Nerve Block vs. Local Infiltration for Paronychia Incision and Drainage
For paronychia incision and drainage, a regional nerve block is recommended over local infiltration anesthesia due to better pain control, reduced tissue distortion, and prolonged anesthesia duration. 1
Anesthesia Options for Paronychia
Nerve Block Advantages
- Provides superior anesthesia for procedures on digits and extremities with less tissue distortion 1
- Decreases tissue swelling and distortion that can complicate the procedure 1
- Prolongs anesthesia duration and reduces postoperative discomfort 1
- Particularly beneficial for infected tissues, which are often more resistant to local anesthesia 2
Local Infiltration Limitations
- Direct infiltration into infected tissues can be more painful for patients 2
- May spread infection and increase tissue distortion 1
- Often requires larger volumes of anesthetic in the already inflamed area 1
- Less effective in acidic environments of infected tissues 2
Technique Recommendations
Digital Nerve Block Approach
- Use 1% or 2% lidocaine with epinephrine (contrary to previous beliefs, epinephrine is safe for use in digits) 1
- Consider buffering the anesthetic with sodium bicarbonate (1:9 ratio of 8.4% sodium bicarbonate to lidocaine) to reduce injection pain 1, 3
- For fingers: perform a traditional digital block at the base of the digit 1
- For toes: consider an ankle block for larger procedures or digital block for isolated paronychia 1
If Local Infiltration Is Chosen
- Use buffered lidocaine to decrease pain during injection 1, 3
- Inject slowly and from healthy tissue toward the infection 1
- Consider topical anesthesia first to reduce the pain of injection 1
- Use the smallest effective concentration of epinephrine (1:200,000) if adding a vasoconstrictor 1
Special Considerations
For Severe or Recurrent Paronychia
- Drainage is mandatory when an abscess is present 4
- Consider warm soaks with Burow solution or 1% acetic acid before the procedure 4
- For chronic paronychia, address underlying causes (irritant exposure, moisture) 4, 5
Procedural Approach
- For simple paronychia with abscess, a simple incision approach is preferred 6
- For more complex cases, consider single or double incision technique along the nail 6
- Ensure adequate drainage is achieved to minimize the need for oral antibiotics 4
Potential Complications and Pitfalls
- Avoid injecting directly into infected tissue when possible 2
- Be aware that infected tissues may require longer onset time for anesthesia to take effect 2
- Monitor for signs of anesthetic toxicity, especially when using larger volumes 1
- For patients with cardiac conditions, consultation with the patient's cardiologist is recommended if uncertain about epinephrine use 1
By following these recommendations, you can provide effective pain control for paronychia incision and drainage while minimizing patient discomfort and procedural complications.