Background: Bier block is a good method of anaesthetizing the extremities. But it has untoward effects because anaesthesia and pain relief are satisfactory as far as the tourniquet is inflated, and once the cuff is deflated the patients experienced the loss of anaesthesia and developed severe postoperative pain (POP). So, scientists search for adjuncts to extend the duration of action and better postoperative analgesia. These adjuncts added to lidocaine like dexamethasone, ketamine, nonsteroidal anti-inflammatory drugs, narcotics, magnesium, paracetamol, nitroglycerine …..etc. Objective: To assess and compare the clinical effects of Bier block, with lidocaine alone, or in a combination with ketamine, paracetamol, and nitroglycerine for anesthesia quality and better postoperative analgesia during Bier block (intravenous regional anaesthesia) for upper limb surgery distal to the elbow. Patients and methods: One hundred patients ASA (American Society of Anesthesiologists) I and II, aged between 20 and 60 years and scheduled for any upper limb surgeries distal to the elbow were comprised in the current prospective, randomized double-blind research which was conducted at Sohag University Hospital from March to September 2023. Results: For groups LP, LN, LK the onset of sensory and motor block were shorter while the sensory and motor block recovery times were increased in comparison with group L (p < 0.05). Also, there was shorter onset of the sensory and motor block in group LN than in groups LP and LK. For the sensory and motor recovery there was no significant difference between the adjuvant groups. Conclusion: Supplementation of ketamine, nitroglycerine or paracetamol to lidocaine during Bier block reduces the onset time and improves the quality of anaesthesia, reduces tourniquet pain feeling, and also, reduces consumption of analgesics intraoperatively and postoperatively without side effects.