Inflate the cuff of the endotracheal tube with sufficient air to seal the area between the trachea and the tube. The data collected including the number visitors, the source where they have come from, and the pages visited in an anonymous form. Apropos of a case surgically treated in a single stage]. We evaluated three different types of anesthesia provider in three different practice settings. Seegobin and Hasselt reached similar conclusions in an in vitro study and recommended cuff inflation pressure not exceed 30 cm H2O [20]. First, inflate the tracheal cuff and deflate the bronchial cuff. To achieve the optimal ETT cuff pressure of 2030cmH2O [3, 8, 1214], ETT cuffs should be inflated with a cuff manometer [15, 16]. The authors declare that they have no conflicts of interest. Zhonghua Yi Xue Za Zhi (Taipei). E. Resnikoff and A. J. Katz, A modified epidural syringe as an endotracheal tube cuff pressure-controlling device, Anaesthesia and Analgesia, vol. Investigators measured the cuff pressure at 60 minutes after induction of anesthesia using a manometer (VBM, Sulz, Germany) that was connected to the pilot balloon of the endotracheal tube cuff via a three-way stopcock. 14231426, 1990. Independent anesthesia groups at the three participating hospitals provided anesthesia to the participating patients. However, this could be a site-specific outcome. . 443447, 2003. Air Leak in a Pediatric CaseDont Forget to Check the Mask! We included ASA class I to III adult patients scheduled to receive general anesthesia with endotracheal intubation for elective surgical operation. Related cuff physical characteristics, Chest, vol. U. Nordin, The trachea and cuff-induced tracheal injury: an experimental study on causative factors and prevention, Acta Oto-Laryngologica, vol. Symptoms of a severe air embolism might include: difficulty breathing or respiratory failure. Smooth Murphy Eye. If an air leak is present, add just enough air to seal the airway and measure cuff pressure again. The manual method used a pressure manometer to adjust pressure at cruising altitude and after landing. Compliance of the cuff system was evaluated by linear regression of measured cuff pressure vs. measured cuff volume. COPD, head injury, ARDS), Rapid sequence induction (RSI) intubation, Procedural variation using rapid anaesthetisation with cricoid pressure to prevent aspiration while airway is quickly secured, Used for patients at risk of aspiration e.g. In case of a very low pressure reading (below 20cmH, https://pdfs.semanticscholar.org/c12e/50b557dd519bbf80bd9fc60fb9fa2474ce27.pdf. These were adopted from a review on postoperative airway problems [26] and were defined as follows: sore throat, continuous throat pain (which could be mild, moderate, or severe), dysphagia, uncoordinated swallowing or inability to swallow or eat, dysphonia, hoarseness or voice changes, and cough (identified by a discomforting, dry irritation in the upper airway leading to a cough). Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, http://www.biomedcentral.com/1471-2253/4/8/prepub. Neither measured cuff pressure nor measured cuff volume differed among the hospitals (Table 2). Abstract: An endotracheal tube includes a main tubular portion including a distal end and a proximal end opposite the distal end, the main tubular portion including a central lumen at least in part defined by a wall of the main tubular portion; a . Methods. 175183, 2010. In the absence of clear guidelines, many clinicians consider 20 cm H2O a reasonable lower limit for cuff pressure in adults. The cookie is used to determine new sessions/visits. Liu H, Chen JC, Holinger LD, Gonzalez-Crussi F: Histopathologic fundamentals of acquired laryngeal stenosis. 965968, 1984. An anesthesia provider inserted the endotracheal tubes, and the intubator or the circulating registered nurse inflated the cuff. General anesthesia was induced by intravenous bolus of induction agents, and paralysis was achieved with succinylcholine or a non-depolarizing muscle relaxant. Support breathing in certain illnesses, such . The cuff was then briefly overinflated through the pilot balloon, and the loss of resistance syringe plunger was allowed to passively draw back until it ceased. An intention-to-treat analysis method was used, and the main outcome of interest was the proportion of cuff pressures in the range 2030cmH2O in each group. It helps us understand the number of visitors, where the visitors are coming from, and the pages they navigate. This method has been achieved with a modified epidural pulsator syringe [13, 18], a 20ml disposable syringe, and more recently, a loss of resistance (LOR) syringe [21, 23, 24]. The individual anesthesia care providers participated more than once during the study period of seven months. Note correct technique: While securing the ET tube with one hand, inflate the cuff with 5-10 cc's of air. We recorded endotracheal tube size and morphometric characteristics including age, sex, height, and weight. The tube is kept in place by a small cuff of air that inflates around the tube after it is inserted. 2017;44 8184, 2015. We also appreciate the statistical analysis by Gilbert Haugh, M.S., and the editorial assistance of Nancy Alsip, Ph.D., (University of Louisville). However, less serious complications like dysphagia, hoarseness, and sore throat are more prevalent [911]. 6, pp. The cookie is updated every time data is sent to Google Analytics. 2, pp. What are the . BMC Anesthesiol 4, 8 (2004). In certain instances, however, it can be used to. 1: anesthesia resident; 2: anesthesia officer; 3: anesthesia officer student; 4: anesthesiologist. At the time of the intervention, the study investigator retrieved the next available envelope, which indicated the intervention group, from the next available block envelope and handed it to the research assistant. The exact volume of air will vary, but should be just enough to prevent air leaks around the tube. Our primary outcomes were 1) measured endotracheal tube cuff pressures as a function of tube size, provider, and hospital; and 2) the volume of air required to produce a cuff pressure of 20 cmH2O as a function of tube size. C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. Ann Chir. This single-blinded, parallel-group, randomized control study was performed at Mulago National Referral Hospital, Uganda. The study was approved by Makerere University College of Health Sciences, School of Medicine Research Ethics Committee (SOMREC), The Secretariat Makerere University College of Health Sciences, Clinical Research Building, Research Co-ordination Office, P.O. The study comprised more female patients (76.4%). Generally, the proportion of ETT cuffs inflated to the recommended pressure was less in the PBP group at 22.5% (20/89) compared with the LOR group at 66.3% (59/89) with a statistically significant positive mean difference of 0.47 with value<0.01 (0.3430.602). Another viable argument is to employ a more pragmatic solution to prevent overly high cuff pressures by inflating the cuff until no air leak is detected by auscultation. 1977, 21: 81-94. R. Fernandez, L. Blanch, J. Mancebo, N. Bonsoms, and A. Artigas, Endotracheal tube cuff pressure assessment: pitfalls of finger estimation and need for objective measurement, Critical Care Medicine, vol. B) Dye instilled into the defective endotracheal tube stops at the entrance of the pilot balloon tubing into the main tubing (arrow in Figure 2A and 2B). Cuff pressure in tube sizes 7.0 to 8.5 mm was evaluated 60 min after induction of general anesthesia using a manometer connected to the cuff pilot balloon. K. C. Park, Y. D. Sohn, and H. C. Ahn, Effectiveness, preference and ease of passive release techniques using a syringe for endotracheal tube cuff inflation, Journal of the Korean Society of Emergency Medicine, vol. This however was not statistically significant ( value 0.052). ); and patients with known anatomical laryngeo-tracheal abnormalities were excluded from this study. One study, for instance, found that cuff pressure exceeded 40 cm H2O in 40-to-90% of tested patients [22]. It should however be noted that some of these studies have been carried out in different environments (emergency rooms) and on different kinds of patients (emergency patients) by providers of varying experience [2]. Previous studies suggest that the cuff pressure is usually under-estimated by manual palpation. Cite this article. We therefore also evaluated cuff pressure during anesthesia provided by certified registered nurse anesthetists (CRNAs), anesthesia residents, and anesthesia faculty. Analytics cookies help us understand how our visitors interact with the website. Anesthesia services are provided by different levels of providers including physician anesthetists (anesthesiologists), residents, and nonphysician anesthetists (anesthetic officers and anesthetic officer students). Cuff pressures were thus less likely to be within the recommended range (2030 cmH2O) than outside the range. Consequences of micro-aspiration of oropharyngeal secretions include nosocomial pulmonary infections [1]. There is a relatively small risk of getting ETT cuff pressures less than 30cmH2O with the use of the LOR syringe method [23, 24], 12.4% from the current study. LOR group (experimental): in this group, the research assistant attached a 7ml plastic, luer slip loss of resistance syringe (BD Epilor, USA) containing air onto the pilot balloon. Ninety-three patients were randomly assigned to the study. Endotracheal tube system and method . trachea, bronchial tree and lung, from aspiration. Cuff pressure adjustment: in both arms, very high and very low pressures were adjusted as per the recommendation by the ethics committee. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs. This cookies is installed by Google Universal Analytics to throttle the request rate to limit the colllection of data on high traffic sites. The Human Studies Committee did not require consent from participating anesthesia providers. Endotracheal tubes are widely used in pediatric patients in emergency department and surgical operations [1]. [22] observed cuff pressure exceeding 40 cm H2O in 91% of PACU patients after anesthesia with nitrous oxide, 55% of ICU patients, and 45% of PACU patients after anesthesia without nitrous oxide. Taking another approach to the same question, we also determined compliance of the cuff-trachea system in vivo by plotting measured cuff pressure against cuff volume. volume4, Articlenumber:8 (2004) Gac Med Mex. Secures tube using commercially approved tube holder. Inflate the cuff with 5-10 mL of air. However, a full hour was plenty of time for the provider to have checked and adjusted cuff pressure to a suitable level. R. D. Seegobin and G. L. van Hasselt, Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs, British Medical Journal, vol. Luna CM, Legarreta G, Esteva H, Laffaire E, Jolly EC: Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube. B) Defective cuff with 10 ml air instilled into cuff. 1981, 10: 686-690. Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H: Intracuff pressures in endotracheal and tracheostomy tubes. BMC Anesthesiology Every patient was wheeled into the operating theater and transferred to the operating table. Box 7072, Kampala, Uganda (Email: rresearch9@gmail.com; research@chs.mak.ac.ug). This is used to present users with ads that are relevant to them according to the user profile. Although this was a single-blinded, single-centre study, results suggest that the LOR syringe method was superior to PBP at administering pressures in the optimal range. 4, pp. A newer method, the passive release technique, although with limitations, has been shown to estimate cuff pressures better [2124]. Crit Care Med. Dont Forget the Routine Endotracheal Tube Cuff Check! The patient was the only person blinded to the intervention group. The relationship between measured cuff pressure and volume of air in the cuff. Accuracy 2cmH2O) was attached. [21] observed that when the cuff was inflated randomly to 10, 20, or 30 cmH2O, participating physicians and ICU nurses were able to identify the group in 69% of the high-pressure cases, 58% of the normal pressure cases, and 73% of the low pressure cases. L. Zuccherelli, Postoperative upper airway problems, Southern African Journal of Anaesthesia and Analgesia, vol. The mean volume of inflated air required to achieve an intracuff pressure of 25 cmH2O was 7.1 ml. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. The cuff was considered empty when no more air could be removed on aspiration with a syringe. 12, pp. A critical function of the endotracheal tube cuff is to seal the airway, thus preventing aspiration of pharyngeal contents into the trachea and to ensure that there are no leaks past the cuff during positive pressure ventilation. 1993, 104: 639-640. A pressure manometer is a hand hand held device used to measure tracheostomy tube cuff pressures. S1S71, 1977. Supported by NIH Grant GM 61655 (Bethesda, MD), the Gheens Foundation (Louisville, KY), the Joseph Drown Foundation (Los Angeles, CA), and the Commonwealth of Kentucky Research Challenge Trust Fund (Louisville, KY). We offer in-person, hands-on training at our Asheville, N.C., Spay/Neuter Training Cent Show more. statement and There was no correlation between the measured cuff pressure and the age, sex, height, or weight of the patients. Informed consent was sought from all participants. All authors have read and approved the manuscript. If using a neonatal or pediatric trach, draw 5 ml air into syringe. W. N. Bernhard, L. Yost, D. Joynes, S. Cothalis, and H. Turndorf, Intracuff pressures in endotracheal and tracheostomy tubes. Secondly, this method is still provider-dependent as they decide when plunger drawback has ceased. A caveat, though, is that tube sizes were chosen by clinicians in our study and presumably matched patient size; results may well have differed if tube size had been randomly assigned. Mandoe H, Nikolajsen L, Lintrup U, Jepsen D, Molgaard J: Sore throat after endotracheal intubation. 87, no. 4, pp. All authors read and approved the final manuscript. Anesthesia continued without further adjustment of ETT cuff pressure until the end of the case. M. L. Sole, X. Su, S. Talbert et al., Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range, American Journal of Critical Care, vol. Standard cuff pressure is 25mmH20 measured with a manometer. The Data Safety Management Board (DSMB) comprised an anesthesiologist, a statistician, and a member of the SOMREC IRB who would be informed of any adverse event. 1.36 cmH2O. On the other hand, high cuff pressures beyond 50cmH2O were reduced to 40cmH2O. . S. W. Wangaka, Estimation of endotracheal tube cuff pressures at Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya, 2006. Note: prolonged over-inflation of the cuff can cause pressure necrosis of the tracheal mucosa. Anesth Analg. 21, no. This cookie is set by Google Analytics and is used to distinguish users and sessions. 10.1007/s001010050146. At the hypobaric chamber at the RAAF base in Edinburgh several hundred air force pilots each year get to check out their reactions to depressurization and the effects of hypoxia. The pressure reading of the VBM was recorded by the research assistant. However, the presence of contradictory findings (tense cuff bulb, holding appropriate inflating pressure in the presence of a major air leak) confounded the diagnostic process, while a preoperative check of the ETT would have unequivocally detected the defect in the cuff tube. LOR = loss of resistance syringe method; PBP = pilot balloon palpation method. We observed a linear relationship between the measured cuff pressure and the volume of air retrieved from the cuff. 3, pp. California Privacy Statement, A) Normal endotracheal tube with 10 ml of air instilled into cuff. None of the authors have conflicts of interest relating to the publication of this paper. Gottschalk A, Burmeister MA, Blanc I, Schulz F, Standl T: [Rupture of the trachea after emergency endotracheal intubation]. Google Scholar. These included an intravenous induction agent, an opioid, and a muscle relaxant. Cuff pressure in endotracheal (ET) tubes should be in the range of 2030 cm H2O. CAS There was a linear relationship between measured cuff pressure (cmH2O) and volume (ml) of air removed from the cuff: Pressure = 7.5. Document Type and Number: United States Patent 11583168 . The integrity of the entire breathing circuit and correct positioning of the ETT between the vocal cords with direct laryngoscopy were confirmed. The study groups were similar in relation to sex, age, and ETT size (Table 1). 87, no. Anaesthesist. 33. Summary Aeromedical transport of mechanically ventilated critically ill patients is now a frequent occurrence. However, there was considerable patient-to-patient variability in the required air volume. Similarly, inflation of endotracheal tube cuffs to 20 cm H2O for just four hours produces serious ciliary damage that persists for at least three days [16]. 21, no. Cuff pressure reading of the VBM manometer was recorded by the research assistant. (States: would deflate the cuff, pull tube back slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air entry). The magnitude of effect on the primary outcome was computed for 95% CI using the t-test for difference in group means. 6422, pp. ETT cuff pressures would be measured with a cuff manometer following estimation by either the PBP method or the LOR method. Upon inflation, folds form along the cuff surface, and colonized oropharyngeal secretions may leak through these folds. At the study hospital, there are more females undergoing elective surgery under general anesthesia compared with males. Only two of the four research assistants reviewed the patients postoperatively, and these were blinded to the intervention arm. Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose. The patient was then preoxygenated with 100% oxygen and general anesthesia induced with a combination of drugs selected by the anesthesia care provider. 10.1007/s00134-003-1933-6. Error in Inhaled Nitric Oxide Setup Results in No Delivery of iNO. 36, no. Below are the links to the authors original submitted files for images. However, these are prohibitively expensive to acquire and maintain in many operating theaters, and as such, many anesthesia providers resort to subjective methods like pilot balloon palpation (PBP) which is ineffective [1, 2, 1620]. Martinez-Taboada F. The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator. N. Suzuki, K. Kooguchi, T. Mizobe, M. Hirose, Y. Takano, and Y. Tanaka, Postoperative hoarseness and sore throat after tracheal intubation: effect of a low intracuff pressure of endotracheal tube and the usefulness of cuff pressure indicator, Masui, vol. Tube positioning within patient can be verified. Although it varied considerably, the amount of air required to achieve a cuff pressure of 20 cmH2O was similar with each tube size. Provided by the Springer Nature SharedIt content-sharing initiative. C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. The regression equation indicated that injected volumes between 2 and 4 ml usually produce cuff pressures between 20 and 30 cmH2O independent of tube size for the same type of tube. Fernandez et al. This has been shown to cause severe tracheal lesions and morbidity [7, 8]. The compliance of the tube was determined from the measured cuff pressure (cmH2O) and the volume of air (ml) retrieved at complete deflation of the cuff; this showed a linear pressure-volume relationship: Pressure= 7.5. chest pain or heart failure. Another study, using nonhuman tracheal models and a wider range (1530cmH2O) as the optimal, had all cuff pressures within the optimal range [21]. A) Normal endotracheal tube with 10 ml of air instilled into cuff. The cookie is updated every time data is sent to Google Analytics. 2003, 13: 271-289. 1mmHg equals how much cmH2O? The author(s) declare that they have no competing interests. The Khine formula method and the Duracher approach were not statistically different. 3 6, pp. The cookie is set by Google Analytics. The anesthesia providers were either physician anesthetists (anesthesiologists or residents) or nonphysicians (anesthetic officer or anesthetic officer student). This work was presented (and later published) at the 28th European Society of Intensive Care Medicine congress, Berlin, Germany, 2015, as an abstract. This adds to the growing evidence to support the use of the LOR syringe for ETT cuff pressure estimation. Necessary cookies are absolutely essential for the website to function properly. Adequacy of cuff inflation is conventionally determined by palpation of the external balloon. Anesthetists were blinded to study purpose. laryngeal mask airway [LMA], i-Gel), How to insert a nasopharyngeal airway (NPA), Common hypertensive emergencyexam questions for medical finals, OSCEs and MRCP PACES, Guedel Airway Insertion Initial Assessment of a Trauma Patient, Haemoptysis case study with questions and answers, A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway the gold standard of airway management), Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required), Patient cant protect their airway (e.g. Cuff pressure should be maintained between 15-30 cm H 2 O (up to 22 mm Hg) . "Aire" indicates cuff to be filled with air. The cookie is set by Google Analytics and is deleted when the user closes the browser. Low pressure high volume cuff. protects the lung from contamination from gastric contents and nasopharyngeal matter such as blood. If using an adult trach, draw 10 mL air into syringe. A) Dye instilled into the normal endotracheal tube travels all the way to the cuff. When this point was reached, the 10ml syringe was then detached from the pilot balloon, and a cuff manometer (VBM, Medicintechnik Germany. Although the ETT pilot balloon was noted to be appropriately tense to the touch, a small amount of air was added to the cuff. C. Stein, G. Berkowitz, and E. Kramer, Assessment of safe endotracheal tube cuff pressures in emergency care - time for change? South African Medical Journal, vol. Incidence of postextubation airway complaints in the study population. We recommend that ET cuff pressure be set and monitored with a manometer. 1984, 24: 907-909. 5, pp. Copyright 2017 Fred Bulamba et al. The AAFP recommends inflating the cuff using air in 0.5-mL increments from a 3-mL syringe until no leak can be heard when the rebreathing bag is squeezed and the pressure in . However, no data were recorded that would link the study results to specific providers. This cookie is installed by Google Analytics. The cookies collect this data and are reported anonymously. We similarly found that the volume of air required to inflate the cuffs to 20 cmH2O did not differ significantly as a function of endotracheal tube size. 6, pp. chin anteriorly), no lateral deviation, Open mouth and inspect: remove any dentures/debris, suction any secretions, Holding laryngoscope in left hand, insert it looking down its length, Slide down right side of mouth until the tonsils are seen, Now move it to the left to push the tongue centrally until the uvula is seen, Advance over the base of the tongue until the epiglottis is seen, Apply traction to the long axis of the laryngoscope handle (this lifts the epiglottis so that the V-shaped glottis can be seen), Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords, Remove laryngoscope and inflate the cuff of the tube with 15ml air from a 20ml syringe, Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning, Consider applying CO2 detector or end-tidal CO2 monitor to confirm placement, if it takes more than 30 seconds, remove all equipment and ventilate patient with a bag and mask until ready to retry intubation. 111115, 1996. Nitrous oxide and medical air were not used as these agents are unavailable at this hospital. These cookies do not store any personal information. After induction of anesthesia, a 71-year-old female patient undergoing a parotidectomy was nasally intubated with a TaperGuard 6.5 Nasal RAE tube using a C-MAC KARL STORZ GmbH & Co. KG Mittelstrae 8, 78532 Tuttlingen, Germany, video-laryngoscope. Lomholt et al. In our study, 66.3% of ETT cuff pressures estimated by the LOR syringe method were in the optimal range. Measured cuff volume averaged 4.4 1.8 ml. While it is likely that these results are fairly representative, it is obvious that results would not be identical elsewhere because of regional practice differences. With the patients head in a neutral position, the anesthesia care provider inflated the ETT cuff with air using a 10ml syringe (BD Discardit II). We use this to improve our products, services and user experience. 9, no. Printed pilot balloon. ETTs were placed in a tracheal model, and mechanical ventilation was performed. However, complications have been associated with insufficient cuff inflation. The pressures measured were recorded. Springer Nature. If more than 5 ml of air is necessary to inflate the cuff, this is an . The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/4/8/prepub. 2001, 55: 273-278. Kim and coworkers, who evaluated this method in the emergency department, found an even higher percentage of cuff pressures in the normal range (2232cmH2O) in their study. Terms and Conditions, How do you measure cuff pressure? The initial, unadjusted cuff pressures from either method were used for this outcome. All tubes had high-volume, low-pressure cuffs. Cuff pressure adjustment: in both arms, very high and very low pressures were adjusted as per the recommendation by the ethics committee. Acta Anaesthesiol Scand. 21, no. Used by Google DoubleClick and stores information about how the user uses the website and any other advertisement before visiting the website. - in cmH2O NOT mmHg. These cookies will be stored in your browser only with your consent. 66.3% (59/89) of patients in the loss of resistance group had cuff pressures in the recommended range compared with 22.5% (20/89) from the pilot balloon palpation method. Our results thus fail to support the theory that increased training improves cuff management. Inflation of the cuff of . H. B. Ghafoui, H. Saeeidi, M. Yasinzadeh, S. Famouri, and E. Modirian, Excessive endotracheal tube cuff pressure: is there any difference between emergency physicians and anesthesiologists? Signa Vitae, vol. The authors wish to thank Ms. Martha Nakiranda, Bachelors of Arts in Education, Makerere University, Uganda, for her assistance in editing this manuscript. 2013 Aug;117(2):428-34. doi: 10.1213/ANE.0b013e318292ee21. (Supplementary Materials). 1, pp. This type of aneroid manometer is nearly as accurate as a mercury manometer, but easier to use [23]. Anesthetists were blinded to study purpose. PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient.
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