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Appendix 3. Former methodological quality assessment tool Item Score 1. Was the assigned treatment adequately concealed prior to allocation? Were the inclusion and exclusion criteria for entry clearly defined? Were important baseline characteristics reported? Were care programmes, other than the trial options, identical?

Were the outcome measures used clearly defined? Were the outcome assessors blinded to treatment status? Was the timing e. Appendix 4. No pain felt in any area below elbow. Medial antebrachial cutaneous forearm? Not specifically stated. Unblocked nerves implicated in the surgical site were blocked by the anaesthesiologist.

Intraoperatively, if the patient complained of pain at the surgical field, supplementation with LA was done by the surgeon. No other details. Not reported Not reported. Notes New search for studies and content updated no change to conclusions. Outcome or subgroup title No. Date Event Description 19 April New citation required but conclusions have not changed This review is an update of the previous Cochrane systematic review Chin The conclusions are unchanged.

We updated the literature search from August to April and retrieved citations from three databases unique citations 2.

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We included one new study Kjelstrup History Protocol first published: Issue 4, Review first published: Issue 1, Date Event Description 7 August New citation required but conclusions have not changed This review is an update of the previous Cochrane systematic review Chin We updated the literature search from March to March We excluded three newly identified studies on the basis of the use of ultrasound guidance.

The title was changed to make it explicit that the scope is restricted to adults. We now assess risk of bias; this replaced the previous methodological quality assessment. We updated our literature search from March date of last search in the previous review to March We excluded a further seven newly identified studies Carre ; Liu ; Sites ; Tuominen ; Youssef ; Yu We added 'Summary of findings' tables for the three comparisons.

Differences between protocol and review Changes made for the current update of the review We clarified our handling of studies with more than two intervention groups e. We described our methods for dealing with missing data.

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We described our methods for assessment of reporting biases. Changes made for the first update of the review Chin Changes made to the inclusion criteria and methods before processing the included trials were as follows.

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Changes made for the first version of the review Chin Important changes made to the protocol before processing the included trials were as follows. The midhumeral approach was no longer specified as included 'Types of studies'. The prior specification of sensitivity and subgroup analyses. Characteristics of studies Characteristics of included studies [ordered by study ID] Baranowski Informed consent Male: not stated; mean age: 49 years Excluded: no details Interventions Multiple neurostimulation method versus multiple paraesthesia method versus single injection All received local anaesthetic LA solution: up to 40 ml lignocaine 1.

No sedation or IV analgesia. All blocks performed or supervised by 1 of the 2 trial authors 1. Multiple injection using neurostimulator: unsheathed block needle. Attempts made to locate 3 to 4 main branches of brachial plexus; nerve specific muscle twitches.

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Incremental LA injections 2. Multiple injection using paraesthesia: 22 gauge regional block needle. Attempts made to locate 3 to 4 main peripheral nerves. Incremental LA injections. Distal pressure applied 3. Single injection via catheter on its insertion introduction with 18 gauge needle in brachial plexus sheath.

Fascial 'click' and easy insertion used to identify sheath. Unclear risk Incomplete information to judge: no gender or type of surgery. Single injection group was 6 years younger not statistically significant Free from performance bias? Low risk "All of the blocks were performed or supervised by one of the two authors. Other treatment none seemed comparable. Coventry Methods Method of randomization: "Technique written on card and placed in envelope. All blocks carried out by one operator Initial sedation with midazolam. Musculocutaneous nerve was first located and 5 ml LA solution injected 1.

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Multiple injection: 15 ml LA to median nerve followed by 10 ml LA to radial nerve 2. Blinded investigator anaesthetist then carried out all assessments. This investigator was totally blind as was the surgeon. Low risk Baseline characteristics including types of surgery detailed and appeared balanced Free from performance bias?

Low risk All blocks carried out by one operator. No cause for concern. Goldberg All blocks performed by first or second year anaesthesiology residents supervised by staff anaesthesiologist usually first author 1. Single injection using nerve stimulator: 23 gauge insulated needle connected to stimulator.

Whole volume of LA injected when maximum stimulation no longer produced muscle activity 3. Single injection groups were 6 and 11 years younger than transarterial groups Free from performance bias?

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Hickey All blocks performed by residents supervised by one staff anaesthesiologist Sedative premedication with IV midazolam: up to 3 mg 1. Double injection: injection of half of LA volume 25 ml anterior to axillary artery, injection of other half 25 ml posterior to axillary artery 2. Single posterior injection: injection of all of LA volume 50 ml posterior to axillary artery 3.

Funding sources and declarations of author interests: none stated Risk of bias Bias Authors' judgement Support for judgement Random sequence generation selection bias Unclear risk "Randomized study". No further details Allocation concealment selection bias Unclear risk No details on allocation concealment Blinding performance bias and detection bias All outcomes High risk No blinding stated seems unlikely given the supervisory aspect Incomplete outcome data attrition bias All outcomes Low risk All participants accounted for Selective reporting reporting bias Unclear risk No protocol.

Insufficient information to judge this Balance in baseline characteristics? Unclear risk Insufficient information to judge this in terms of lack of details on surgical interventions. Double injection group on average 8 years older Free from performance bias?

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Low risk All blocks performed by residents directly supervised by the same member of staff. Imbelloni The identity and experience level of the operator performing the blocks was not stated No premedication given 1. Patients were followed up for 48 hours postoperatively to assess for complications Sensory blockade Analgesic failure use of supplementary anaesthesia; general anaesthesia, pain at surgical site Time to readiness for surgery Tourniquet discomfort and pain Complications during block injection and operation, and up to 48 hours after Block duration Patient satisfaction Notes Block outcomes were vaguely defined, and assessment timing not specified The ASA American Society of Anesthesiologists physical status classification is a system for assessing the fitness of patients before surgery.