before beginning the procedure Consider procedural sedation for complex or painful procedures if topical or local anesthesia is not anticipated to provide adequate pain relief Topical Anesthetic The application of LET (lidocaine, epinephrine, tetracaine) gel is particularly useful in well-vascularized areas such as the head and neck Prepare the wound by removing any debris and blood clot Apply the gel directly into the wound using a syringe and/or a cotton-tipped swab Cover with an occlusive clear dressing, such as Tegaderm The wound is ready for closure or other procedures when blanching of the skin appears in a halo distribution around the wound, usually in 30 to 45 minutes The duration of anesthesia is approximately hour EMLA and ELA-Max are effective topical anesthetics that continue to gain popularity in use They are applied to intact skin to achieve local anesthesia for procedures such as venipuncture, LP, a simple local procedure, or needle aspiration The cream is placed on the skin and then covered with an occlusive dressing The time to anesthetic effectiveness varies between brands so you should consult the labeling The J-tip is a single-use device in which compressed carbon dioxide gas rapidly expels lidocaine through intact skin to a depth of to mm in 0.2 second without a needle ( Fig 130.45 ) This allows quicker anesthesia (less than a minute) than topical anesthetics (30 to 45 minutes) and is most commonly used prior to IV insertion as it avoids vasoconstriction caused by topical anesthetics The J-tip may be a good option for younger children or patients with a severe needle phobia, though patients should be informed of the loud popping and hissing sound the device makes when the medication is released (similar to opening a can of soda) The J-tip is contraindicated for patients receiving chemotherapeutic agents