Loss of hand and forearm following Bier block: a case report

Few complications have been reported with the use of the Bier block for intravenous regional anesthesia. The method requires little expert training and produces good analgesia in a bloodless field for a period of 1 to 1.5 hours. The loss of an upper extremity in a 25-year-old white woman who had the performance of a Bier block for removal of a ganglion cyst is reported. The block was performed with 200 mg of mepivacaine without epinephrine. Total tourniquet time was 25 minutes. The patient had prompt onset of pain and swelling followed by loss of motor and sensory function. Operative exploration revealed necrosis of the forearm compartments. Arteriography demonstrated thrombosis of the terminal branches of the radial and ulnar artery. Below elbow amputation was performed 1 week later. Essentially all complications reported with regional anesthesia have been related to the systemic pharmacologic effects of the local agent used. Loss of an upper extremity has not been reported. We postulate three possible mechanisms: (1) possible cannulation and injection of the radial artery, (2) an idiosyncratic allergic reaction to the anesthetic agent or the preservative, and (3) erroneous injection of a foreign substance into the forearm venous system. We conclude the last mechanism is the most likely cause in this patient.