From the Guidelines
Bier's block is generally safer than procedural sedation for elderly men requiring distal radius reduction. Bier's block (intravenous regional anesthesia) involves applying a tourniquet to the affected arm and injecting lidocaine (typically 50-100 ml of 0.5% lidocaine without epinephrine) into a vein distal to the tourniquet, providing regional anesthesia without systemic effects as long as the tourniquet remains inflated. This technique avoids the respiratory depression, hypotension, and cognitive side effects that commonly occur with procedural sedation medications like propofol, ketamine, or benzodiazepines. Elderly patients are particularly vulnerable to these sedation-related complications due to age-related changes in drug metabolism, decreased physiologic reserve, and higher prevalence of comorbidities, as highlighted in the guidelines for peri-operative care of the elderly 1.
When performing a Bier's block, the tourniquet should remain inflated for at least 20 minutes even if the procedure ends sooner, to minimize systemic lidocaine toxicity risk. The main limitations include a maximum safe duration of about 1-2 hours due to tourniquet pain, and the procedure requires specific training. Patient monitoring should include vital signs and assessment for signs of lidocaine toxicity if the tourniquet fails. For very anxious patients, minimal sedation can be added, but the primary advantage of Bier's block is avoiding deeper sedation in this vulnerable population.
The use of regional anesthesia, such as Bier's block, is supported by recent guidelines on the management of trauma in elderly and frail patients, which emphasize the importance of multimodal analgesia and the effectiveness of peripheral nerve blocks in reducing opioid consumption and improving outcomes 1. These guidelines highlight the benefits of regional anesthesia in reducing pain, minimizing opioid-related adverse events, and promoting earlier mobilization, which are particularly important in elderly patients with distal radius fractures.
Key considerations for Bier's block in elderly patients include:
- Careful patient selection and monitoring
- Use of appropriate lidocaine dosing and concentration
- Maintenance of tourniquet inflation for at least 20 minutes
- Availability of emergency equipment and personnel in case of complications
- Consideration of minimal sedation for anxious patients
- Emphasis on multimodal analgesia and pain management strategies to minimize opioid use.
Overall, Bier's block is a safe and effective alternative to procedural sedation for elderly men requiring distal radius reduction, and its use should be considered in conjunction with other multimodal analgesia strategies to optimize outcomes and minimize risks in this vulnerable population.
From the FDA Drug Label
The potential for these latter effects is increased in debilitated patients, those receiving concomitant medications capable of depressing the CNS, and patients without an endotracheal tube but undergoing a procedure involving the upper airway such as endoscopy or dental (see Boxed WARNING and WARNINGS.) Midazolam Injection should only be administered intramuscular or intravenous (see WARNINGS) Care should be taken to avoid intra-arterial injection or extravasation (see WARNINGS).
The FDA drug label does not answer the question.
From the Research
Comparison of Anesthesia Methods
- Bier block (intravenous regional anesthesia) is a method of anesthesia that can be used for distal radius reduction 2.
- Procedural sedation and analgesia is another method that can be used for pain control during distal radial fracture reduction, but it may have more adverse effects compared to ultrasound-guided hematoma block 3.
- Ultrasound-guided hematoma block may be a safe and effective alternative to procedural sedation and analgesia for distal radial fracture reduction 3.
Considerations for Elderly Patients
- For elderly patients with distal radius fractures, the necessity of restoration of radiologic parameters by closed reduction may depend on the patient's activity level and demand 4.
- Malalignment of the distal radius may not increase disability or pain score in low-demand elderly patients, but it can lead to decreased grip strength, dissatisfaction with appearance, and certain wrist limitations in more active patients 4.
- Volar locking plate (VLP) provides better radiological outcomes, wrist supination, and lower complication rates compared to external fixation (EF) in patients with distal radius fractures aged > 80 years 5.