Letters to the Editor: Letters & Announcements
To the Editor:
IV regional blocks were first described in 1908 by August Bier, a German surgeon (1). Bier block has multiple advantages that include ease of administration, rapid onset, rapid recovery, and muscular relaxation. It is an excellent technique for short surgical procedures such as close reduction of bony fractures; however, it is not devoid of difficulties and complications. Tourniquet discomfort, difficulty in providing bloodless field, and accidental deflation of tourniquet leading to toxic reactions are common. Rare complications such as development of compartment syndrome and loss of limb have been described (2).
A 41-yr-old female, 63-kg, ASA physical status I patient was posted for release of left trigger thumb as an ambulatory case. Her routine complete blood count and biochemistry, including blood glucose and renal and liver function tests, were within normal limits. Electrocardiogram and chest radiograph were normal. She had no history of inherited blood disorders, including thalassemia or sickle cell disease; her hemoglobin electrophoresis was also normal. She was given premedication with diazepam 10 mg with a sip of water 1 h before the scheduled operation. In the operating room before initiation of Bier’s block her vital signs were recorded; her heart rate was 82 bpm with normal sinus rhythm, arterial blood pressure was 138/76 mm Hg, and oxygen saturation was 99%. An IV cannulation with 20-gauge cannula was done in the nonoperative limb and administration of dextrose in normal saline was started. IV cannulation with a 22-gauge cannula was performed on the forearm of the operative limb, capped and secured well in place. A double-cuffed tourniquet was applied over the upper arm and an Esmarch bandage was used to exsanguinate the forearm. The proximal cuff was inflated to 275 mm Hg, and 40 mL of 0.5% lidocaine (prepared by diluting 20 mL of 1% lidocaine with 20 mL of normal saline) was slowly injected through the cannula on the operative limb. There were no additives or adjuvants to this solution. During injection of lidocaine, mottling of the skin was observed.
After 5 min the distal cuff was inflated to the same pressure and the proximal cuff was released. The surgical procedure was started and completed in 35 min without any difficulty or complications. When surgical drapes were removed and dressing of the wound was started, we noticed uniform, circumferential reddish brown and, in places, purple discoloration of the forearm below the tourniquet (Fig. 1). After dressing the wound, the cuff was deflated in cyclical fashion and the patient remained hemodynamically stable in the recovery room. She was admitted to the ward for observation. She did not have any other complaints except pain at the operative site. The next day an ultrasonogram and Doppler study of the limb were performed to exclude any hematoma or collection and any circulatory predicament but the results were found to be normal. After 48 h, the discoloration started fading and completely disappeared on the eighth postoperative day, which brought a sigh of relief to us and to the patient.
Although the discoloration disappeared without any treatment, it caused undue psychological trauma, aesthetic setback, and inconvenience to the patient. This sort of discoloration has not been reported earlier with IV regional anesthesia and the cause of this iatrogenic complication remains elusive. We would like to conclude that this form of rare complication of IV regional anesthesia can occur although it seems to be an easy procedure.
Mohammad Mobarak Hussain Ansari, MD
Annamma Abraham, MBBS, DA
Prince Saud Bin Jalawi Hospital
Al-Hasa, Saudi Arabia
1. Bier A. Ueber einen neuen weg lokalanasthesie an den gliedmassen zu erzcugen. Verh Dtsch Ges Chir 1908;27:204.
2. Wedel DJ. Nerve blocks. In: Miller RD, ed. Anesthesia. Philadelphia: Churchill Livingstone, 2000:1529–30.