Cyanotic Congenital Heart Disease (cCHD) is characterized by intra-cardiac right-to-left shunting resulting in entrance of unsaturated blood into the systemic circulation and arterial hypoxemia. One of the common example of cCHD is TOF. It is characterised by right ventricular outflow tract obstruction, ventricular septal defect, overriding of aorta, right ventricular hypertrophy. Brain abscess is common in patient of right to left shunt. Surgery for brain abscess is preferred to be done under local anesthesia, as the general anesthesia is consider as a risky option. But in uncooperative children, GA is preferred. Major an aesthetic considerations are cyanotic spell, perioperative hemodynamic instability, electrolyte and acid-base imbalance and sudden cardiac arrest. We present a case of 10 year 20 kg child suffering from brain abscess who is known case of TOF, posted for craniotomy and excision of brain abscess. Our aim was to prevent raised intracranial pressure, electrolyte imbalance, dehydration and cyanotic spell. To avoid increase right to left shunt fraction, we avoid the use of propofol, Thiopentone sodium, high concentration of inhalation agent which cause systemic vasodilatation, decrease in systemic vascular resistance and decrease in after load. De-airing of IV line is important to prevent air embolism. If patient develop cyanotic spell, it should be managed with knee-chest position, oxygen, morphine, phenylephrine, Sodium Bicarbonate, volume resuscitation, beta blockers.
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