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Abstract Bier block, or IVRA, is a method of anesthesia for upper extremity surgeries. IVRA was first described by August Bier in 1908, and after a period of latency, it began to gain widespread use after Holmes reemphasized its use in 1963. Bier blocks are technically easy to perform, and the rates for successful anesthesia approach 98%. Furthermore, when compared with brachial plexus blocks for outpatient hand and upper extremity surgery, IVRA may realize lower costs and faster post-anesthesia recovery. If the local anesthetic gains access to a patient’s systemic circulation, the central nervous system (CNS) and cardiovascular system can be affected. The CNS is usually affected first, with symptoms including dizziness, tinnitus, perioral paresthesia, and seizures. Anesthetic-induced toxicity of the cardiovascular system may manifest as hypotension, bradycardia, arrhythmias, or cardiac arrest. This prospective cohort, controlled, single-blinded, randomized study enrolled 80 trauma patients scheduled for both elective and emergency Hand and Forearm surgery who were further divided into four groups: • group one (lidocaine or control LE) Early deflation. • group two (lidocaine, ketorolac LKE) Early deflation. • group three (lidocaine or control LL) Late deflation. • group four (lidocaine, ketorolac LKL) Late deflation. Summary of our results: • There was no significant difference in LAST risk between early and late deflation of distal tourniquet in IVRA.Summary 109 • Pain evaluation intraoperative by VAS was significantly higher at 5 min at group one than group two (P value =0.002) with no significant difference between group four and group three. and was insignificantly different at baseline at 10, 20, 30 min, among the studied groups. At 40 min, VAS was significantly higher in group one than group two, three and four (P value <0.05) with no significant difference among groups two, three and four. At 50 min, VAS was significantly higher in group three than four (P value <0.001) with no significant difference among groups one, two and three. At 60 min, VAS was insignificantly different at baseline among the studied groups. These results are compatible with patient’s pain score. • Postoperative VAS was significantly different at 1, 2, 4, 12 and 24 h and was insignificantly different at 6 h among the studied groups. At 1, 2 and 4 h, VAS was significantly higher in group one than both group two and four (P value <0.001) with no significant difference between groups one and two and was significantly higher in group three than group two and four (P value <0.001) with no significant difference between groups two and four. At 12 h, VAS was significantly higher in group one than group two, three and four (P value <0.05) with no significant difference among groups two, three and four. At 24 h, VAS was significantly higher in group one than group two and four and was significantly lower in group two than group three (P value <0.05) with no significant difference between groups two and four and groups three and four. reduction of postoperative pain is as a result of residual ketorolac in the operative arm, and its redistribution to the systemic circulation after tourniquet deflation. • Intraoperative heart rate, mean arterial pressure and peripheral oxygen saturation were insignificantly different among the studied groups.Summary 110 • Postoperative heart rate and mean arterial pressure was significantly lower in both group two and four than group one and three at 1, 2, 4, 12 and 24 h (P value <0.05) and was insignificantly different at 6 h among the studied groups. • Onset of sensory block was significantly higher in group one than group two and four (P value <0.05) with no significant difference between group one and three, and among groups two, three and four. Onset of motor block was insignificantly different among the studied groups. Onset of sensory recovery was significantly lower in group one than both groups two and four and was significantly higher in group two than both groups three and four and was significantly lower in group three than group four (P value <0.001) with no significant difference between group one and three. • Onset of motor recovery was significantly lower in group one than both groups two and four and was significantly higher in group two than group three, was significantly lower in group three than group four (P value<0.05) with no significant difference between group one and three and between group two and four. • Surgeon and patient satisfaction was insignificantly different among the studied groups. • Intraoperative sedation, tourniquet pain and field congestion were insignificantly different among the studied groups. • Patients’ characteristics (age and gender) were insignificantly different among the studied groups. • Duration of surgery wasn’t significantly variable and inflation time were significantly lower in group one than group three and group four (P value <0.001) with no significant difference between group one and twoSummary 111 and was significantly lower in group two than both group three and group four (P value <0.001) and was insignificantly different between group three and four. Conclusions from the present study results, we could conclude that there is no difference between early and late deflation of distal tourniquet in IVRA as regard signs of LAST & effects on hemodynamics, addition of ketorolac to local anesthetic in intravenous regional anesthesia showed positive results regarding postoperative hemodynamic stability (lower heart rate and MAP), lower pain score and shorter sensory block onset and longer recovery time of sensory and motor blocks with no significant difference in surgeon and patient satisfaction in IVRA for hand and forearm surgery. Limitations • A relatively small sample size. • It was a single center study. • Another limitation is that delayed postoperative pain after 24 hours were not assessed. Recommendations • A larger scale studies with larger sample size and multicenter collaboration are required. • Comparative studies of ketorolac with other NSAIDS are required. • Studies evaluating the effect of deflation time in lower limb surgery are needed. • Studies identify an optimal dose of ketorolac for IVRA can be performed. |