Propofol-remifentanil target-controlled infusion for emergency craniotomy following multiple trauma in a resource-limited setting

Background: Target-controlled infusion (TCI) allows intravenous anesthetics to be titrated to model-predicted plasma or effect-site concentrations. In emergency neuroanesthesia, however, its clinical value depends not only on the selected target concentration but also on how these targets are adjusted in response to changing surgical stimulation while maintaining cerebral and systemic physiologic stability. We report the use of propofol TCI with the Schnider model and remifentanil TCI with the Minto model during emergency craniotomy in a patient with severe traumatic brain injury (TBI) and major thoracic trauma in Eastern Indonesia. Case Description: A 32-year-old male weighing approximately 80 kg presented with severe TBI after a 5-m fall, accompanied by right hemopneumothorax, multiple rib fractures, and a clavicular fracture. A chest tube was inserted before anesthetic induction. Propofol was administered using the Schnider model with an effect-site target concentration (Ce) of 3–5 µg/mL during induction and 2.5–4 µg/mL during maintenance. Remifentanil was administered using the Minto model at target concentrations of 4–5 ng/mL during induction and 2–3 ng/mL during maintenance, although the anesthesia record did not consistently specify whether plasma or effect-site targeting was used for remifentanil during maintenance. After induction, the targets were reduced and subsequently adjusted according to the stage and intensity of surgical stimulation, hemodynamic response, ventilation, and surgical conditions. During the 4-h procedure, systolic blood pressure remained between 102 and 125 mmHg, oxygen saturation was maintained at 99–100%, and end-tidal carbon dioxide remained between 30 and 35 mmHg. The brain remained relaxed without clinically apparent swelling. This case illustrates how separate hypnotic and opioid targets can be used to guide stepwise titration of propofol and remifentanil during emergency craniotomy when advanced depth-of-anesthesia and intracranial monitoring are not available. Conclusion: Propofol TCI using the Schnider model and remifentanil TCI using the Minto model provided a practical framework for independently titrating the hypnotic and opioid components of anesthesia during emergency craniotomy. In a resource-limited setting, model-predicted concentrations should not be regarded as fixed doses but rather as adjustable targets interpreted in conjunction with surgical stimulation, hemodynamic tolerance, ventilation, brain relaxation, and the limitations of available monitoring.