Successful Awake Endotracheal Intubation in a Patient With Predicted Anatomical and Physiological Difficult Airway Undergoing Emergency Surgery at a Secondary-Level Hospital: A Case Report

The management of a predicted difficult airway represents a significant clinical challenge, particularly in emergency settings and in patients with associated anatomical and physiological alterations. Awake tracheal intubation has demonstrated high success rates and a favorable safety profile; however, its use remains limited. We present the case of a 50-year-old female patient with late-onset sepsis secondary to chronic pyelonephritis who required an urgent left nephrectomy. During the preanesthetic assessment, multiple anatomical and physiopathological predictors of high complexity were identified, allowing classification as a predicted difficult airway with a mixed component. Given this scenario, awake endotracheal intubation was chosen, maintaining spontaneous ventilation, using airway topicalization, titrated sedoanalgesia with fentanyl and propofol, and videolaryngoscopy. Intubation was successful and without respiratory complications. The coexistence of multiple anatomical and physiological predictors of difficult airway in the context of emergency surgery constitutes a high-risk scenario during anesthetic induction, with an increased likelihood of hypoxia and hemodynamic instability. In this context, awake tracheal intubation allows preservation of spontaneous ventilation and reduces the risk of airway management failure. The use of videolaryngoscopy, combined with adequate topical anesthesia and titrated sedation, facilitated a safe approach tailored to the operator’s experience and available resources. Difficult airway management in emergency settings requires individualized decision-making based on comprehensive patient assessment, anesthesiologist experience, and the clinical environment. Awake tracheal intubation may contribute to optimizing perioperative safety, as demonstrated in the present case.