OTHER PROCEDURES

Intravenous Regional Anesthesia

Intravenous regional anesthesia (i.e., a Bier block) has been used in children for upper limb operations (mainly for fractures) distal to an inflated tourniquet.^{[291] [292]} Only 0.5% procaine and, preferably, 0.5% lidocaine without epinephrine can be used safely at a dose not exceeding 3 mg/kg (0.6 mL/kg).^[293] The technique is the same as that used in adults. After establishment of an infusion line on the other arm, an intravenous plastic cannula is inserted in a vein as close as possible to the site of surgery, and the limb is exsanguinated, preferably by compression with an Esmarch bandage. A tourniquet is placed proximally and inflated (two to three times the systolic pressure) before the Esmarch bandage is removed and the anesthetic solution is injected. Ten minutes later, a second tourniquet is placed immediately below the first one (i.e., in an anesthetized area) and inflated to the same pressure value. The upper tourniquet is then removed, and the surgeon can proceed. In no case should the tourniquet be deflated before 20 minutes or later than 90 minutes.

The tourniquets are not well tolerated by children, and the technique has many contraindications such as extensive wounds, ischemic disorders, unstable fractures, convulsive disorders, septicemia, cardiac dysrhythmias, hypovolemia, and sickle cell disease. The Bier block cannot be considered a safe procedure because it depends on the ability of the tourniquet to stop the venous drainage completely. Systemic toxicity is a risk.