Bier block is intravenous regional anesthesia which was originally introduced by  August K. G. Bier in 1908 and thus the name.

Bier bock  used in surgery of distal part of upper limb like wrist, hand and distal forearm. It is not useful in surgery around the elbow.

The main advantages of this technique are its simplicity and reliability.

Principle

With tourniquet tied intravenous anaesthetic agent like lignocaine is injected in previously exsanguinated limb. There is a  direct diffusion of the local anesthetic from the vessels into the nearby nerves as the drug is not distributed due to circulation blockage by tourniquet.

Peripheral nerve endings of the extremities are nourished by small blood vessels. Injection of a local anesthetic solution into a venous system results in diffusion of the local anesthetic into the nerve endings with the consequent development of anesthesia. The duration of the anesthesia and analgesia are limited by the duration tourniquet.

Technique

With patient in supine position, a tourniquet is placed on the proximal arm of the  affected limb. Sometimes double cuffs are used.

A small IV intravenous catheter (e.g, 22-gauge) is introduced and secured in the dorsum of the patient’s hand on the affected limb. After exsanguination of the limb, the cuffs are inflated.

When double cuffs are used following sequence of events carry better exsanguination and bring distal cuff in zone of anesthesia.

1. Inflate the distal cuff.
2. Inflate the proximal cuff.
3. Deflate the distal cuff.

The usual recommended pressure is systolic blood pressure+100 mm Hg

The anaesthetic agent is pushed through the cannula. Within 5 minute, the effect of anesthesia can be noticed.

Note: After about 30-45 minutes the patients report discomfort due to tourniquet pressure. When this happens, the distal cuff is inflated and proximal cuff is deflated. This provides another 15-20 minutes of relief from discomfort. The sequence is

1.     Inflate the distal cuff.
2.     Check the pressure in the distal cuff.
3.     Deflate the proximal cuff.

When the surgery is done, a gradual deflation of the tourniquet is done to avoid toxicity of the drug in the body. Some anesthetists recommend deflation for 10 seconds and reinflation for one minute and then gradual deflation.

The release of the tourniquet will result in a rapid resolution of anesthesia and analgesia.

Complications

Complications are mostly limited to systemic toxicity from the local anesthetic  or  problems with the tourniquet.

• Systemic toxicity of local anesthetic
• Hematoma  formation at iv catheter site
• Engorgement of the extremity – Avoidable with proper tourniquet application

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CRP was first discovered as a substance in the serum of patients with acute inflammation that reacted with the C- (capsular) polysaccharide of pneumococcus and thus the name.

It was discovered by Tillett and Francis in 1930 and is synthesized in liver.

A rise in CRP occurs as acute phase response  in a wide range of conditions like infections, inflammatory diseases, malignancy and autoimmune disordres. The levels of CRP rapidly increase within 2 hours of acute insult, reaching a peak at 48 hours.

An elevated CRP level does not diagnose a specific disease but is an indicator of inflammatory response that might occur in variety of conditions.

Scleroderma, polymyositis, and dermatomyositis and SLE  do not cause a rise in CRP.

RP level is an independent risk factor for atherosclerotic disease. High CRP means higher risk of developing  stroke, myocardial infarction, and severe peripheral vascular disease.

Normal Values

Normal concentration in healthy human serum is usually lower than 10 mg/L. CRP  slightly increases with aging. Higher levels are also found in found in late pregnant women

CRP returns to normal more quickly than ESR in response to therapy.

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The articular surfaces are connected together by the following ligaments:

• Volar radioulnar ligament
• Dorsal radioulnar ligament
•  Articular disk (Triangular fibrocartilage)

Triangular fibrocartilage complex is ulnar continuation of distal radius & presents concave surface for articulation with lunate and triquetrium.

Distal Radio Ulnar Joint

Distal radio ulnar joint is involved in pronation and supination movements of the forearm. In pronation,  ulna assumes a small relative negative variance position, ulnar head moves dorsally, and volar ligaments become tight;

In supination,  ulna assumes a small relative positive variance position, ulnar head moves volarly, and dorsal ligaments become tight.

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The amount of blood removed varies between one and three units (450 to 500 mL = 1 unit) usually.

The withdrawn blood is anticoagulated and maintained at room temperature, in the operating room, for up to eight hours. It is reinfused into the patient as needed during, or after, the surgical procedure.

Acute normovolemic hemodilution should be considered for patients with good initial hematocrits and who are expected to lose more than two units of blood.

ANH is contraindicated in the following settings:

• Cardiac disease
• Impaired renal function
• Low hemoglobin
• Low serum proteins
• Inadequate vascular access
• Inadequate monitoring capability.

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An atlantodens interval that exceeds 5 mm in lateral flexion and 4 mm in lateral extension indicates instability and is suspicious for ligamentous disruption.

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It is an autosomal recessive disease. It means both the parents should pass a copy of defective genes to the child if the child gets the disorder.

Due to this inefficient breakdown, a substance called homogentisic acid builds up in the skin and other body tissues.

The acid leaves the body through the urine. The urine turns brownish-black when it mixes with air.

No related posts.

These include Weight loss, fevers, fatigue, and malaise,chills, night sweats, and decreased appetite etc

These symptoms are non specific and occur in vast number of diseases.

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• the medial cuneiform
• the intermediate cuneiform also known as the middle cuneiform
• the lateral cuneiform

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An Example of Cervical Thoracic Lumbar Sacral Orthosis

The device is usually custom made after taking the measurements of the patient in whom it is to be applied.

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The Axis (C2) too is quite unique. There is a pivot articulation between the odontoid process of the axis and the ring formed by the anterior arch and the transverse ligament of the atlas.

Image Credit: http://www.chiropractic-help.com/Atlanto-axial-joint-anatomy.html

There are two atlanto-axial joints: median and lateral.

The median joint has one joint   between the posterior surface of the anterior arch of atlas and the front of the odontoid process and other between the anterior surface of the ligament and the back of the odontoid process

The lateral atlantoaxial joint involves articular process of the lateral mass of atlas and axis forming an arthrodial or gliding joint.

Anterior atlantoaxial ligament, Posterior atlantoaxial ligament and  Transverse ligament of the atlas are important ligaments between these two vertebrae.

Thus the atlantoaxial joint in common terminology is actually a composition of three -  two lateral and one median atlantoaxial joints.

This atlanto axial joint is responsible for most of the rotatory movements of the neck.

Because of its proximity to the brain stem and importance in stabilization, fracture or injury at this level can be dangerous.

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