Perioperative Challenges in Emergency Neurosurgery for a Paediatric Patient with Unrepaired Tetralogy of Fallot: A Case Report

Paediatric patients with unrepaired Tetralogy of Fallot (TOF) presenting for emergency neurosurgery pose a unique perioperative challenge due to the delicate relationship between cyanotic heart disease physiology and elevated Intracranial Pressure (ICP). The anaesthetic management of an uncorrected six-year-old male with a lateral ventricular brain abscess, ventriculitis, hydrocephalus, and thrombocytopenia was presented. Preoperative evaluation revealed central cyanosis, a systolic murmur, and an aberrant coronary artery passing through the Right Ventricular Outflow Tract (RVOT), which posed a problem in anaesthetic management. Acute desaturation and hypotension during surgery after intracranial decompression were probably due to increased right-to-left shunting secondary to a decrease in Systemic Vascular Resistance (SVR). This was managed with phenylephrine boluses (10 mg) and 100% oxygen. A stable cerebral and cardiac status was achieved with an anaesthetic technique involving thiopentone, atracurium, and controlled sevoflurane administration. The patient recovered uneventfully postoperatively, without any new neurological deficit, and was haemodynamically stable on discharge. This case emphasises the importance of close perioperative care, anticipation of cyanotic spells, and individualised anaesthetic care in the management of complex neurosurgical emergencies in patients with cyanotic congenital heart disease. It reinforces that early therapy and understanding of cardiocerebral pathophysiology can optimise outcomes even in high risk children.