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Background and Aims Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex procedure, associated with significant physiological alterations, postoperative pain and morbidity. While epidural analgesia is recommended in Enhanced Recovery After Surgery protocols, its use in CRS-HIPEC can be limited by perioperative coagulopathy, early anticoagulation resumption and compounded hypotensive effects. The erector spinae plane (ESP) block emerges as an alternative, yet no studies describe its continuous use in this setting.Methods We present the case of a 72-year-old female, ASA III, scheduled for CRS-HIPEC due to appendiceal adenocarcinoma. Her history included permanent atrial fibrillation on anticoagulation, an implantable cardioverter-defibrillator after in-hospital cardiac arrest and prior cerebrovascular accident following orthopedic surgery. A combined anesthetic approach was planned: balanced general anesthesia and continuous bilateral ESP block at T8-T9 under standard ASA monitoring, supplemented with invasive arterial pressure, processed electroencephalography, neuromuscular blockade and urine output monitoring. The block was performed using a catheter-over-needle system, under ultrasoung guidance. An initial bolus of 10 mL ropivacaine 0.2% was administered bilaterally, followed by intraoperative boluses every three hours (totaling 100 mg ropivacaine), complemented with multimodal systemic analgesia.Results The patient remained hemodynamically stable, with uneventful extubation. In the post-anesthesia care unit (PACU), fixed intermittent boluses of 10 mL ropivacaine 0.2% were administered via the perineural catheter, ensuring effective pain control without rescue analgesia. Anticoagulation was resumed on postoperative day (POD) 1. On POD 3, administration was transitioned to on-demand boluses, and the catheter was removed on POD 4. PACU stay was uneventful.Conclusions This case demonstrates the successful use of the ESP block, a fascial plane technique, to provide both visceral and somatic analgesia in managing severe surgical trauma while mitigating the risks associated with epidural techniques, including epidural hematoma, infection, and hypotension. Additionally, it contributed to reduced opioid use and promoted enhanced postoperative recovery.