The evacuation of the blood necessary for the production of venous anaesthesia has the inconvenience that the constricting, centrally located bandage causes severe pressure pain in numerous cases. Beir A. On local anaesthesia, with special reference to vein anaesthesia. Edin Med J, 1910; 5: 103-123. Corning J. Prolonged local anaesthetization by incarceration of the anaesthetic fluid in the field of operation. New York Medical Journal 1886; 43: 12-16. Kroeff-Pires published his experiences with the IVRA technique between 1946-1954 using procaine 0.5% in a volume of 80 mL (upper extremity) or 150 mL (lower extremity). He advocated for the use of a double tourniquet and arm elevation for exsanguination instead of the Esmarch bandage.

Fig 1: There is now a simple way to get rid of this pressure pain. Now place a third constricting bandage between the central (I) and peripheral (II), i.e. in the anaesthetic area, and loosen the central bandage No. 1. The constricting bandage number 3 then caused no discomfort in the course of the operation. The longest period in which the constricting bandage No. 3 was left in place was 25 minutes. James Leonard Corning (1855-1923) described a new method of regional anaesthesia using subcutaneous injections of cocaine hydrochloride ‘ incarcerated‘ by a proximally placed Corning tourniquet and Corning clamp. In the casualty and outpatient departments many operations are done on the limbs. Inevitably the patient is often ill-prepared for general anaesthesia, which is made all the more hazardous if delegated to a junior anaesthetist. This paper describes a safe and simple method of producing analgesia of the limbs. It is a modification of the technique of “venous anaesthesia” described by Bier.

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Fig 2: The procedure can also be used for operations in the area of direct anesthesia, without the surgical field being significantly restricted by the application of bandage number 3. The constricting bandage No. 1 is placed a little further in the center and after the injection into the vein, bandage No. 3 is placed directly next to bandage No. 1. The constricting bandage no. 3 can be put on over the wound made to locate the vein, which is covered with sterile gauze. Kroeff-Pires F. Metodo de “Bier” para anaesthesia regional de membros [Bier’s method of regional anesthesia of the limbs]. Revista Brasileira de Anestesiologia 1954; 4: 21–24. Holmes CM. Intravenous regional analgesia. A useful method of producing analgesia of the limbs. Lancet. 1963; 281(7275): 245-247.

Brazilian Flavio Kroeff-Pires (1917- ) first saw the technique demonstrated by an assistant to the Uruguayan orthopedist José Luis Bado (1903-1977). Bado had apparently been using the technique for many years, since a visit to Bier’s medical school in Berlin during the 1920s, but had not produced any formal scientific reports on the method.

Bier A. Ueber einen neuen WegLocalanästhesie an denGliedmassen zu erzeugen. Arch Klin Chir, 1908; 86: 1007-1016.