Aims:To compare and evaluate the effect of adding ketamine or nitroglycerin (NTG) as adjuncts to lidocaine for intravenous regional anesthesia (IVRA) on intraoperative and postoperative analgesia, sensorial and motor block onset times, and tourniquet pain.Settings and Design:A prospective, randomized, double-blind study was carried out.Materials and Methods:Seventy-five patients undergoing hand surgery were divided into three groups as follows: control group receiving lidocaine 2%, LK group receiving lidocaine 2% with ketamine, and LN group administered lidocaine 2% with NTG. Sensory and motor blocks' onset and recovery times were recorded. Visual analog scale (VAS) for tourniquet pain was measured after tourniquet application and it was also used to measure postoperative pain. Analgesic consumption for tourniquet pain and postoperatively were recorded.Results:Sensory block onset times were shorter in the LK (4.4 ± 1.2 minutes) and LN (3.5 ± 0.9 minutes) groups compared with the control group (6.5 ± 1.1 minute) (P < 0.0001) and motor block onset times were shorter in the LK (7.3 ± 1.6 minutes) and LN (3.6 ± 1.2 minutes) groups compared with the control group (10.2 ± 1.5 minutes) (P< 0.0001). Sensory recovery time prolonged in the LK (6.7 ± 1.3 minutes) and LN (6.9 ± 1.1 minutes) groups compared with the control group (5.3 ± 1.4 minutes) (P = 0.0006 and < 0.0001, respectively). Motor recovery time prolonged in the LK (8.4 ± 1.4 minutes) and LN (7.9 ± 1.1 minutes) groups compared with the control group (7.1 ± 1.3 minutes) (P = 0.0014 and 0.023, respectively). The sensory and motor block onset times were also shorter in LN group than in the LK group (3.5 ± 0.9 versus 4.4 ± 1.2 minutes, P=0.004; and 3.6 ± 1.2 versus 7.3 ± 1.6 minutes, P < 0.0001, respectively). The amount of fentanyl required for tourniquet pain was less in adjuvant groups when compared with control group. It was 13.6 ± 27.9 and 27.6 ± 34.9 µg in LK group and LN groups, respectively, versus 54.8 ± 28 µg in the control group. VAS scores of tourniquet pain were higher at 10, 20, 30, 40 minutes in the control group compared with the other study groups (P < 0.0001). It was also higher in LN group compared with LK group at 30 and 40 minutes (P < 0.001). Postoperative VAS scores were higher for the first 4 h in control group compared with the other study groups (P< 0.0001).Conclusions:The adjuvant drugs (ketamine or NTG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance and improving the postoperative analgesia in comparison to the control group. Ketamine as an adjuvant produced better tolerance to tourniquet than the other groups. NTG as an adjuvant produced faster onset of sensory and motor blockades in comparison to other groups.

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Introduction: One of the major issues of liver resections is blood loss necessitating perioperative blood transfusion. Blood transfusion is independently associated with serious postoperative adverse events. The objective of this study was to identify perioperative predictors of blood transfusion in patients undergoing liver resections. Predicting which patients are at high risk of blood loss requiring transfusion will allow us to introduce targeted interventions to reduce this complication. Methods: Following institutional approval, data on all patients undergoing liver resections at the an academic institution between January , 2004 and December , 2006 were collected from the patients chart retrospectively. Perioperaive variables extracted include: demographics, primary hepatic disease, comorbidities (diabetes mellitus, systemic hypertension, renal insufficiency/failure), smoking history, medications (antiplatelet and anticoagulants), laboratory parameters (hemoglobin concentration (Hb), platelet count, PTT/INR), surgical variables (type of anesthesia, duration of the surgery and intraoperative fluid management). Statistical analyses were performed using SAS version 9.1 (SAS institute, Cary, NC). Unadjusted association of potential predictors of transfusion was evaluated for both continuous (t-test) and categorical (Chi-squared test) variables. Independent predictors of transfusion were identified by multivariable logistic regression analysis. Results: 66 out of 300 patients (22%) received intraoperative blood transfusion. Unadjusted univariate analyses identified 8 predictors of RBC transfusion (Age, weight, height, pre op Hb, pre op INR, platelet count, intraoperative crystalloid volume and use of Pentaspan > 500 ml). In multivariable logistic regression 5 independent predictors were identified. The model is well calibrated (Hosmer-Lemeshow test P = 0.592) and is highly discriminative (ROC area 0.842). Discussion: RBC transfusion in liver resections can be reliably predicted by readily available pre and intraoperative variables. While this model requires validation, it may be used to improve the perioperative management of patient undergoing liver resection and their clinical outcome. References: None

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