Patient Position: Supine, with the extremity to be blocked supported on a side table extension.

Indications: Surgery of the arm below the level of the cuff, usually at or below the elbow. Duration is not to exceed 90 minutes.

Needle Size: 20-gauge, 150-mm intravenous cannula in dorsum of hand and away from surgical site.

Volume: 1 mL/kg up to 60 mL 0.5% lidocaine.

Anatomic Landmarks: A convenient distal vein away from the surgical site; distal vein of the hand.

Approach and Technique: Insert and secure an intravenous cannula (Fig. 21-1). Next, wrap the upper arm with a 10-cm Webril (Kendall Co., Boston, MA) padding band, and then apply an appropriate-sized pneumatic double cuff to the upper arm. The lower end of the distal cuff is secured with foam tape (10 cm) to prevent migration. Next, check the integrity of both cuffs by sequential inflation and deflation. The arm is elevated, and the patient is asked to close the hand firmly on a padding bandage. A 10-cm latex bandage is wrapped from distal to proximal to provide exsanguination of the limb (Fig. 21-2). The proximal (upper) tourniquet is inflated to 100 mm Hg above systolic pressure, or at least 250 mm Hg, and then the latex bandage is removed. Absence of brachial and distal pulses indicates correct function. Fifty milliliters of 0.5% lidocaine is injected slowly. The cannula is removed and the arm prepared for surgery. Adequate sensory anesthesia should be achieved in approximately 10 to 15 minutes.