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#35053 External oblique Intercostal fascial plane block for patients undergoing liver transplantation: a case series
  1. Sindhuja Nimma1,
  2. Kishan Patel1,
  3. Dana Perry2,
  4. Stephen Aniskevich III1,
  5. Ryan Chadha1 and
  6. Hari Kalagara1
  1. 1Anesthesiology and perioperative medicine, Mayo Clinic, Jacksonville, USA
  2. 2Transplant surgery, division chair, Mayo Clinic, Jacksonville, USA


Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less)

Background and Aims In patients undergoing liver transplantation, postoperative pain control can be challenging since a neuraxial block is contraindicated with ongoing coagulopathy. This led us to investigate the utility of ultrasound-guided external oblique intercostal (EOI) blocks in this patient population. Local anesthetic is injected in the fascial plane between the external oblique and intercostal muscle at the T6 and T8 levels, bilaterally, for somatic coverage of the ‘chevron’ incision. Here, we present a small comparative case series.

Methods This is a retrospective chart review comparing the postoperative opioid utilization of five patients with and without the EOI block.

Results The average oral morphine equivalents (OME) for POD 0, 1, 2, and 3 were 39mg, 70.5mg, 28.4mg, and 12.3mg in the EOI group and 71.8mg, 109.1mg, 85.5mg, and 53.5mg in the control group (table 1).

Abstract #35053 Table 1

Comparing the postoperative opioid utilization of five patients with and without the EOI block

Abstract #35053 Figure 1

This animation depicts the location of a typical subcostal ‘chevron’ incision along with ultrasound probe placement for the EOI fascial plane block. The expected sensory distribution of blockade is seen extending from midline to the lateral abdomen from anesthetizing the lateral and anterior cutaneous branches of the intercostal nerves. Illustrator: Kishan Patel, MD

Abstract #35053 Figure 2

This animation depicts the relative anatomy for the EOI fascial plane block. Note that the origin of the external oblique muscle is at the external surface of ribs 5 through 12. The tip of the Tuohy needle can be seen at the fascial layer between the external oblique muscle and intercostal muscles. This is the plane where local anesthetic is placed to anesthetize the lateral and anterior cutaneous branches of the intercostal nerves. Illustrator: Kishan Patel, MD

Conclusions 30ml of 0.25% bupivacaine mixed with 20ml of liposomal bupivacaine was used and 12.5ml of this mixture was injected at each level. The average OME for each postoperative day was higher in the control group compared to the EOI group. The average OME values in the control group were close to double on POD 0 and 1 and more than doubled on POD 2 and 3 compared to EOI group. The EOI block made a clinically significant difference in our patients’ opioid usage and overall satisfaction. The EOI block is superficial with reliable sonoanatomy and can be performed in the supine position without interfering with the surgical incision. Most importantly it can be performed in liver transplant patients with ongoing coagulopathy.

Attachment EOI_livertransplant_ESRA_abstract_final.docx

  • external oblique intercostal fascial plane block
  • liver transplant
  • coagulopathy
  • chevron incision

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