Does anyone have any suggestions to improve the incidence of complete surgical anesthesia with a Bier block. We usually use them for carpal tunnel repair.

I have read the studies of the various additives such as Ketorlac, Dexmedetomidine, Clonidine, Nitroglycerin, Cisatricurium,  Demerol, Ketamine, and Sodium bicarbonate but have no clinical experience with these additives. I have used the forearm tourniquet a few times with adequate results. I have used 50cc of 0.5% lidocaine and also 15cc of 2%  lidocaine as suggested by the New York School of Regional Anesthesia web site.  I hold the arm up for a while and do a tight wrap of the Esmark bandage, I inflate the tourniquet to at least 100mmHg above systolic BP and inject with a distal tourniquet  and wait about 8 minutes until incision, but I still occasionally get patients complaining of sharp sensations on incision suggesting incomplete sensory block. Any ideas appreciated.

Thanks

Gary Yurina