fellowship critical care dr. vandewiele bert supervisor ......epstein sk, ciubotaru rl: independent...

Fellowship Critical Care Dr. Vandewiele Bert

Supervisor: Prof. Dr. Pretorius Jan

I. Spontaneous Breathing Trial

II. Extubation failure

III. Prolonged ventilation

IV. Peripheral muscle strength

V. A potential predictor

V Chapters And my study

The end of a story? Almost! Reason for intubation

Mechanical ventilation

Weaning mechanical ventilation

Identify patients ready for extubation

SBT

Succesfull extubation

Fill ICU

Empty ICU

41 % of total ventilation time

Different modes of weaning

Indices to predict success

Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning: a national survey of Spanish hospitals; the Spanish Lung Failure Collaborative Group. Chest 1994; 106:1188–1193

MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ (2001) Evidence-based guidelines for weaning and discontinuing ventilator support: a collective task force

Intermittent Mandatory Ventilation (rate weaning)

Pressure support ventilation (pressure support weaning)

intermittent trials of spontaneous breathing, conducted two or more times a day if possible

once-daily trial of spontaneous breathing

Esteban A, Frutos F, Tobin MJ, et al: A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995, 332:345–350.

Ely EW, Baker AM, Dunagan DP, et al: Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996 Dec 19;335(25):1864-9.

the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen had to exceed 200 = P/F ratio

the positive end-expiratory pressure could not exceed 5 cm of water

there had to be an adequate cough during suctioning (that is, the airway reflexes had to be intact)

the ratio of the respiratory frequency to the tidal volume could not exceed 105 breaths per minute per liter = RSBI

no infusions of vasopressor agents or sedatives could be used (dopamine could be given in doses not exceeding 5 microgram per kilogram of body weight per minute, and intermittent dosing of sedatives was allowed).

For a patient to pass the screening test, all five criteria had to be met. Thereafter a spontaneous breathing trial was performed

ventilatory support was removed

The patient was allowed to breathe through

a T-tube circuit

a ventilatory circuit using “flow triggering” and continuous positive airway pressure of 5 cm of water.

No change was made in the fraction of inspired oxygen

Duration of the test: 120 minutes

a respiratory rate that exceeded 35 breaths per minute for five minutes or longer

An arterial oxygen saturation below 90 percent A heart rate that exceeded 140 beats per minute,

sustained changes in the heart rate of 20 percent in either

direction, a systolic blood pressure greater than 180 mm Hg

or less than 90 mm Hg Increased anxiety, diaphoresis.

Sounds familiar??

HR BP RR Saturation Anxiety Sweating

0

5

10

15

30

45

60

90

120

If the SBT was succesfull, the physician was notified:

all clinical decisions, including the decision to discontinue mechanical ventilation, were made by the attending physicians

Epstein SK, Ciubotaru RL: Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med Vol 158. pp 489–493, 1998

3.3-23.5% of extubated patients needs reintubation, with inherent complications

Risks after Reintubation Mortality is significantly higher

10% in a burn-trauma unit (1)

40% in a general surgical ICU (2)

In one study the mortality rate for patients that needed reintubation was 27% compared to 2.6% for the patients that did not need reintubation. (3)

Prolonged stay in ICU

need for transfer to a long-term care or rehabilitation facility

(1) Demling RH, Read T, Lind LJ, et al. Incidence and morbidity of extubation failure in surgical intensive care patients. Crit Care Med 1988; 16:573-77 (2) Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995;152:137-41 (3) Esteban A, Alía I, Gordo F, et al: Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med 1997, 156:459–465.

Minute ventilation Respiratory frequency Tidal Volume (TV/patients weight) Maximal inspiratory pressure (MIP) Dynamic/Static compliance Rapid shallow breathing index RSBI > 105 CROP index

Change in RSBI during SBT

5% change upward after 30 min 20% change upward after 120 min

Indicators for prolonged weaning (might be associated with

extubation failure as well) Raised PCO₂ >54 mmHg at the end of the first SBT Heart Rate > 105/min at the end of the first SBT

What we use up till 13 June 2011

See next slide

Segal LN, Oei E, Oppenheimer B, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med. 2010 Mar; 36(3): 487-95.

.

Boles JM, Bion J, Connors A et al. Weaning from mechanical ventilation. Eur Respir J. 2007 May;29(5):1033-56.

Funk GC, Anders S, Breyer MK, et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J. 2010 Jan;35(1):88-94.

Electromyographie

Nerve conduction velocity

Quantitative assessment of skeletal muscle force

Voluntary

Medical Research Council Score

Handgrip Strenght

Evoked

Abductor pollicis

Bittner EA, Martyn JA, George E, Frontera WR, Eikermann M. Measurement of muscle strength in the intensive care unit. Crit Care Med. 2009 Oct;37(10 Suppl):S321-30.

We would like to develop an index to predict which patient with a prolonged time of mechanical ventilation will develop respiratory failure an a need for reintubation after passing a spontaneous breathing trial (SBT) and extubation.

We will use the MRC score for daily evaluation of the peripheral muscle strength of the patient.

The evolution of the muscle strength and absolute value at the time of extubation will be correlated to the extubation outcome.

We want to find out if there is a threshold value to predict extubation outcome (negative or positive).

Get Baseline data in our ICU’s (We safe this for last)

Select the patient population to examine: Inclusion criteria Exclusion criteria

Standardize Selection criteria for awakening and comprehension

Richmond Agitation Sedation Scale Comprehension testing

Readiness for weaning criteria Spontaneous Breathing Trial MRC Score Post extubation Data

Mechanically ventilated for 5 days

18 years or older

Selection criteria for awakening and comprehension fullfilled

Patients referred from an other ICU Previous inclusion in the study

Previously identified disease of the peripheral nervous system Inability to assess muscle strength in six muscle groups in at least

two extremities due to Amputations Severe burns, skin lesions, or dressings limiting ability of examiner to

access the patients extremities

Bi-hemispheric or brainstem lesions

Known upper airway obstruction

Morbid Obesity (BMI > 40 kg/m²) Language barrier Patients with a 'do not resuscitate or intubate' status

Assessment if patient is calm and awake by the Richmond Agitation Sedation Scale If the patient scores -1, 0 or 1 the patient was considered to be calm and

awake

The comprehension was tested with the following 5 commands involving neck and face muscles, which are commonly spared in CINM. “open/close your eyes” “look at me” “open your mouth and put out your tongue” “nod your head” “raise your eyebrows when I have counted up to five”

The first day that the patient responds to at least three of these orders on two consecutive evaluations at a 6-hr interval is referred to as “awakening.”

The day of awakening is the first day muscle strength will be measured in the four limbs using the MRC score.

Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44.

Nesibopho guidelines

A Collective Task Force Facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine

Previous Publications regarding

Weaning

Weaning failure

Extubation failure

Ensure that the original indication for ventilation has satisfactorily resolved Reduce and/or stop sedation, analgesia and muscle relaxant Ensure appropriate organ system function as follows:

Respiratory Appropriate FiO2: Weaning the FiO2 completely may not be necessary, provided that

respiratory mechanics are acceptable. Also, lower oxygen saturations may be acceptable if the patient has background respiratory disease (such as COPD or pulmonary fibrosis). Typically a PaO2 / FiO2 ratio of greater than 200 is acceptable provided the patient is on a PEEP of less than 10 cm H2O.

Resolution of any reversible pulmonary pathology such as ARDS, pulmonary oedema, bronchospasm or pneumonia.

Ensure that no “mechanical” factors (such as flail chest) prevent normal respiration.

Cardiovascular Haemodynamically stable. Not requiring ongoing resuscitation. Low doses of inotropes.

Neurological and Muscular Ensure the patient is able to cooperate and will be able to protect the airway, cough and

mobilize secretions. Additionally ensure that the adequate negative inspiratory force is more negative than -20

cmH2O. Endurance is best assessed with a Rapid Shallow Breathing Index (RSBI) (see below)

Metabolic Ensure that there are no other factors, such as a severe acidosis, which increase the work of

breathing and that the electrolytes are normal. Hyper/hypokalaemia, hyper/hypocalcaemia and hypophosphataemia all have the potential to cause weakness.

MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ (2001) Evidence-based guidelines for weaning and discontinuing ventilator support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 120:375S–395S

Original indication for ventilation satisfactorily resolved Stop muscle relaxant and continuous sedation Stopped/Reduced Analgesia Respiratory

PEEP < 10 PaO2/FiO2 >200 No mechanical factors prevent normal respiration

Cardiovascular Haemodynamically stable No ongoining resuscitation Stopped/reduced Inotropes

Neurological Cooperative patient: Richmond Agitation Sedation Scale Gag reflex

Metabolic pH, Potassium, Calcium, Phosphate, Magnesium

Absence of fever Hemoglobin >8 g/dL

Spontaneous Breathing Trial (SBT)

RASS Arterial bloodgas Before After

Patient Sticker SOFA pH

APACHE II PO2

CPIS PCO2

RSBI Saturation

CXR

Clear

Localized infiltrate position

Diffuse infiltrates

Pulmonary oedema

To + min HR BP RR TV RSBI MV Saturation Sweating Anxiety paradoxal

B

0

5

10

15

30

45

60

90

120

SBT failure Date

reason

SBT Succesfull Extubation

Date

Hour

No Extubation

reason

MUSCLE GROUPS SCORING

Abduction arm L + R

Flexion forearm L + R

Extension wrist L + R

Flexion hip L + R

Extension knee L + R

Dorsal flexion foot L + R

Head Lift?

1. No muscular contraction 2. Barely detectableflicker or

trace of contraction 3. Active movement with

gravity eliminated 4. Active movement against

gravity 5. Active movement against

gravity and some resistance

6. Active movement against gravity and full resistance

Psychological Ability: Richmond Agitation Sedation Scale (minus 5 - plus 4) (For scoring, see other side)

RASS -Score

Medical Research Council Score (For scoring, see other side)

Date

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Abduction of the arm

left

right

Flexion of the forearm

left

right

Extension of the wrist

left

right

Flexion of the leg

left

right

Extension of the knee

left

right

Dorsal flexion of the foot

left

right

Head lift

Total score:

Average:

Functional Progress Report (For Scoring, see other side)

Ability to help with bedwash

Sitting in chairposition

Sit on side of bed

Standing

Walking to chair

Extubation

Date

Hour

Post Extubation SBT

BP HR Saturation RR Sweating Anxiety Paradoxal B

0

5

30

1h

2h

3h

4h

6h

8h

12h

24h

48h

Course in ICU

VAP

ARDS

FES

Lung contusion

Steroids

Type

Daily dose

Tapering

Yes

No

Total dose

Total days

Paralytics

Type

Total dose

Total days

Extubation succes

Extubation failure

Date

Hour

Reason

How long do patients have to be ventilated before we include them in the study 2 days

5 days

1 week

2 weeks

The faster we include, the more subjects, the smaller the incidence of ICUAP

The longer we wait, the more difficult to get our numbers, the smaller the chance patients will get extubated (higher mortality)

Which ICU’s can contribute

Surgical ICU

Medical ICU

Cardiothoracic ICU

Neurosurgical ICU

Surgical and medical ICU

How often to do the MRC score

Daily

Every other day NOT in weekends

Three times a week NOT in weekends

What else do we want to measure? MIP

MEP

VC

Handgrip strength with dynamometer

Oesophageal pressure

Predictive capacity of staff Prof

Nurses (differentiate in experience)

Fellows

Registrars

Physiotherapists

Functional Progress

Is this Realistic?

Who will do What?

All patients Admission Data: Registrars

Processing of this data

Technologists

Secretary

Study - Selected patients RASS score: Registrars

MRC score – Physiotherapists

Readiness for weaning criteria - Nursing staff

New SBT form - Nursing Staff

Follow up after Extubation (0 – 24 hours) – Nursing Staff

Follow up after Extubation (24 – 48 hours) – Dr. Vandewiele

Statistics

Submission Mmed and

ethical committee

Patient recruitment/Data collection

Poster with preliminary data

Data Analysis

Prepare article for publication

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12

To follow

Estimate ??

Dr. Vandewiele Bert

Fellowship Critical Care Steve Biko Academic Hospital

To increase the workload

To waste more paper and ink

To find a reason to pick on the ones who don’t complete them

To make me happy

Because it will work smoothly

Statistics

Lenght of Stay

....

Studies

Base line characteristics of our ICU population

2 parts

Admission

Discharge

Consists of general information that should already be part of the file on admission of the patient to ICU

5 minutes work when completed immediately

• The complete team !!! • The doctor that saw the patient first is responsible

for the admitting part, even if he saw the patient in casualties and could not admit him straight to ICU

• The doctor who writes the discharge letter is responsible for the discharge part and checks the document again to see if all parts are completed.

• If a patient passes away, he still needs a discharge letter and a completed admission data file.

In the front of the plastic file at the bedside of every patient

The sisters will include this paper in this file automatically on every new admission

The completion is entirely to be done by the doctors!!!!

In absence of these papers, contact the sister in charge

• After discharging a patient

– Transfert to

• Highcare

• Ward

• Other ICU

• Other Hospital

– Death of a patient

• Attached to the discharge letter together with the antibiotic form

Patients sticker Chronic medication

name daily dose

1

2

General 3

Sex 4

Age 5

Race 6

Height 7

Weight 8

Drug History Reason for intubation (mark with X)

Smoker (yes or no) COPD exacerbation

Packyears Pneumonia Community Acquired

Date stopped Hospital Acquired

Alcohol (yes or no) Aspiration

Weekly doses Sepsis

Elicit drugs Heart Failure

Dose and type Postoperative

Trauma Lungcontusion

Medical History yes no Inhalation burns

Cardiac ischaemia Airway protection Low conciousness

Cardiac failure Laryngeal/pharyngeal swelling

Hypertension Other (specify below)

Diabetes .....................................................................

COPD

Inhaler dependent APACHE II SCORE 71

Steroid dependent GCS 15

Oxygen dependent SOFA-score 24

Asthma (Turn page to complete scores)

HIV ? Diagnosis on admission

Tuberculosis ?

APACHE II (Worst values during the first 24 hours of admission) CHRONIC HEALTH POINTS (CHP)

High abnormal range Low abnormal range Cirkel the chronic health group of the patient

4 3 2 1 0 1 2 3 4 If the patient has a history of severe organ system insufficiency or is immunocompromised, assign points as follow: TEMPERATURE - rectal (°C) ≥41 39-40.9 38.5-38.9 36.0-38.4 34.0-35.9 32.0-33.9 30.0-31.9 ≤29.9

MEAN ARTERIAL PRESSURE - mmHg ≥160 130-159 110-129 70-109 50-69 ≤49

for nonoperative or emergency postoperative patients

5

HEART RATE (ventricular respons) ≥180 140-179 110-139 70-109 55-69 40-54 ≤39 for elective postoperative patient 2

RESPIRATORY RATE (ventilated or not ventilated) ≥50 35-49 25-34 12-24 10-11 6-9 ≤5

OXYGENATION A-aDO2 or PaO2

FiO2 ≥ 0.5 record A-aDO2 >500 350-499 200-349 <200 Definitions Organ insufficiency or immunocompromised state must have been evident prior to this hopital admission and conform to the following criteria

FiO2 ≤ 0.5 record only PaO2 >70 61-70 55-60 ≤55

ARTERIAL pH ≥7.7 7.6-7.69 7.5-7.59 7.33-7.49 7.25-7.32 7.15-7.24 <7.15 LIVER Biopsy-proven cirrhosis and documented portal hypertension; episodes of past upper GI bleeding attributed to portal hypertension; or prior episodes of hepatic failure/encephalopathy/coma

SERUM SODIUM (mmol/L) ≥180 160-179 155-159 150-154 130-149 120-129 111-119 ≤110

SERUM POTASSIUM (mmol/L) ≥7 6-6.9 5.5-5.9 3.5-5.4 3-3.4 2.5-2.9 <2.5 SERUM CREATININE (µmol/l) (double point score for acute renal failure)

≥308 176-307 132-175 53-131 <53 Immunocompromised Immunosuppression, chemotherapy, radiation, long-term or recent

high-dose steroids, or has a disease that is sufficiently advanced to suppress resistance to infection, e.g., leukemia, lymphoma, AIDS

HEMATOCRIT (%) ≥60 50-59.9 46-49.9 30-45.9 20-29.9 <20 RESPIRATORY Chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, i.e. unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia,secondary polycythemia, severe pulmonary hypertension (>40 mmHg), or respiratory dependency.

WHITE BLOOD COUNT (1000s/mm³) ≥40 20-39.9 15-19.9 3-14.9 1-2.9 <1

GLASCOW COMA SCALE (GCS) Score = 15 minus actual GCS

Total ACUTE PHYSIOLOGY SCORE (APS) RENAL Receiving chronic dialysis

CARDIOVASCULAR New York Heart Association Class IV

AGE POINTS (AP) Cirkel the age group of the patient

<44 0 Apache II= APS + AP + CHP

45-54 2 Transfert From

55-64 3

65-74 5 Admission Date ICU

>75 6

Admission Hour ICU SOFA SCORE (Worst values during the first 24 hours of admission)

0 1 2 3 4 Transfert to

Respiration PaO2/FiO2 (mmHg) >400 300-400 200-300 100-200 <100

Coagulation Platelets 10³/mm³ >150 100-149 50-99 20-49 <20

Discharge Date ICU Liver Bilirubin (mg/dL) <1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0

Cardiovascular Hypotension No hypotension MAP < 70 Dopamine ≤ 5 or

dobutamine (any) Dopamine > 5 or

norepinephrine ≤ 0.1 Dopamine > 15 or

norepinephrine > 0.1 Discharge Hour ICU

CNS Glascow Coma scale 15 13-14 10-12 6-9 <6

Renal Creatinine (µg/L) or urine output (ml/d)

<106 106-175 176-307 308 - 440 or <500 >440 or <200 Death YES NO

Glascow Coma Score Date of Death

Eye opening Best Verbal Respons Best Motor Respons Time of Death

Spontaneous 4 Orientated 5 Obeys commands 6

To sound 3 Confused conversation 4 Localizes pain 5

To pain 2 Inappropriate words 3 Flexion (withdraws) 4 Diagnosis on Admission

Never 1 Incomprehensible sounds 2 Flexion (abnormal) 3

None 1 Extension 2

/ Nothing 1

Pat

ien

tnu

mb

er

Ad

mis

sio

n D

ate

Ad

mis

sio

n H

ou

r

Dis

char

ge D

ate

Dis

char

ge H

ou

r

Death

Tota

l IC

U le

ngh

t o

f st

ay

(ho

urs

)

General Drug history

Yes

No

Smoker alcohol Elicit drugs

Dat

e o

f D

eath

Tim

e o

f D

eath

Sex

Age

(ye

ars

+ m

on

ths)

Rac

e

Hei

ght

(cm

)

Wei

ght

(kg)

pac

kyea

rs (

= p

acka

ges/

day

X

year

s sm

oki

ng)

Dat

e st

op

ped

wee

kly

do

ses

Typ

e

do

se

Medical History Reason for intubation

AP

AC

HE

II s

core

GC

S

SOFA

-sco

re

Car

dia

c is

chae

mia

Car

dia

c fa

ilure

Hyp

erte

nsi

on

Dia

bet

es

COPD

Ast

hm

a

HIV

TB

CO

PD

exa

cerb

atio

n Pneumonia

Seve

re s

epsi

s/se

pti

c sh

ock

Hea

rt f

ailu

re

Trauma Airway

protection

Oth

er

Inh

aler

dep

end

ent

Ster

oid

dep

end

ent

Oxy

gen

dep

end

ent

Co

mm

un

ity

Acq

uir

ed

Ho

spit

al A

cqu

ired

Asp

irat

ion

pn

eum

on

ia

lon

gco

ntu

sio

ns

Inh

alat

ion

Bu

rns

Low

leve

l of

con

scio

usn

ess

Lary

nge

al/P

har

ynge

al

swel

ling

Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning: a national survey of Spanish hospitals; the Spanish Lung Failure Collaborative Group. Chest 1994; 106:1188–1193

Esteban A, Frutos F, Tobin MJ, et al: A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995, 332:345–350.


Demling RH, Read T, Lind LJ, et al. Incidence and morbidity of extubation failure in surgical intensive care patients. Crit Care Med 1988; 16:573-77

Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995;152:137-41

Esteban A, Alía I, Gordo F, et al: Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Respir Crit Care Med 1997, 156:459–465.


MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ (2001) Evidence-based guidelines for weaning and discontinuing ventilator support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 120:375S–395S

Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity

and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44.

Segal LN, Oei E, Oppenheimer B, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med. 2010 Mar; 36(3): 487-95.

Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008 Mar 27;358(13):1327-35.

De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002 Dec 11;288(22):2859-67.

Boles JM, Bion J, Connors A et al. Weaning from mechanical ventilation. Eur Respir J. 2007 May;29(5):1033-56.

Funk GC, Anders S, Breyer MK, et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J. 2010 Jan;35(1):88-94.

Bittner EA, Martyn JA, George E, Frontera WR, Eikermann M. Measurement of muscle strength in the intensive care unit. Crit Care Med. 2009 Oct;37(10 Suppl):S321-30.

Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007 May;29(5):1033-56

fellowship critical care dr. vandewiele bert supervisor ......epstein sk, ciubotaru rl: independent...

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