Top Tweets for #rainchildren

almost 3 years ago

"RA in Male genital Sx.: Target spinal segments S2-S4 (for Penile Sx) & L1-L2 + S2-S4 (for Scrotal Sx)." #RAingenitalsurgery #Penileblock #RAinpediatrics #RAinchildren #RAinscrotalsx #RAinUrogenitalSurgeries #pediatricRA My 10 Points: A. FUNCTIONAL ANATOMY: 1. PENIS is divided into 3 parts: Root: Contains 3 erectile tissues (2 crura + 1 bulb) and 2 Ms. (Ishiocavernosus & Bulbospongiosus). Body: Composed of 3 cylinders of erectile tissue: 2 corpora cavernosa and corpus spongiosum. Glans: Most distal part, conical in shape, and formed by distal expansion of corpus spongiosum. 2. SCROTUM is pigmented external sac formed by skin + muscle that houses the testes, epididymis, and spermatic cord. The spermatic cord, a connective tissue matrix, contains vas deferens, 3 arteries, 3 veins, and 2 nerves. Third nerve (ilioinguinal N.) lies just lateral to the cord. 3. FASCIA: Penile layers include -Skin, Superficial fascia (external fascia of Colles) is a continuation of Scarpa fascia; deep fascia (Buck’s fascia) is a continuation of deep perineal fascia, and Tunica albuginea (under Buck’s facia) forms an individual capsule around each cavernous body. Scrotal layers include- Skin, superficial (Dartos) fascia, external spermatic fascia, cremaster muscle, internal spermatic fascia, and tunica vaginalis. B. INNERVATIONS: 4. Penis: S2-S4 segments. Sensory & Sympathetic innervation (skin + glans) Penis: Pudendal N. through Dorsal nerve of the penis (DNP) + Perineal nerves. Encapsulated somatosensory receptors (mechanoreceptors/nociceptors) are present in prepuce. Glans is innervated by free nerve endings and has protopathic sensitivity. Parasympathetic: From the cavernous nerves from the peri-prostatic nerve plexus. 5. Scrotum & Testis: L1-L2 and S2-S4 (through IHG, IIN, GFN, and pudendal N). Somatosensory: Anterolateral surface - Genital br. of GFN. Anterior surface - Anterior scrotal Ns. (br. of the IIN), Posterior surface- Posterior scrotal Ns. (from perineal N.), Inferior surface - Long scrotal br. (of PFCN). Autonomic: Testes embryologically derived from the same level as the kidneys, so share common autonomic innervation. 90% Sympathetic from T10-L1 segments and 10% Parasympathetic from S2-S4. Autonomic nerves (3 groups): Superior spermatic Ns. (from renal & intermesenteric plexuses), Middle spermatic Ns. (from superior hypogastric plexus), Inferior spermatic Ns. (from inferior hypogastric plexus). 6. MYOTOMES: Penile muscles (2 Bulbospongiosus + 2 Ishiocavernosus) : Deep branch of the perineal N. (branch of pudendal N). Scrotal muscles (Dartos and Cremaster): Sympathetic and somatic fibres of the genital branch of GFN. C. RA TECHNIQUES: Target segments: S2-S4: For all penile surgeries (Circumcision, hypospadias, urethroplasty, etc). L1-L2, S2-S4: For all scrotal surgeries (Orchipexy, testis Sx, TURP etc) 7. Available RA techniques: Caudal anesthesia -0.25-0.5 ml/kg LA volume (Lumbosacral segments). Associated with tachycardia, motor block of LL, and vomiting. Topical analgesia using Lidocaine/Lidocaine + prilocaine. Ring block – For analgesia. 8% failure rate, bleeding, and edema. Penile block: Landmark-guided associated with swelling, hematoma/edema, or bruising. Ultrasound-guided is relatively safer. 8. Penile block (Landmark-guided): Subpubic approach. Landmarks: Pubic symphysis & inferior border of the pubic rami. 2 needle entry points on lateral side of pubic symphysis, just below the pubic ramus (0.5 cm for babies and 1 cm for older boys). Needle direction: Slightly medial & caudal direction (10-15 degrees to the vertical axis). LA deposited- after a“POP” as the needle penetrates Scarpas Fascia and enters into the subpubic space. Coverage: DNP. Sparing: Ventral penis, especially frenulum. 9. Penile block (USG-guided): Probe kept transversely at the base of the penis between the shaft and the scrotum. Sonoanatomy: Corpora cavernosa identified. Dorsal arteries, dorsal nerves, and dorsal vein are located beneath the deep fascia of the penis (Buck’s Fascia). Standard 2-inj technique: LA injected laterally (0.1 ml/kg) to the penile A. inside Buck’s Fascia on each side. Modified (by Suleman et al.) single inj. technique: Needle: In-plane approach entering from the right side. After negative aspiration 0.15-0.25 ml/kg LA injected within the fascia around right DNP. Needle slightly retracted under the corpora cavernosa. A 1-2 ml of LA deposited on the median line. Needle was advanced towards the contralateral nerves and LA deposited under the fascia to block left DNP. Advantage: Single entry needle with bilateral anesthesia of DNP + ventral glans. Circumferential spread of LA with anesthesia of the entire penis. 10. Supplementary RA techniques: a) Ring block of penis: Same cutaneous puncture as the dorsal block. Needle can be fanned out subcutaneously to the 3 and 9 o’clock position and then by repositioning the needle to these position to subcutaneous involve 6 o’clock/scrotal area. b) Ilioinguinal + iliohypogastric nerves block: Landmark-guided - Needle entry point 2cm medial and 2cm superior to the ASIS. USG-guided: Probe is Kept obliquely on a line joining ASIS with umbilicus. Both nerves can be located between IOM-TAM with pulsating DCA adjacent to them. c) Pudendal nerve block: Landmark/PNS-guided- With the patient in the lithotomy, the ischial spine is palpated via transrectal (male) or transvaginal (female). LA deposition- Posterior to the ischial spine at the attachment of sacro-spinous ligament. Ultrasound-guided: Pt in lateral decubitus position. Probe (curvilinear): Kept on the midpoint of the line connecting GT and PSIS. Sonoanatomy: Continuous hyperechoic line - iliac bone. The probe moved parallel and caudal to the lesser sciatic notch. Needle: 80-120 mm needle inserted in-plane from lateral-to-medial direction until tip located close to the pudendal A. Pudendal N. stimulation - Paresthesia in the perineum. LA volume: 15-20 ml LA.

KartikBSonawane's tweet photo. "RA in Male genital Sx.:
Target spinal segments S2-S4 (for Penile Sx) & L1-L2 + S2-S4 (for Scrotal Sx)."

#RAingenitalsurgery #Penileblock #RAinpediatrics #RAinchildren #RAinscrotalsx #RAinUrogenitalSurgeries #pediatricRA

My 10 Points:

A. FUNCTIONAL ANATOMY:

1. PENIS is divided into 3 parts:

Root: Contains 3 erectile tissues (2 crura + 1 bulb) and 2 Ms. (Ishiocavernosus & Bulbospongiosus).

Body: Composed of 3 cylinders of erectile tissue: 2 corpora cavernosa and corpus spongiosum.

Glans: Most distal part, conical in shape, and formed by distal expansion of corpus spongiosum.

2. SCROTUM is pigmented external sac formed by skin + muscle that houses the testes, epididymis, and spermatic cord. The spermatic cord, a connective tissue matrix, contains vas deferens, 3 arteries, 3 veins, and 2 nerves. Third nerve (ilioinguinal N.) lies just lateral to the cord.

3. FASCIA:
Penile layers include -Skin, Superficial fascia (external fascia of Colles) is a continuation of Scarpa fascia; deep fascia (Buck’s fascia) is a continuation of deep perineal fascia, and Tunica albuginea (under Buck’s facia) forms an individual capsule around each cavernous body.

Scrotal layers include- Skin, superficial (Dartos) fascia, external spermatic fascia, cremaster muscle, internal spermatic fascia, and tunica vaginalis.

B. INNERVATIONS:

4. Penis: S2-S4 segments.

Sensory & Sympathetic innervation (skin + glans) Penis: Pudendal N. through Dorsal nerve of the penis (DNP) + Perineal nerves.
Encapsulated somatosensory receptors (mechanoreceptors/nociceptors) are present in prepuce.
Glans is innervated by free nerve endings and has protopathic sensitivity.
Parasympathetic: From the cavernous nerves from the peri-prostatic nerve plexus.

5. Scrotum & Testis: L1-L2 and S2-S4 (through IHG, IIN, GFN, and pudendal N).

Somatosensory: Anterolateral surface - Genital br. of GFN. Anterior surface - Anterior scrotal Ns. (br. of the IIN), Posterior surface- Posterior scrotal Ns. (from perineal N.), Inferior surface - Long scrotal br. (of PFCN).

Autonomic: Testes embryologically derived from the same level as the kidneys, so share common autonomic innervation.
90% Sympathetic from T10-L1 segments and 10% Parasympathetic from S2-S4.

Autonomic nerves (3 groups):
Superior spermatic Ns. (from renal & intermesenteric plexuses), Middle spermatic Ns. (from superior hypogastric plexus), Inferior spermatic Ns. (from inferior hypogastric plexus).

6. MYOTOMES:
Penile muscles (2 Bulbospongiosus + 2 Ishiocavernosus) : Deep branch of the perineal N. (branch of pudendal N).
Scrotal muscles (Dartos and Cremaster): Sympathetic and somatic fibres of the genital branch of GFN.

C. RA TECHNIQUES:

Target segments:
S2-S4: For all penile surgeries (Circumcision, hypospadias, urethroplasty, etc).
L1-L2, S2-S4: For all scrotal surgeries (Orchipexy, testis Sx, TURP etc)

7. Available RA techniques:

Caudal anesthesia -0.25-0.5 ml/kg LA volume (Lumbosacral segments). Associated with tachycardia, motor block of LL, and vomiting.

Topical analgesia using Lidocaine/Lidocaine + prilocaine.

Ring block – For analgesia. 8% failure rate, bleeding, and edema.

Penile block: Landmark-guided associated with swelling, hematoma/edema, or bruising. Ultrasound-guided is relatively safer.

8. Penile block (Landmark-guided):

Subpubic approach. Landmarks: Pubic symphysis & inferior border of the pubic rami.
2 needle entry points on lateral side of pubic symphysis, just below the pubic ramus (0.5 cm for babies and 1 cm for older boys).
Needle direction: Slightly medial & caudal direction (10-15 degrees to the vertical axis).
LA deposited- after a“POP” as the needle penetrates
Scarpas Fascia and enters into the subpubic space.
Coverage: DNP.
Sparing: Ventral penis, especially frenulum.

9. Penile block (USG-guided):

Probe kept transversely at the base of the penis between the shaft and the scrotum.
Sonoanatomy: Corpora cavernosa identified. Dorsal arteries, dorsal nerves, and dorsal vein are located beneath the deep fascia of the penis (Buck’s Fascia).

Standard 2-inj technique: LA injected laterally (0.1 ml/kg) to the penile A. inside Buck’s Fascia on each side.

Modified (by Suleman et al.) single inj. technique:

Needle: In-plane approach entering from the right side. After negative aspiration 0.15-0.25 ml/kg LA injected within the fascia around right DNP.

Needle slightly retracted under the corpora cavernosa. A 1-2 ml of LA deposited on the median line.

Needle was advanced towards the contralateral nerves and LA deposited under the fascia to block left DNP.

Advantage: Single entry needle with bilateral anesthesia of DNP + ventral glans. Circumferential spread of LA with anesthesia of the entire penis.

10. Supplementary RA techniques:

a) Ring block of penis:
Same cutaneous puncture as the dorsal block. Needle can be fanned out subcutaneously to the 3 and 9 o’clock position and then by repositioning the needle to these position to subcutaneous involve 6 o’clock/scrotal area.

b) Ilioinguinal + iliohypogastric nerves block:
Landmark-guided - Needle entry point 2cm medial and 2cm superior to the ASIS.

USG-guided: Probe is Kept obliquely on a line joining ASIS with umbilicus. Both nerves can be located between IOM-TAM with pulsating DCA adjacent to them.

c) Pudendal nerve block:

Landmark/PNS-guided- With the patient in the lithotomy, the ischial spine is palpated via transrectal (male) or transvaginal (female). LA deposition- Posterior to the ischial spine at the attachment of sacro-spinous ligament.

Ultrasound-guided: Pt in lateral decubitus position. Probe (curvilinear): Kept on the midpoint of the line connecting GT and PSIS. Sonoanatomy: Continuous hyperechoic line - iliac bone. The probe moved parallel and caudal to the lesser sciatic notch. Needle: 80-120 mm needle inserted in-plane from lateral-to-medial direction until tip located close to the pudendal A. Pudendal N. stimulation - Paresthesia in the perineum. LA volume: 15-20 ml LA.

The Electric Banana @ElectricBanwsm

over 7 years ago

Guillotine Dream and Rain Children this Saturday in Weston Super Mare !! @ElectricBanwsm #GothicRock #Rock #Independent #Lemuria #RainChildren #PostPunk #GothicAmericana #PsychedelicDreamPop #AnnaAndertonArt #vocalist #songwriter #darkandbeautiful #guitarist

McGothicfox Promotions @MGothicfox

about 8 years ago

The Musician Pub + tomorrow = 3 fab bands, great friends & lots of drink = day in bed hungover on Monday = well worth it 😂 #arielmanikiandtheblackhalos #auger #rainchildren #McGothicfoxpromotions #teamauger #themusicianpub #jackdaniels

MGothicfox's tweet photo. The Musician Pub + tomorrow = 3 fab bands, great friends & lots of drink = day in bed hungover on Monday = well worth it 😂
#arielmanikiandtheblackhalos #auger #rainchildren #McGothicfoxpromotions #teamauger #themusicianpub #jackdaniels https://t.co/nId5P6ljJP

McGothicfox Promotions @MGothicfox

about 8 years ago

The fantastic #auger are supporting the amazing #Lordofthelost on their UK tour😎 See them here first at The Musician Pub, Sunday 26th August, playing along with #arielmanikiandtheblackhalos & #rainchildren, doors 8pm 😎

MGothicfox's tweet photo. The fantastic #auger are supporting the amazing #Lordofthelost on their UK tour😎 See them here first at The Musician Pub, Sunday 26th August, playing along with #arielmanikiandtheblackhalos & #rainchildren, doors 8pm 😎 https://t.co/FHXNgMBZkq

McGothicfox Promotions @MGothicfox

about 8 years ago

Get yourselves down to #themusicianpub on Sunday, doors 8pm #arielmanikiandtheblackhalos, #auger, #rainchildren, #teamauger, #mcgothicfoxpromotions

MGothicfox's tweet photo. Get yourselves down to #themusicianpub on Sunday, doors 8pm #arielmanikiandtheblackhalos, #auger, #rainchildren, #teamauger, #mcgothicfoxpromotions https://t.co/PRkA4UuitV

McGothicfox Promotions @MGothicfox

about 8 years ago

Our first gig is made up of duos, #Auger, #RainChildren, except #Arielmanikiandtheblackhalos star a guest bassist making it 3, so we thought we'd show you the awesome duo, (some may say otherwise but don't listen to them 😉), that make up McGothicfox Promotions!!#McGothicfox

MGothicfox's tweet photo. Our first gig is made up of duos, #Auger, #RainChildren, except #Arielmanikiandtheblackhalos star a guest bassist making it 3, so we thought we'd show you the awesome duo, (some may say otherwise but don't listen to them 😉), that make up McGothicfox Promotions!!#McGothicfox https://t.co/fMU4y5393R

McGothicfox Promotions @MGothicfox

about 8 years ago

Why not treat yourselves to some fab gothic rock on August bank holiday weekend? No work the next day? No excuse then!! Get yourselves down to the musician 26/8/18 #arielmanikiandtheblackhalos #teamauger #rainchildren