Bier's block revisited: intercuff block

Bier introduced his intravenous technique of local anaesthesia to facilitate palliative surgery on the elbow or knee. He cannulated a suitably large vein in the vicinity of the joint to inject procaine after first isolating the operating site with a proximal and a distal tourniquet. This extra containment of the local anaesthetic solution made it feasible to flush out any unfixed drug with saline before release of the main tourniquet, an advantage which has been lost in the currently fashionable technique of intravenous regional anaesthesia (IVRA) involving a single tourniquet above the elbow or knee and a fine butterfly needle in a vein on the dorsum of the hand or foot. A modern version of Bier's original method is described, conveniently called an intercuff block (ICB), which reintroduces the possibility of effective flushing, offers better operating conditions and engenders new ideas for further study.