External oblique intercostal plane block in paediatric patients with thrombocytopenia for open splenectomy: Simple and promising…

Dear Editor,

Upper abdominal surgeries with subcostal incisions can lead to severe postoperative pain and respiratory impairment.[1] Fascial plane blocks have emerged as an effective analgesic alternative to the neuraxial techniques in such surgeries.

Here we describe the successful use of external oblique intercostal (EOI) block in six pediatric patients (mean age: 2.6 ± 0.97 years) with beta thalassemia major having thrombocytopenia (platelet count ranging from 30,000- 60,000/mm³) and scheduled for open splenectomy.

General anesthesia was induced with intravenous (IV) fentanyl 2 μg/kg, propofol 2 mg/kg, and atracurium 0.5 mg/kg. An appropriately sized endotracheal tube was inserted. With the patient in supine position, a high-frequency pediatric linear transducer (5–16 MHz, Turbo M, Sonosite) was placed in the sagittal plane between the midclavicular and anterior axillary line at the level of sixth/seventh rib. A 5-cm echogenic needle was inserted from cranial to caudal direction to deposit 0.4 ml/kg of 0.2% ropivacaine between the external oblique (EO) and the intercostal muscle (IM) [Figure 1]. Successful block was ascertained by the lifting of EO muscle from IM due to the drug deposited in between [Figure 1]. Any increase in heart rate or mean arterial pressure by more than 20% was treated with IV fentanyl 0.5 μg/kg. IV paracetamol was given to the patients eighth hourly as per their body weight.

Figure 1.

Ultrasound image of external oblique intercostal plane block

Faces, leg, activity, cry, and consolability (FLACC) score was used for postoperative pain assessment at 0, 2, 4, 6, 8, 12, 16, and 24 h. Postoperatively, IV fentanyl 0.5 μg/kg was given as rescue analgesia for patients if the FLACC score was ≥4. The median (interquartile range) of pain was 3.5 (2–4). Intraoperatively, only three patients required fentanyl top-ups with a mean of 1.33 ± 0.47 μg/kg. The mean 24-h fentanyl consumption was 1.33 ± 0.471 μg/kg. No adverse effects like nausea, vomiting, sedation, and respiratory depression were documented.

Traditionally, neuraxial blocks have been used for abdominal surgeries. In patients with low platelet count, this might not be a feasible option.[2] Interfascial plane blocks like subcostal transversus abdominis plane block spare the lateral cutaneous branch of the intercostal nerve, while rhomboid intercostal subserratus plane block spares the anterior cutaneous branch.

External oblique block has the advantage of providing both anterior and lateral abdominal wall analgesia due to the spread of the drug to cover the anterior and lateral cutaneous branches of the intercostal nerves from T6/7 to T10/11.[3]

It is technically easy to perform in pediatric patients, where it is difficult to locate the depth of the anatomical target site. The point of the block is away from the operative site, making it a viable option in redo surgeries and in the presence of infection/drain at the site of surgery. It is performed in the supine position with ease of catheter insertion.[4]

A disadvantage of this block is that it does not ensure visceral analgesia, which is represented by requirement of opioids perioperatively. Hence, we recommend that EOI block can form a part of multimodal analgesic regimen in pediatric patients with thrombocytopenia or coagulation abnormality scheduled for upper abdominal surgeries. Further randomized studies are required to validate our findings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.