From: Franz Babl ([log in to unmask])> is there evidence that double prevents cuff failure?
--> Evidence? How would one obtain such? Long time since I looked at this, but I think the articles were all surveys of complications from UK mostly and also Australia. They noted methodology was variable and prilocaine was safe. I don't recall anyone mention single cuffs, but I CAN tell you that in the UK, where the data was obtained, is somewhere I have been in for some time and I cannot recall seeing a single cuff machine for Bier's block. Of course, there may be some.
A double cuff was the original procedure. I am not aware of a reason to switch to a single. I doubt anyone will try to set up a decent study to prove single is as good as double, when it's so unlikely to come us as better than! What would be the point?
Still, absence of evidence against something which is APPARENTLY less safe, as you say, should not make us switch to it without good reason...
> In MHO the issue is more the incorrect application of the cuff (not tight enough before inflation, not confirming loss of pulse and sats) and lack of exsanguination (injecting volume into full veins).
--> I think (my fault) we are not talking about exactly the same thing. My use of the word "failure" is not ONLY accidental mechanical failure and/or failure to follow correct procedure. The issues you bring up are sensible, but they don't cover all "failures". Let's use the word "unsuccessful" instead.
Maybe an example...- Take a procedure which takes longer than one minute... Say initial reduction not perfect and one needs to wait for re-Xray which shows this and then re-do under same block...- Say patient is a smaller child after a sporting injury (not unusual)... Muscles with lactate MIGHT play a role - not sure...- SINGLE cuff in use... Just proximal to lesion... Rest of Bier's procedure CORRECTLY performed... NO mechanical failure, pulse was lost, sats monitor picked no signal, good exsanguination...- Before completion, say at 15-20 mins, patient begins to complain of ischaemic pain at the cuff site, which rapidly escalates as is now severe... This is EXPECTED - ischeamic pain- At this stage, the next step, as described originally, would be to inflate the distal of 2 cuffs (which has thus far been left lax), then deflate the proximal to resolve the ischaemic pain... With a single cuff we have a problem!
An additional issue MIGHT be (please let me know - I have no single cuffs to check) that the single cuff used would NOT be one designed for the procedure - it might simply be an old BP cuff - which would deflate in any "accident" instead of remain inflated. Of course, nothing prevents people from getting the "right" sort of single cuff in this respect, but I am just thinking that sometimes people make do...
Funny! I can't believe I find myself defending Bier's - as I have already stated, I am NOT the choice for this - it's not my favourite. I have not looked into the lit. It won't make sense for me, as one who's "gone off" it as a favourite method and who HAS a double cuff and has never even heard anyone say a single is better... I'll have to leave this search for those who WISH to use Bier's...
Just checked Wikipedia. It says DOUBLE cuff. How could we possibly argue with this ;-)
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