From the Guidelines
For toenail removal procedures, a digital block using lidocaine with epinephrine is recommended, as it provides several benefits including less need for tourniquet, faster onset, and longer duration of anesthesia, without increasing the risk of necrosis 1.
Key Considerations
- The use of epinephrine in digital blocks for toenail removal has been shown to be safe and effective, with no reported cases of necrosis 1.
- The addition of epinephrine to local anesthesia results in less need for tourniquet, faster onset, and longer duration of anesthesia, making it a preferred choice for digital blocks 1.
- The recommended concentration of epinephrine is 1:100,000 or 1:200,000, as these concentrations have been shown to have the same effects on vasoconstriction and may prolong the anesthetic duration of lidocaine by approximately 200% 1.
Procedure
- To perform the digital block, inject 1% or 2% lidocaine with epinephrine at the base of the toe on both sides (web spaces), targeting the digital nerves.
- Allow 5-10 minutes for complete anesthesia before beginning the procedure.
- The anesthetic effect typically lasts 1-2 hours, which is sufficient for most toenail procedures.
- Always aspirate before injecting to avoid intravascular administration, and be aware of the maximum safe dose to prevent systemic toxicity.
Benefits and Risks
- The benefits of using epinephrine in digital blocks include less need for tourniquet, faster onset, and longer duration of anesthesia, without increasing the risk of necrosis 1.
- The risks associated with epinephrine use are minimal, but may include symptoms of palpitations and anxiety in some patients, highlighting the importance of using the lowest effective concentration of epinephrine 1.
From the FDA Drug Label
INDICATIONS & USAGE Lidocaine HCl Injections are indicated for production of local anesthesia by infiltration techniques such as percutaneous injection by peripheral nerve block techniques such as brachial plexus and intercostal, when the accepted procedures for these techniques as described in standard textbooks are observed. The FDA drug label does not answer the question.
From the Research
Toenail Removal Digital Block Lidocaine with Epi
- The use of digital block with epinephrine is considered safe in selected patients for toenail removal, as shown in a study published in 2010 2.
- A comprehensive review of articles on the use of local anesthetics with epinephrine in digital blocks found no consistent evidence that commercial preparations of local anesthesia with epinephrine cause digital necrosis 3.
- A clinical trial published in 2015 compared the efficacy of anaesthetic digital block with epinephrine vs. tourniquet in ingrown toenail surgery, and found that the use of local anaesthetic with vasoconstrictor reduced post-operative bleeding and produced better and longer perioperative pain control 4.
- A review of various techniques for digital blocks with local anesthetic, with or without epinephrine, found that the advantages of adding epinephrine to the anesthetic solution are minor when compared to the risks of the procedure 5.
- A randomized double-blind trial published in 2019 found that the use of anesthetics with epinephrine had a significantly lower mean onset time and no adverse effects were recorded 6.
- The studies suggest that digital block with lidocaine and epinephrine can be an effective and safe form of local anesthetic for toenail removal, with benefits including reduced post-operative bleeding and prolonged duration of anesthesia 2, 4, 6.