I NTRAVENOUS regional anesthesia (IVRA), commonly known as Bier 's block, was first described in 1908 by Karl August Bier, Professor of Surgery at the University of Berlin.1 The technique gained popularity early on, but fell into relative obscurity because it was too cumbersome. Two tourniquets had to be applied: one proximal and one distal to the surgical site. It was necessary to wrap esmarch bandages in a precise manner. Surgical cutdown was required to gain venous access for injection of local anesthetic. By 1911, percutaneous brachial plexus blocks were developed, completely overshadowing Bier 's technique due to their relative ease and safety. In 1931, Morrisori z revived and modified Bier 's block. His method required one tourniquet and percutaneous cannulation of the desired vein. He was the first to suggest.a mechanism of action for IVRA, postulating that there was a direct effect of local anesthetics on terminal nerve filaments and major nerve trunks. Enthusiasm for the technique remained muted until revived by Holmes in 1963 when 0.5% lidocaine was used to achieve IVRAfl Homes published several papers that once again popularized the block. His modifications of the technique included prior determination of blood pressure, careful exsanguination of the extremity with either esmarch bandages or by elevation of the arm, and use of a pneumatic tourniquet. Holmes also suggested the use of a subcutaneous band of local anesthetic and/or a second pneumatic cuff to help control tourniquet pain. As such, IVRA has since developed into a relatively safe and effective technique that has withstood the test of time. Although in existence for nearly 100 years, interest remains in main-