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All Journal Open Access Indonesian Journal of Medical Reviews Journal of Anesthesiology and Clinical Research
Anak Agung Ngurah Aryawangsa
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Biochemistry, Genetics & Molecular Biology Health Professions Immunology & microbiology Medicine & Pharmacology Neuroscience

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Navigating the Nexus: Anesthetic Management of Craniotomy for Brain Abscess in a Pediatric Patient with Uncorrected Tetralogy of Fallot Anak Agung Ngurah Aryawangsa; Ida Bagus Krisna Jaya Sutawan
Journal of Anesthesiology and Clinical Research Vol. 6 No. 1 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i1.766

Abstract

Introduction: Tetralogy of Fallot (TOF) is the most prevalent cyanotic congenital heart disease, predisposing patients to brain abscesses via right-to-left shunting that bypasses pulmonary bacterial filtration. Anesthetic management for craniotomy in pediatric patients with uncorrected TOF and a concurrent brain abscess presents a formidable challenge, requiring meticulous integration of neuroanesthetic and cardiac anesthetic principles. Literature detailing comprehensive perioperative anesthetic strategies for this specific dual pathology remains scarce. Case presentation: An 11-year-old male with uncorrected TOF and a large left frontoparietal brain abscess with significant mass effect underwent emergent craniotomy and abscess evacuation. Preoperative echocardiography confirmed TOF with severe pulmonary stenosis and right-to-left shunting. Anesthetic induction was achieved with titrated ketamine and propofol, followed by fentanyl and rocuronium. Maintenance involved sevoflurane, oxygen-air mixture, and intermittent fentanyl and rocuronium, focusing on normovolemia, normocapnia to slight hypocapnia, and invasive hemodynamic monitoring. Phenylephrine was utilized for blood pressure support. The perioperative period was uneventful, with the patient experiencing no neurological or cardiac complications. Conclusion: This case underscores the critical importance of a tailored anesthetic approach, integrating neuroprotective strategies with meticulous cardiovascular management, in children with uncorrected TOF undergoing major neurosurgery. Comprehensive preoperative assessment, vigilant intraoperative monitoring, strategic pharmacological interventions, and a deep understanding of the complex pathophysiology are paramount to preventing cyanotic spells, managing intracranial pressure, and ensuring a successful outcome in this high-risk cohort.
Hemodynamic Stability via Ultrasound-Guided Axillary Brachial Plexus Block with Levobupivacaine-Dexamethasone in a Patient with Impending Thyroid Storm and Hand Fracture Anak Agung Ngurah Aryawangsa
Open Access Indonesian Journal of Medical Reviews Vol. 6 No. 1 (2026): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v6i1.855

Abstract

The perioperative management of patients with uncontrolled hyperthyroidism requiring emergency surgery presents an acute clinical challenge, as surgical trauma and anesthesia can precipitate a life-threatening thyroid storm. This case report examines the strategic role of regional anesthesia in mitigating such risks through complete afferent blockade and sympathetic stabilization. A 28-year-old male presented with multiple right-hand fractures following a motorcycle accident. The patient had a history of untreated hyperthyroidism for one year and exhibited classic clinical thyrotoxicosis, including tachycardia of 104 bpm, hypertension of 164/90 mmHg, bilateral exophthalmos, and hyperkinesis. Laboratory investigations confirmed primary hyperthyroidism with a markedly elevated free T4 of 86.6 pmol/L and suppressed TSH. His Burch-Wartofsky Point Scale (BWPS) score was calculated at 30, indicating an impending thyroid storm. Following rapid medical optimization with propylthiouracil, propranolol, hydrocortisone, and amlodipine, surgical intervention was successfully performed under ultrasound-guided axillary brachial plexus block. The anesthetic mixture comprised 20 mL of 0.5 percent levobupivacaine and 8 mg of perineural dexamethasone. The patient demonstrated remarkable hemodynamic stability throughout the two-hour procedure, maintaining a systolic blood pressure between 115 and 135 mmHg and a heart rate between 82 and 94 bpm, without progressing to a thyroid crisis. In conclusion, ultrasound-guided regional anesthesia, specifically the axillary approach, offers a superior safety profile for thyrotoxic patients by avoiding airway instrumentation and preventing the sympathetic surges associated with general anesthesia. The synergistic use of levobupivacaine and dexamethasone provides a dual benefit of enhanced cardiac safety and peripheral endocrine stabilization.
Co-Authors Ida Bagus Krisna Jaya Sutawan