title: Infraclavicular brachial plexus block for regional anaesthesia of the lower arm.
abstract: BACKGROUND
  Several approaches exist to produce local anaesthetic blockade of the brachial plexus. It is not clear which is the technique of choice for providing surgical anaesthesia of the lower arm although infraclavicular blockade (ICB) has several purported advantages. We therefore performed a systematic review of ICB compared to the other brachial plexus blocks (BPBs).
  
  
  OBJECTIVE
  To evaluate the efficacy and safety of ICB compared to other BPBs in providing regional anaesthesia of the lower arm.
  
  
  METHODS
  We searched CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to September 22nd 2008) and EMBASE (1980 to September 22nd 2008). We also searched conference proceedings (from 2004 to 2008) and the www.clinicaltrials.gov registry. No language restriction was applied.
  
  
  METHODS
  We included any randomized controlled trials that compared ICB with other BPBs as the sole anaesthetic techniques for surgery on the lower arm.
  
  
  METHODS
  The primary outcome was adequate surgical anaesthesia within 30 minutes of block completion. Secondary outcomes included sensory block of individual nerves, tourniquet pain, onset time of sensory blockade, block performance time, block-associated pain and complications related to the block.
  
  
  RESULTS
  We identified 15 studies with 1020 participants, of whom 510 received ICB and 510 received other BPBs. The control group intervention was the axillary block in 10 studies, mid-humeral block in two studies, supraclavicular block in two studies and parascalene block in one study. Three studies employed ultrasound-guided ICB. The risk of failed surgical anaesthesia and of complications were low and similar for ICB and all other BPBs. Tourniquet pain was less likely with ICB (risk ratio (RR) 0.47, 95% CI 0.24 to 0.92, P = 0.03). When compared to a single-injection axillary block, ICB was better at providing complete sensory block of the musculocutaneous nerve (RR for failure 0.46, 95% CI 0.27 to 0.60, P < 0.0001) and the axillary nerve (RR of failure 0.37, 95% CI 0.24 to 0.58, P < 0.0001). ICB was faster to perform than multiple-injection axillary (mean difference (MD) -2.7 min, 95% CI -4.2 to -1.1, P = 0.0006) or midhumeral blocks (MD -4.8 min, 95% CI -6.0 to -3.6, P < 0.00001) but this was offset by a longer sensory block onset time (MD 3.9 min, 95% CI 3.2 to 4.5, P < 0.00001).
  
  
  CONCLUSIONS
  ICB is a safe and simple technique for providing surgical anaesthesia of the lower arm, with an efficacy comparable to other BPBs. The advantages of ICB include a lower likelihood of tourniquet pain during surgery, and more reliable blockade of the musculocutaneous and axillary nerves when compared to a single-injection axillary block.
authors.affiliation: Department of Anesthesia, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
authors.forename: Ki Jinn
authors.initials: KJ
authors.lastname: Chin
authors.forename: Mandeep
authors.initials: M
authors.lastname: Singh
authors.forename: Veerabadran
authors.initials: V
authors.lastname: Velayutham
authors.forename: Victor
authors.initials: V
authors.lastname: Chee
mesh_terms: D000328:Adult; D001917:Brachial Plexus; D002648:Child; D002968:Clavicle; D005542:Forearm / Q000601:surgery*; D006801:Humans; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic