A physiology-guided ketofol-based anaesthetic approach for emergency burr hole craniotomy in a child with Eisenmenger syndrome: a case report

BACKGROUND: Eisenmenger syndrome presents substantial perioperative risk because small perturbations in systemic or pulmonary vascular resistance may precipitate cardiovascular collapse. Evidence guiding anaesthetic management during emergency neurosurgery in paediatric patients remains limited. CASE PRESENTATION: We report an 11-year-old boy with Eisenmenger syndrome and severe pulmonary hypertension who underwent emergency burr hole craniotomy for drainage of a cerebral abscess. Perioperative management was guided by physiology-driven strategy encompassing invasive haemodynamic monitoring, preserving systemic vascular resistance, limiting pulmonary vascular resistance, and avoiding hypoxia and hypercarbia using vasoactive support and lung-protective ventilation. General anaesthesia was maintained using a self-prepared 1:4 ketamine-propofol (ketofol) infusion titrated to a bispectral index of 45-60, incorporated as one component of this approach. The intraoperative course remained stable without major desaturation or haemodynamic instability. The patient was extubated at the end of surgery, vasoactive support was subsequently weaned, and he was discharged with favourable neurological and clinical outcomes. CONCLUSION: This case illustrates that ketofol-based general anaesthesia can be incorporated into a physiology-driven perioperative strategy for emergency neurosurgery in selected patients with Eisenmenger syndrome. However, favourable outcomes cannot be attributed to the anaesthetic agent alone, and conclusions regarding superiority or generalisability cannot be drawn from a single case report.