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Meta-Analysis
. 2013 Aug 28;2013(8):CD005487.
doi: 10.1002/14651858.CD005487.pub3.

Infraclavicular brachial plexus block for regional anaesthesia of the lower arm

Ki Jinn Chin  1 , Husni Alakkad, Sanjib D Adhikary, Mandeep Singh
Affiliations
Meta-Analysis

Infraclavicular brachial plexus block for regional anaesthesia of the lower arm

Ki Jinn Chin et al. Cochrane Database Syst Rev. .

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). This review was originally published in 2010 and was updated in 2013.

Objectives: The objective of this review was to evaluate the efficacy and safety of infraclavicular block (ICB) compared to other approaches to the brachial plexus in providing regional anaesthesia for surgery on the lower arm.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 5); MEDLINE (1966 to June 2013) via OvidSP; and EMBASE (1980 to June 2013) via OvidSP. We also searched conference proceedings (from 2004 to 2012) and the www.clinicaltrials.gov trials registry. The searches for the original review were performed in September 2008.

Selection criteria: We included any randomized controlled trials (RCTs) that compared ICB with other BPBs as the sole anaesthetic technique for surgery on the lower arm.

Data collection and analysis: 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.

Main results: In our original review we included 15 studies with 1020 participants and excluded two. In this updated review we included seven new studies and excluded six, bringing the total number of included studies to 22 and involving 1732 participants. The control group intervention was the axillary block in 14 studies, supraclavicular block in six studies, mid-humeral block in two studies, and parascalene block in one study. One study compared ICB to both axillary and supraclavicular blocks. Nine studies employed ultrasound-guided ICB. The risk of failed surgical anaesthesia 30 minutes after block completion was similar for ICB and all other BPBs (11.4% versus 12.9%, risk ratio (RR) 0.88, 95% CI 0.51 to 1.52, P = 0.64), but tourniquet pain was less likely with ICB (11.9% versus 18.0%; RR of experiencing tourniquet pain 0.66, 95% CI 0.47 to 0.92, P = 0.02). Subgroup analysis by method of nerve localization, and by control group intervention, did not show any statistically significant differences in the risk of failed surgical anaesthesia. However 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). ICB had a slightly longer sensory block onset time (mean difference (MD) 1.9 min, 95% CI 0.2 to 3.6, P = 0.03) but was faster to perform than multiple-injection axillary (MD -2.7 min, 95% CI -3.4 to -2.0, P < 0.00001) or mid-humeral (MD -4.8 min, 95% CI -6.0 to -3.6, P < 0.00001) blocks.

Authors' conclusions: ICB is as safe and effective as any other BPBs, regardless of whether ultrasound or neurostimulation guidance is used. The advantages of ICB include a lower likelihood of tourniquet pain during surgery, more reliable blockade of the musculocutaneous nerve when compared to a single-injection axillary block, and a significantly shorter block performance time compared to multi-injection axillary and mid-humeral blocks.

PubMed Disclaimer

Conflict of interest statement

Ki Jinn Chin: none known

Husni Alakkad: none known

Sanjib D Adhikary: I have worked as an adviser for a proposed company initiated trial by Paccira Pharmaceuticals, New Jersey, USA. I have also participated as a principal investigator (PI) at a site for a Phase 4 trial conducted by Cumberland Pharmaceuticals. However, I do not have any direct or indirect financial conflict of interest with the submitted Cochrane review

Mandeep Singh: none known

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Infraclavicular block versus all other blocks, outcome: 1.1 Adequate surgical anaesthesia, subgrouped by time of block assessment.
1.1
1.1. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 1 Adequate surgical anaesthesia.
1.2
1.2. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 2 Adequate surgical anaesthesia (subgrouped by LA volume and block type).
1.3
1.3. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 3 Supplementation required to achieve adequate surgical anaesthesia.
1.4
1.4. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 4 General anaesthesia required to achieve adequate surgical anaesthesia.
1.5
1.5. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 5 Complete sensory block in individual nerve territories within 30 minutes.
1.6
1.6. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 6 Tourniquet pain.
1.7
1.7. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 7 Onset time of adequate surgical anaesthesia (minutes).
1.8
1.8. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 8 Duration of postoperative analgesia (minutes).
1.9
1.9. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 9 Block performance time (minutes).
1.10
1.10. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 10 Pain associated with block performance (scored 0‐10).
1.11
1.11. Analysis
Comparison 1 Infraclavicular block versus all other blocks, Outcome 11 Horner's syndrome.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Arcand 2005 {published data only}
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Frederiksen 2010 {published data only}
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Fredrickson 2009 {published data only}
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Heid 2005 {published data only}
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Kapral 1999 {published data only}
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Koscielniak‐N 2009 {published data only}
    1. Koscielnak‐Nielsen ZJ, Frederiksen BS, Rasmussen H, Hesselbjerg L. A comparison of ultrasound‐guided supraclavicular and infraclavicular blocks for upper extremity surgery. Acta Anaesthesiologica Scandinavica 2009;53(5):620‐6. [PUBMED: 19419356] - PubMed
Minville 2005 {published data only}
    1. Minville V, Amathieu R, Nguyen L, Gris C, Fourcade O, Samii K, et al. Infraclavicular brachial plexus block versus humeral approach: comparison of anesthetic time and efficacy. Anesthesia and Analgesia 2005;101:1198‐201. [PUBMED: 16192544 ] - PubMed
Minville 2006 {published data only}
    1. Minville V, Fourcade O, Idabouk L, Claassen J, Chassery C, Nguyen L, et al. Infraclavicular brachial plexus block versus humeral block in trauma patients: a comparison of patient comfort. Anesthesia and Analgesia 2006;102:912‐6. [PUBMED: 16492851] - PubMed
Niemi 2007 {published data only}
    1. Niemi TT, Salmela L, Aromaa U, Pöyhiä R, Rosenberg PH. Single‐injection brachial plexus anesthesia for arteriovenous fistula surgery of the forearm: a comparison of infraclavicular coracoid and axillary approach. Regional Anesthesia and Pain Medicine 2007;32(1):55‐9. [PUBMED: 17196493 ] - PubMed
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Tran 2008 {published and unpublished data}
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Tran 2009 {published data only}
    1. Tran DQH, Russo G, Munoz L, Zaouter C, Finlayson RJ. A prospective, randomized comparison between ultrasound‐guided supraclavicular, infraclavicular, and axillary brachial plexus blocks. Regional Anesthesia and Pain Medicine 2009;34(4):366‐71. [PUBMED: 19574871] - PubMed
Yang 2010 {published data only}
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References to studies excluded from this review

Fredrickson 2011 {published data only}
    1. Fredrickson MJ, Wolstencroft P. Evidence‐based medicine supports ultrasound‐guided infraclavicular block over the corner pocket supraclavicular technique. Regional Anesthesia and Pain Medicine 2011;36(5):525‐6. - PubMed
Mariano 2008 {published data only}
    1. Mariano ER, Cheng GS, Loland VJ, Chu LF. Comparison of supplementation rates for perivascular axillary and coracoid infraclavicular blocks in ambulatory upper extremity surgery. Ambulatory Surgery 2008;14(2):53‐5.
Mariano 2011a {published data only}
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Mariano 2011b {published data only}
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Neuburger 1998 {published data only}
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Rodriguez 2003 {published data only}
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References to studies awaiting assessment

Astore 2012 {published data only}
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Danelli 2008 {unpublished data only}
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Lopez Morales 2011 {published data only}
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References to ongoing studies

Boivin 2013 {unpublished data only}
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Hillel Yaffe 2013 {unpublished data only}
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References to other published versions of this review

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Publication types