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Background and Aims A 68 years old, Frailty 5, cachectic male was admitted to the emergency department with acute severe abdominal pain, haematemesis and shock. He had known hypertension, tonsillar cancer (treated by irradiation), shigillocellular gastric adenocarcinoma. Examinations revealed gastric perforation needing urgent surgery. He had severe postirradiation contracture and rigid scar tissues on the neck with limited retroflexion and potentially difficult airway. Our aim was to secure the airway safely, providing efficient analgesia and minimising the use of opioids.

Methods We decided to perform an awake fiberoptic intubation (AWFOI) to avoid potential intubation failure, mask ventilation, aspiration, Cannot Intubate Cannot Oxygenate scenario. AWFOI was carried out uneventfully with low dose remifentanil and lidocaine topicalisation. Through bilateral subcostal incision Billroth II gastrojejunostomy and cholecystectomy was performed. After the operation ultrasound-guided bilateral external oblique intercostal (EOI) plane catheter was introduced and loaded with 20-20 ml 0.25% bupivacaine avoiding the potentially life threatening consequences of epidural analgesia in a patient with severe shock. The patient was transferred to ICU, hours later he was extubated with VAS scale 1/10.

Results Continuous EOI blocks were accomplished by intermittent boluses 12 hourly for 2 days in order to facilitate mobilization. For analgesic supplementation paracetamol was used. On the first postoperative day the patient was discharged from ICU, 7 days later he was discharged from the hospital to his home.

Conclusions EOI catheter can be a safe and effective analgesic method for bilateral subcostal incisions especially in fragile patients.