Anaesthetic Management of Anti-NMDA Receptor Encephalitis with Super-Refractory Status Epilepticus Undergoing Laparoscopic Ovarian Cystectomy and Tracheostomy: A Case Report

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune encephalitis predominantly affecting young women and frequently associated with ovarian teratoma. Anaesthetic management is challenging due to the interaction of commonly used agents with NMDA receptor pathways, and the risk of seizures, autonomic instability, and super-refractory status epilepticus (SRSE). We report the perioperative management of a 22-year-old woman with anti-NMDAR encephalitis who underwent laparoscopic ovarian cystectomy and subsequent tracheostomy. Despite immunotherapy and multiple antiepileptic agents, she progressed to SRSE requiring ketamine infusion. Both procedures were performed under propofol-based total intravenous anaesthesia (TIVA) with remifentanil, dexmedetomidine, midazolam, and continued ketamine infusion as antiepileptic therapy. Bilateral transversus abdominis plane block provided opioid-sparing analgesia for the laparoscopic procedure. Intraoperative monitoring included invasive arterial pressure, central venous pressure, point-of-care metabolic testing, and processed EEG. No epileptiform activity or haemodynamic instability was observed during either procedure. Subsequently, the patient weaned off adjunctive anit-epileptics and achieved seizure freedom one month postoperatively. This case illustrates the importance of multidisciplinary planning, disease-specific anaesthetic drug selection, invasive monitoring, and cautious EEG interpretation in anti-NMDAR encephalitis complicated by SRSE.