51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

The External Oblique Intercostal (EOI) nerve block is a relatively new fascial plane block for post-operative analgesia of the upper anterior and lateral abdominal wall.¹ The EOI fascial plane is amenable to placement of nerve catheters for ongoing administration of local anesthetic.²The EOI block is superficial, performed under ultrasound guidance superior to surgical dressings, and can be performed while the patient is sedated and supine. It has emerged as an analgesic option for patients undergoing major abdominal surgery to reduce post-op pain and facilitate recovery.³ We report on the use of EOI peripheral nerve catheters (PNCs) for post-op analgesia in a liver transplant recipient with severe thrombocytopenia.

Case Description

A 57 year old female with a history of end stage liver disease secondary to alcohol use, previous Roux-en-Y gastric bypass, mild pulmonary hypertension, anxiety, and fibromyalgia underwent a DBD (donation after brain death) liver transplant with a Chevron incision. Surgery was complicated by significant blood loss (35 liters) and massive transfusion. She was transferred to the ICU intubated after surgery. On post-op day one, the transplant team requested PNC placement prior to extubation for post-operative pain control. They felt that the patient was stable from a bleeding standpoint, and she would not need to return to the operating room, but her platelet count would likely not improve within the next few days. Platelet count at time of catheter placement was 18 K/uL, and her INR was 1.4. She was extubated on post-op day two.

Ropivacaine 0.15% 8 mL was administered in each PNC as a bolus every hour, and the PNCs were maintained for four days. While catheters were in place, the patient received acetaminophen 500 mg q6h scheduled, two doses of oxycodone 10 mg, and no other pain medications. The patient was seen twice daily by the Acute Pain Service with the catheter sites assessed each morning. She reported mild to moderate pain throughout the post-operative period. She reported satisfaction with her pain regimen and felt that the PNCs were helpful. On the day of PNC removal, platelet count was 24 and INR was 1.1.

Discussion

This case demonstrates the successful use of continuous EOI blocks for post-operative pain control in a patient with thrombocytopenia after a liver transplant. The EOI block is proposed as an alternative to neuraxial analgesia, which is contraindicated in patients at high risk of bleeding, such as those with coagulopathy associated with liver disease.

•The 2025 AABB and the ICTMG recommend (“conditional recommendation; very low–certainty evidence”) platelet transfusion for IR procedures if platelets are <20 × 10⁹/L for low-risk procedures and <50 × 10⁹/L for high-risk procedures.⁴

•National guidelines recommend against prophylactic transfusion of platelets for low-risk procedures (such as paracentesis and thoracentesis) in stable cirrhosis patients.^5,6

•A practice advisory by the Regional Anesthesia and Acute Pain Section of the Canadian Anesthesiologists Society categorized serratus anterior blocks and intercostal blocks as “intermediate” risk (expert opinion).⁷

•There are no established formal guidelines regarding minimum platelet count or bleeding risk for the EOI block specifically.

With the expanding clinical use of fascial plane blocks, further research is needed to better define minimum platelet thresholds for fascial plane catheters to guide their use as a safe component of multimodal analgesia.

References

1. Elsharkawy H, Kolli S, Soliman LM, et al. Pain Med. 2021;22(11):2436-2442.

2. Liotiri D, Diamantis A, Zacharoulis D. Br J Anaesth. 2025;134(4):1187-1189.

3. Yi S, Zhang X, Song Y, et al. BMC Anesthesiol. 2025;25(1):158.

4. Metcalf R, Nahirniak S, Guyatt G, et al. JAMA. 2025;334(7):606-617.

5. Biolato M, Vitale F, Galasso T, et al. World J Gastrointest Surg. 2023;15(2):127-141.

6. Northup P, Garcia‐Pagan J, Garcia‐Tsao G, et al. Hepatology. 2021;73(1):366-413.

7. Tsui B, Kirkham K, Kwofie M, et al. Can J Anaesth. 2019;66(11):1356-1384.

51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

External Oblique Intercostal Catheters for Liver Transplant Recipient with Severe Thrombocytopenia

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