Complicaciones en anestesia regional / Regional anesthesia complications

Febrero 28, 2018. No. 3008

La anestesia general epidural combinada se asoció con un menor riesgo de complicaciones postoperatorias en pacientes sometidos a cirugía abdominal abierta por feocromocitoma: un estudio de cohortes retrospectivo. Combined epidural-general anesthesia was associated with lower risk of postoperative complications in patients undergoing open abdominal surgery for pheochromocytoma: A retrospective cohort study. Li N1, Kong H1, Li SL1, Zhu SN2, Wang DX1. Author information PLoS One. 2018 Feb 21;13(2):e0192924. doi: 10.1371/journal.pone.0192924. eCollection 2018. Abstract BACKGROUND: Current evidences show that regional anesthesia is associated with decreased risk of complications after major surgery. However, the effects of combined regional-general anesthesia remain controversial. The purpose of our study was to analyze the impact of anesthesia (combined epidural-general anesthesia vs. general anesthesia) on the risk of postoperative complications in patients undergoing open surgery for pheochromocytoma. METHODS: This was a retrospective cohort study. 146 patients who underwent open surgery for pheochromocytoma (100 received combined epidural-general anesthesia and 46 received general anesthesia) in Peking University First Hospital from January 1, 2002 to December 31, 2015 were enrolled. The primary outcome was the occurrence of postoperative complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between the choice of anesthetic method and the risk of postoperative complications. RESULTS: 17 (11.6%) patients developed complications during postoperative hospital stay. The incidence of postoperative complications was lower in patients with combined epidural-general anesthesia than in those with general anesthesia (6% [6/100] vs. 23.9% [11/46], P = 0.006). Multivariate Logistic regression analysis showed that use of combined epidural-general anesthesia (OR 0.219, 95% CI 0.065-0.741; P = 0.015) was associated with lower risk, whereas male gender (OR 5.213, 95% CI 1.283-21.177; P = 0.021) and perioperative blood transfusion (OR 25.879; 95% CI 3.130-213.961; P = 0.003) were associated with higher risk of postoperative complications. CONCLUSIONS: For patients undergoing open surgery for pheochromocytoma, use of combined epidural-general anesthesia may decrease the occurrence of postoperative complications. PDF Tratamiento con emulsiones lipídicas para el mioclono posterior a la anestesia espinal Lipid Emulsion Treatment for Post Spinal Anesthesia Myoclonus Nguyen TA, Phan DV, Dang TT, Joseph Eldor. J Health Sci Development 2018; 1:1 (19-24). Abstract Two case reports of myoclonus of legs post spinal anesthesia treated successfully by IV lipid emulsion are first described in the medical literature. A review of cases of myoclonus post regional anesthesia (spinal or epidural) are discussed with the hypothesis that the Lipid Emulsion effects are on the mitochondria and the intracellular calcium. Keywords: Myoclonus; Post spinal anesthesia myoclonus; Post epidural anesthesia myoclonus; Intralipid; Lipidem; Fat emulsion; Mitochondria; Intracellular calcium PDF Fallas y complicaciones en la Anestesia Regional Obstétrica Dr. Francisco J Cisneros-Rivas,* Dr. Israel Chávez-Ruiz* Rev Mex Anestiol Vol. 40. Supl. 1 Abril-Junio 2017 pp S150-S154 Introducción La anestesia neuroaxial es la técnica preferida en la paciente embarazada debido a que reduce o inhibe el dolor en las diferentes fases del trabajo de parto, el alumbramiento, así como en caso de requerirse en la cesárea, además de disminuir el uso de medicamentos que atraviesen la barrera placentaria que pudieran afectar al producto. Como cualquier otro procedimiento, la anestesia regional no se encuentra libre de fallas y complicaciones, debiendo tener en cuenta alternativas como la anestesia general y en caso de complicaciones saber cuáles son, con qué frecuencia se presentan, cuál es su sintomatología, saber cómo prevenirlas y en su caso cómo tratarlas, para evitar lesiones permanentes que puedan ser causa de una acción legal en contra de nosotros, independientemente de la seguridad y calidad que brindemos a nuestros pacientes. PDF Evaluación de la seguridad y eficacia de la anestesia regional en comparación con la anestesia general en el procedimiento de biopsia pulmonar toracoscópica en pacientes con fibrosis pulmonar idiopática. Evaluation of safety and efficacy of regional anesthesia compared with general anesthesia in thoracoscopic lung biopsy procedure on patient with idiopathic pulmonary fibrosis. Hajjar WM1, Al-Nassar SA1, Al-Sugair GS1, Al-Oqail A1, Al-Mansour S1, Al-Haweel R1, Hajjar AW2. Author information Saudi J Anaesth. 2018 Jan-Mar;12(1):46-51. doi: 10.4103/sja.SJA_265_17. Abstract BACKGROUND: Interstitial lung diseases are diseases that need histology diagnosis or obtaining a lung biopsy to establish the diagnosis. Surgical biopsies are performed usually using the thoracoscopy technique under general anesthesia (GA) although this procedure is still associated with morbidity rate. The aim of this study is to determine the effectiveness and safety of regional anesthesia (RA) compared with GA in thoracoscopic lung biopsy procedures done on patients with idiopathic pulmonary fibrosis (IPF). SUBJECTS AND METHODS: This is a retrospective qualitative study based on adult cases of video-assisted thoracoscopy (VAT) lung biopsy on patients with IPF admitted in the division of Thoracic Surgery, Department of General Surgery, King Khalid University Hospital, Riyadh, KSA. We included 67 patients with IPF, 26 with RA, and 41 with GA, who underwent this procedure from January 2008 to December 2015. Procedures performed under RA were done using three different approaches, intercostal nerve blocks, extrapleural infusion, and paravertebral block while GA was performed using double-lumen endotracheal tube placement. For statistical analysis, SPSS program, version 21.0. Software used to analyze the obtained data. The statistical significance was defined as P < 0.05. RESULTS: Sixty-seven patients underwent the procedure of thoracoscopic lung biopsy. Twenty-six of them (38.8%) underwent the procedure under RA and 41 (61.2%) under GA. The cross tabulation of the intercostal chest tube duration showed that it was significantly longer in GA group (6.23 ± 5.1 days) compared to RA group (3.12 ± 1.5 days), P = 0.004. Furthermore, for the Intensive Care Unit (ICU) stay, it was significantly longer in GA group (3.38 ± 2.1 days) compared to RA group (1.09 ± 0.7 days), P = 0.019. Regarding the relation between the number of biopsies taken and type of anesthesia performed, the probability values for GA group as well as RA group come out to be >0.05 (statistically independent) and the results of risk estimate also show that there was no significant association found between them. The cross tabulation of the representation of biopsies taken by the two methods showed that all biopsies taken under both settings were representative of the disease. Of 41 procedures done under GA, 16 of the total showed a number of complications. Likewise, of 26 procedures under RA, five cases showed complications. The significant (two-sided) value was (P = 0.110), there was no statistical significance between the risks of complications and the two types of anesthesia. CONCLUSION: There was a significant decrease in chest tube duration and ICU stay in RA group compared to the GA group. There was no statistical difference between both types of anesthesia in the number of biopsy, representation, and postoperative complications although the rate of these complications was much less in the RA group. Based on this outcome, we can conclude that VAT lung biopsy procedure on patients with IPF under RA is safe, representative, and effective operation. In addition, high-risk patients for GA can go through this procedure under RA as an alternative and safe option with no added complications. KEYWORDS: General anesthesia; idiopathic pulmonary fibrosis; regional anesthesia; thoracoscopic lung biopsy PDF Simposio Internacional de Emergencias Médicas y Paciente Crítico Santiago de Chile 31 de Mayo al 1 de Junio, 2018 Informes / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

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Anestesia regional para cirugía de tórax y brazos / Regional anesthesia for thoracic surgery and upper extremities

Febrero 21, 2018. No. 3001

Analgesia epidural torácica para procedimientos oncológicos de mama: una mejor alternativa a la anestesia general Thoracic epidural analgesia for breast oncological procedures: A better alternative to general anesthesia Ravi PR, Jaiswal P. J Mar Med Soc 2017;19:91-5 Abstract Objective: The objective of the study was to compare the outcomes of the incidence of nausea/vomiting and other complications along with the time taken for discharged in patients undergoing Thoracic Epidural Analgesia (TEA) and General Anaesthesia (GA) for breast oncological surgeries. Background: GA with or without TEA or other postoperative pain-relieving strategies remains the traditional anesthetic technique used for breast oncological procedures. We initiated the use of high segmental TEA for patients undergoing these procedures in our hospital. Methods: Eighty patients undergoing breast oncological procedures performed by one surgical team were randomly allocated into two groups receiving TEA and GA. The Chi-square test and Fisher's exact test were used for categorical parameters, paired t-test and Student's t-test was used for continuous measurements. Results: In comparison with GA, TEA was associated with lesser incidence of complications of nausea/vomiting. In lumpectomy with axillary node dissection, 1 out of 18 patients (5.55%) in the TEA group had nausea/vomiting, while 11 out of 19 (57.8%) of the GA group had similar symptoms (P < 0.001). The discharge rate for the thoracic epidural group was 12 out of 18 by day 3 (66.6%) while all patients in the GA group required more than 3 days of hospitalization (P< 0.001). Conclusion: Thoracic epidural anesthesia is a safe technique and its use in breast oncological procedures could improve patients' recovery and facilitate their early discharge to home. Keywords: Bupivacaine, general anesthesia, postoperative nausea and vomiting, regional anesthesia, ropivacaine PDF El bloqueo retrolaminar guiado por ultrasonido: distribución de inyecciones dependiente del volumen. The ultrasound-guided retrolaminar block: volume-dependent injectate distribution. Damjanovska M1, Stopar Pintaric T1,2, Cvetko E2, Vlassakov K3. Author information J Pain Res. 2018 Feb 7;11:293-299. doi: 10.2147/JPR.S153660. eCollection 2018. Abstract PURPOSE: The ultrasound-guided retrolaminar block is one of the newer and simpler alternatives to the traditional, often technically challenging, paravertebral (PV) block. Its feasibility, safety, and efficacy have already been clinically demonstrated in patients with multiple rib fractures using higher volumes of local anesthetic, when compared with the traditional approach. The primary aim of this observational anatomical study was to assess the spread of local anesthetic from the retrolaminar injection point to the PV space and its volume dependence. Second, we assessed the incidence of epidural and contralateral PV spread in the both groups. METHODS: Ten fresh porcine cadavers were randomized into 2 groups (n=5 each) to receive ultrasound-guided retrolaminar injections at Th4-Th5 level with either 10 mL (low-volume group) or 30 mL (high-volume group) of 2% lidocaine and methylene blue mixture. After the procedure, the cadavers were dissected and frozen. Cross-section cuts (~1 cm thick) were performed to evaluate the injectate spread. RESULTS: In the high-volume group, injectate spread from the retrolaminar to the PV space was observed in all specimens (5 out of 5; 100%), while in the low-volume group, no apparent spread to the PV space was found (0 out of 5; 0%). No epidural or contralateral PV spread was observed in any of the specimens. CONCLUSION: Following ultrasound-guided retrolaminar injections in fresh porcine cadavers, injectate spread from the retrolaminar tissue plane to the PV space is strongly volume dependent, suggesting that, clinically, high local anesthetic volumes maybe critical for achieving regional anesthesia and analgesia consistent with traditional PV blockade. KEYWORDS: injections; local anesthetic; paravertebral space; vertebral lamina PDF Bloqueo cervical epidural continuo. Tratamiento del hipo intratable Continuous cervical epidural block: Treatment for intractable hiccups. Kim JE1, Lee MK, Lee DK, Choi SS, Park JS. Author information Medicine (Baltimore). 2018 Feb;97(6):e9444. doi: 10.1097/MD.0000000000009444. Abstract Intractable hiccups, although rare, may result in severe morbidity, including sleep deprivation, poor food intake, respiratory muscle fatigue, aspiration pneumonia, and death. Despite these potentially fatal complications, the etiology of intractable hiccups and definitive treatment are unknown.......Continuous C3-C5 level cervical epidural block has a successful remission rate. We suggest that continuous cervical epidural block is an effective treatment for intractable hiccups. PDF Bloqueo cervical epidural para manejo de cirugía de trauma de miembro superior Dra. Leslian Janet Mejía-Gómez Rev Mex Anestesiol Volumen 36, Suplemento 1, abril-junio 2013 INTRODUCCIÓN Según la Organización Mundial de la Salud (OMS), los accidentes de tránsito producen diez millones de heridos y 300,000 muertes por año (1). En los países con mayor población de personas menores de 45 años los accidentes automovilísticos y laborales son la primera causa de cirugía por traumatismo de miembro superior (2). La proporción hombre:mujer es de 3 a 1(1,6). El manejo clínico y las decisiones anestésicas y terapéuticas dependen del tipo y de la gravedad de la fractura (3). Actualmente el trauma de miembro superior ocupa el tercer lugar dentro de los traumatismos en general, después que el trauma abdominal. Grant J (4), refi ere la incidencia del 78% de trauma en el miembro superior. El mecanismo de lesión más frecuente es directo y en segundo lugar por mecanismo indirecto secundario a tracción flexión (4,5). Las más afectadas son personas jóvenes en edad productiva, recibiendo los hombres, más lesiones que las mujeres en una proporción de 3:1.1(1,6). PDF Bloqueo cervicotorácico en cirugía de mama Videoclip World Congress on Regional Anesthesia & Pain Medicine April 19-21, 2018, New York City, USA Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Anestesia regional y cáncer / Regional anesthesia and cancer

Enero 29, 2018. No. 2978

Relación entre anestesia regional y cáncer. Un meta-análisis The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis. Grandhi RK, Lee S, Abd-Elsayed A. Author information Ochsner J. 2017 Winter;17(4):345-361. Abstract BACKGROUND: Some studies have suggested using epidural analgesia after cancer surgery to reduce metastasis. This article examines the relationship between regional anesthesia (RA) and cancer metastasis in an array of cancers. METHODS: We conducted a review of the literature using PubMed and included 67,577 patients across 28 studies in a metaanalysis, evaluating the hazard ratios (HRs) of overall survival, recurrence-free survival, and biochemical recurrence-free survival. RESULTS: We found no benefit to RA as it relates to cancer. The HR was 0.92 for overall survival, 1.06 for recurrence-free survival, and 1.05 for biochemical recurrence-free survival. Despite the overall analysis showing no benefit, we found some benefit when we evaluated only the randomized trials. However, we found no significant benefit of RA when we evaluated the cancers (gastrointestinal, prostate, breast, and ovarian) individually. CONCLUSION: This metaanalysis shows that RA has no overall survival, recurrence-free survival, or biochemical recurrence-free survival benefit. However, some individual studies have shown significant benefit in terms of cancer recurrence. Further, RA reduces the use of opioids, which has led to some secondary benefits. Further studies are needed to establish the benefits of RA as it relates to cancer. PDF Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information World Congress on Regional Anesthesia & Pain Medicine April 19-21, 2018, New York City, USA Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Hematoma neuraxial y anestesia regional/ Neuraxial hematoma and regional anesthesia

Febrero 21, 2017. No. 2607

Hematoma espinal subdural con síndrome de cauda equina: Complicación de anestesia espinal-epidural combinada Spinal subdural hematoma with cauda equina syndrome: A complication of combined spinal epiduralanesthesia. Singhal N1, Sethi P2, Jain JK3, Agarwal S3. J Anaesthesiol Clin Pharmacol. 2015 Apr-Jun;31(2):244-5. doi: 10.4103/0970-9185.155158.Abstract Combined spinal-epidural anesthesia (CSE) is considered safe in lower limb surgeries. We report a case of sudden neurological deterioration in a stable postoperative patient who was given CSE for total knee replacement and low molecular weight heparin in postoperative period. On the 4(th) postoperative day, she developed sudden onset weakness in left lower limb along with bladder incontinence. Magnetic resonance imaging spine revealed a subdural hematoma at L2-L3 level. Immediate laminectomy along with cord decompression was done and patient recovered well except for a persistent foot drop on left side. KEYWORDS:Cauda equina syndrome; combined spinal epidural anesthesia; epidural analgesia; subdural hematoma PDF Uso de plaquetas antes de punciones lumbares o anestesia epidural para la prevención de complicaciones en pacientes con trombocitopenia Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Estcourt LJ1, Ingram C, Doree C, Trivella M, Stanworth SJ. Cochrane Database Syst Rev. 2016 May 24;(5):CD011980. doi: 10.1002/14651858.CD011980.pub2. Abstract BACKGROUND:People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, epidural haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epiduralanaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians of the correct management of these patients. The risk of bleeding appears to be low but if bleeding occurs it can be very serious (spinal haematoma). Therefore, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit. OBJECTIVES: To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count). SEARCH METHODS: We searched for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2016, Issue 3), MEDLINE (from 1946), EMBASE (from 1974), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 3 March 2016. SELECTION CRITERIA: We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter. We only included RCTs published in English. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We identified no completed or ongoing RCTs in English. We did not exclude any completed or ongoing RCTs because they were published in another language. AUTHORS' CONCLUSIONS: There is no evidence from RCTs to determine what is the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future RCT would need to be very large to detect a difference in the risk of bleeding. We would need to design a study with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. PDF Recuperación espontánea de paraplegia producida por hematoma epidural después de retirar el catéter peridural Spontaneous recovery of paraplegia caused by spinal epidural hematoma after removal of epidural catheter. Iwashita K1, Shigematsu K1, Higa K1, Nitahara K1. Case Rep Anesthesiol. 2014;2014:291728. doi: 10.1155/2014/291728. Epub 2014 May 5. Abstract We report a patient who developed paraplegia caused by a spinal epidural hematoma after removal of an epidural catheter, which resolved spontaneously. A 60-year-old woman underwent thoracoscopic partial resection of the left lung under general anesthesia combined with epidural anesthesia. She neither was coagulopathic nor had received anticoagulants. Paraplegia occurred 40 minutes after removal of the epidural catheter on the first postoperative day. Magnetic resonance images revealed a spinal epidural hematoma. Surgery was not required as the paraplegia gradually improved until, within 1 hour, it had completely resolved. Hypoesthesia had completely resolved by the third postoperative day. PDF Hematoma epidural secundario a anestesia espinal. Tratamiento conservador M. Bermejo1 , E. Castañón1 , P. Fervienza1 , F. Cosío1 , M. Carpintero1 y M. L. Díaz-Fernández1 Rev. Soc. Esp. Dolor 11: 452-455, 2004 PDF Hematoma subdural-epidural grande, espontáneo después de anestesia peridural para cesárea. Manejo conservador con evolución excelente Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome. Siasios ID1, Vakharia K1, Gibbons KJ1, Dimopoulos VG1. Surg Neurol Int. 2016 Sep 22;7(Suppl 25):S664-S667. eCollection 2016. Abstract BACKGROUND:Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. CASE DESCRIPTION: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. CONCLUSIONS: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients. KEYWORDS: Caesarean section; hematoma; intensive care unit; subdural-epidural HTML  Hematoma epidural después de inyección epidural de esteroides Epidural hematoma after routine epidural steroid injection. Alkhudari AM1, Malk CS1, Rahman A1, Penmetcha T1, Torres M1. Surg Neurol Int. 2016 May 6;7:55. doi: 10.4103/2152-7806.181906. eCollection 2016. Abstract BACKGROUND:There are few reported cases of an epidural spinal hematoma following interventional pain procedures. CASE DESCRIPTION: We report a case of a spinal epidural hematoma in a patient with no known risk factors (e.g. coagulopathy), who underwent an epidural steroid injection (ESI) in the same anatomic location as two previously successful ESI procedures. CONCLUSION: Early detection was the key to our case, and avoiding sedation allowed the patient to recognize the onset of a new neurological deficit, and lead to prompt diagnosis as well as surgical decompression of the resultant hematoma. KEYWORDS:Epidural hematoma; epidural steroid injection; increased risk of neurological deficit; no long-term efficacy; paraparesis HTML Hematoma espinal subaracnoideo secundario a anestesia espinal. Reporte de un caso Dr. Oscar Eduardo Martínez-Baeza,* Dra. Claudia Agustina Ramos-Olmos,** Dr. Arnulfo Durá Revista Mexicana de Anestesiología Volumen 38, No. 2, abril-junio 2015 PDF Bloqueo epidural, hematoma peridural y enoxaparina Dr. Elio Cordero-Escobar, Dr. Carlos Segovia-García, Dr. Victor Whizar-Lugo, Dr. Josué Torres-Chávez, Carlos Villareal-Rubio  Anestesia en México Volumen 16 Número 3 Julio - Septiembre 2004 HTML Guía de práctica clínica para el manejo de la anestesia regional en el paciente que recibe anticoagulación y tromboprofilaxis Revista Mexicana de Anestesiología  Vol. 35. Supl. 2 Julio-Septiembre 2012 pp S390-S424 PDF Curso sobre Anestesia en Trasplantes, Cirugía abdominal, Plástica, Oftalmología y Otorrinolaringología. Committee for European Education in Anaesthesiology (CEEA)  y el Colegio de Anestesiólogos de León A.C. Abril 7-9, 2017, León Guanajuato, México Informes  (477) 716 06 16, kikinhedz@gmail.com 4° Congreso Internacional de Control Total de la Vía Aérea Asociación Mexicana de Vía  Aérea Difícil, AC Ciudad de México 21, 22 y 23 de Abril 2017 Informes: amvadmexico@gmail.com

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