=McEwen2011/>
--->
-==See Also==
-*[[Anesthesia]]
-*[[August Bier]]
-*[[Regional anaesthesia|Regional Anesthesia]]
-*[[Surgical tourniquet|Surgical Tourniquets]]
-==References==
-{{Reflist|1}}
-==External Links==
-*[http://tourniquets.wordpress.com/2011/06/21/ivra_whats_new_and_why/ Advances in IVRA Instrumentation]
-[[Category:Regional anesthesia]]
-[[de:Intravenöse Regionalanästhesie]]