Described by August Bier in 1908, “vein anesthesia” was originally proposed for surgery of the elbow and amputations of the feet. It was noted to use a “new avenue” for getting the anesthetic agent “to the end apparatus of the nerves as well to the nerve trunks”: the blood vessel. Though Bier reported his method in at least five journals over the course of 2 years, the technique did not rapidly gain popularity. It involved special equipment (Esmarch bandages were not widely available at the time), meticulous exsanguinations of the limb, and a cutdown to locate the vein. With the introduction of brachial plexus blocks in 1911, interest in “vein anesthesia” quickly faded.

Nearly three decades after its introduction, use of the technique surged when it became particularly useful on the battlefields of World War II. The introduction of safer amide local anesthetics (i.e., lidocaine), the use of percutaneous needles to cannulate veins, and the introduction of a commercially available double-cuff tourniquet helped what was then known as the Bier block gain popularity.

With some of the initial disadvantages being overcome by advancements in the field of anesthesia, the advantages of the block are more apparent. From a technical standpoint, all that is needed is successful cannulation of a vein in the involved extremity. Anesthesia can be set up quickly and easily, the
length of anesthesia is predictable, recovery is rapid, and the block itself is extremely reliable.

Any clinician planning to use the block technique must also be aware of the disadvantages of the procedure. As originally described by Bier himself, upon release of the tourniquet, the local anesthetic may cause systemic toxicity. Second, pain from tourniquet use is the primary limitation on the duration of anesthesia. To combat this, double tourniquets and subcutaneous infiltration anesthesia have been proposed but have not yet eliminated this limitation. It is also important to note that postoperative pain relief is virtually nonexistent with this method. Unlike brachial and lumbar plexus blocks, once the tourniquet is released, surgical anesthesia quickly dissipates and the patient is left without the benefit of residual analgesia.

Two other limitations involve patient selection. First, the block cannot be used for a patient in whom movement of the operative extremity causes pain. The process of exsanguination with an Esmarch bandage can generate significant pressures that can be quite painful. Second, the venous system of the involved extremity must be intact. Traumatic hematomas, open fractures, and the like are contraindications to performing the block.