Figure 2. Integrated perioperative and intraoperative timeline of anesthetic management and clinical course.

The figure illustrates the patient’s perioperative clinical course (top panel) alongside the intraoperative anesthetic timeline (bottom panel). The perioperative timeline summarizes key milestones from initial diagnosis to postoperative recovery. Preoperative evaluation demonstrated severe restrictive lung disease with otherwise unremarkable cardiac assessment.

The intraoperative timeline outlines the sequence of anesthetic interventions relative to induction. Following induction and neuromonitoring setup, ketamine (K) 0.25 mg·kg⁻¹ and lidocaine (L) 1 mg·kg⁻¹ boluses were administered, followed by continuous infusions at rates of 0.25 mg·kg⁻¹·h⁻¹ and 1 mg·kg⁻¹·h⁻¹, respectively, initiated at 45 minutes, preceding surgical incision at 50 minutes. Maintenance anesthesia consisted of total intravenous anesthesia with propofol and remifentanil in combination with ketamine and lidocaine, with stable neuromonitoring signals throughout. Midway through the procedure, at approximately the sixth hour, magnesium sulfate 40 mg·kg⁻¹ was administered over 30 minutes.

During surgical closure at approximately 8.5 hours, ketamine and lidocaine infusions were discontinued, and adjunct analgesia with ketorolac 0.5 mg·kg⁻¹ and paracetamol 15 mg·kg⁻¹ was administered, along with morphine. This was followed by the development of hypoventilation with respiratory acidosis, necessitating naloxone administration prior to successful extubation at approximately 10 hours after induction.

The figure was created using Microsoft PowerPoint (Microsoft Corporation, Redmond, WA, US).