Anticipated difficult intubation in a septic shock patient

Difficult intubation can be a real challenge for any anesthesiologist. It is particularly hazardous and much more difficult to manage in an emergency situation. We present a case of a 72 years old male patient who was brought to ER with stridor and increasing shortness of breath. He was unstable hemodynamically on presentation, so was managed with adrenaline/salbutamol nebs, I/V fluids and intermittent boluses of vasopressors in the ER. ENT referral was also sought who tried a quick nasal scope, but couldn’t come to any conclusion. During neck examination they could feel a mass in the upper part of the neck and made a provisional diagnosis of a pharyngeal abscess. Portable chest x-ray was unremarkable and there was no time to do a CT neck to confirm the diagnosis due to the patient’s worsening condition. It was decided to rush the patient to OR for an awake fibre-optic intubation in the presence of ENT team in case if there was a need to do an emergency tracheostomy. The OR was prepared accordingly and the patient’s upper airway was sprayed and nebulized with lignocaine.  A very small dose of remifentanil infusion was started for better tolerance of the procedure. Patient remained in an extremely critical condition with a systolic blood pressure 60-70 mmHg, despite of I/V fluids and metaraminol infusion. He also required intermittent boluses of 25 mics of adrenaline. There was no time for central venous access.