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Background and Aims 85 yr Female for hip hemiarthroplasty ASA 4(?pathological fracture) She had advanced Breast cancer(palliative),Bronchial Asthma, Cellulitis, Morbidly obese, Anaemia(Hb-97),severe neck deformity(OA/Spondylosis) Recent upper limb DVT post PICC line insertion, poor iv access due to lymphedema. Her neck was extremely rotated to the right side due to neck spasm.Methods Patient cooperation was difficult for GA as in too much pain already. Patient also had fracture right arm(conservative ) and so could not lay on her side for spinal block. General anaesthesia was chosen for anaesthesia. DAS airway guidelines for anticipated difficult intubation was followed. Standard induction with GA Fentanyl, Propofol, Rocuronium . Neck remained extremely laterally flexed despite muscle relaxants! Patient was successfully intubated orally thro ambu fibreoptic intubation scope. We requested surgeons to put hard cervical collar preventatively to avoid neck movements during positioning laterally as her neck was very fragile . For pain management, patient received US guided Facia Iliaca and PENG blocks with no NSAIDS or long acting opioids due to her complex co-morbidities. Surgery was completed and patient was transferred back to the ward with no adverse events.Results Patient was extubated in theatre and the neck collar was removed in the recovery room after making sure she had no neurological deficits after the surgery due to her neck problems. Patient had no pain in recovery and for 18 hrs post nerve blocks.Abstract P060 Figure 1CT neck spineAbstract P060 Figure 2CT C-spine lateral viewConclusions Complex ASA 4 patients are common in trauma fracture hip fracture management. Our patient, in addition to being ASA 4, had difficult airway posing significant challenge .DAS guidelines for anticipated intubation was applied and successful in the first attempt of airway management. Patient made an uneventful recovery