Refinement of a simple technique with new relevance for exsanguination of the upper limb.

Many techniques have been described for exsanguination of the upper limb before the application of a pneumatic tourniquet. These require additional equipment such as the Esmarch bandage, the Urias bag, the Pomidor roll-cuff, the Northwick Park exsanguinator, or the Rhys-Davies exsanguinator. At a time of increasing demand on scarce resources and increasing medico-legal claims, these techniques have a number of disadvantages: increasing tourniquet and theater time, having cost implications, posing a risk of transmission of infection such as methicillin-resistant Staphylococcus aureus and Group A Streptococcus, being contraindicated in certain upper limb pathologies, and causing potential injury or even fatal pulmonary embolism. Some of these techniques continue to be in common usage but a review of the literature suggests that they may be unnecessary in routine practice, and should be reserved for select situations. The present article describes the formalization and refinement of a simple technique with new relevance, 101 years after Bier first mentioned it in the literature, where the brachial artery is compressed in the cubital fossa before elevation of the arm and then the tourniquet is inflated. This method is simple, cost-effective, time-saving, and most importantly safe and fomite free.