Kelly Shinkaruk, MD FRCPC HLT 123 October 17, 2009 1.

Kelly Shinkaruk, MD FRCPCHLT 123

October 17, 2009

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Fluid Therapy ObjectivesBody Fluid CompartmentsFluid Requirements

Maintenance and Insensible LossesFluid DeficitThird SpaceBlood Loss

Types of Fluid and ResuscitationCrystalloidsColloids

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Fluid Therapy ObjectivesIntravenous Access

Sites for Line InsertionAdvantages and DisadvantagesComplication RisksInsertion Techniques

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The Human BodyWater composition

1 – Males 55-60%2 – Females 50-55%3 – Infants 75-80%

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Fluid Compartments60% water by

weight

Intracellular 2/3

Extracellular 1/3 Interstitial ¾ Intravascular 1/4

Intracellular

Interstitial

Intravascular

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Differences in Body FluidsAge and Gender:

Prems – 90mL/kgChildren – 80mL/kgAdult Male – 70 -

75mL/kgAdult Female – 60 -

65mL/kg

Obesity:Water volume based

on ideal body weight (IBW)

IBW = 50kg + 2.3kg per inch over 5ft

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Operative Fluid RequirementsDeficits

Overnight fasting Bowel preps: Liters of losses potentially Diuretics

Maintenance GI losses: 100-200 ml/day Insensible: 500-1000 ml/day Urinary: variable, >1000 ml/day

Ongoing Losses Blood loss Third space losses

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Maintenance Fluids

First 10 kg of body weight = 4 ml/kg/hrSecond 10 kg = 2 ml/kg/hrEvery kg over 20 = 1 ml/kg/hr

80 kg person = 40 + 20 + 60 = 120 cc/hr

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Fluid Requirements for SurgeryCalculated per hour during OR:

Fluid deficit (NPO for 6+ hours): 4/2/1Ongoing fluid requirements: 4/2/1Replacement of blood loss

Crystalloid 3:1, Colloid 1:1“Third-space” loss

4/6/8 rule: 4 ml/kg/h for minor surgery (hernias, wrist ORIF,

breast) 6 for moderate surgery (gyne, ortho, thoracics) 8 for major procedures (major bowel, vascular, trauma)

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Clinical example29 yo 70 kg male with

femur fracture for ORIF NPO 12 hours

Calculate deficit ½ over first hour ½ over the rest of the

caseProvide maintenance

4 - 2 - 1 RuleReplace losses

3 to 1 for bleeding Third space (4-7

cc/kg/hr)

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CalculationDeficit

Maintenance X hours NPO 110 cc/hr X 12 hours = 1320 cc 660 cc in first hour – the rest over the case

Maintenance 4 – 2 – 1 Rule = 110 cc/hr

Third spacing and bleeding 6 cc/kg/hr = 420 cc/hr

1190 cc of crystalloid in the first hour alone

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What is osmolarity?

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What is osmolarity?Osmolarity: a measure of how many

dissolved particles are in the bloodEquilibrium: dissolved particles “pull” water

across membranes so that total concentration of dissolved particles (osmolarity) is equal on each side (give or take, with some electrochemistry involved)

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What is normal serum osmolarity?

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OsmolarityHypertonic: more concentrated than plasmaHypotonic: less concentrated than plasmaIsotonic: the same concentration as plasma

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OsmolarityIf you give too much hypotonic fluid, cells can

swell and burstIf you give too much hypertonic fluid, cells

can shrinkFast correction of electrolyte imbalances is

BADWhere is this most important?

The brain! WHY?

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Types of FluidsClassification: based on their behaviour once

givenMostly go to ICF: free waterStay in ECF: crystalloidStay in plasma: colloid

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Free Water

Pure water is NEVER given IV! It is very hypotonic and will burst RBCs and cause electrolyte imbalances!

Dextrose5% or D5W10 % or D10W50% or D50W (low

volume packages)

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IMPORTANT NOTE:

Free WaterD5W: most commonly used

D10W and D50W usually used for low blood glucose levels, not free water deficit

Stats:Dextrose 5gm/dLpH 5.0 Osmolarity 253

IV infusion: little stays intravascularDextrose is actively transported into cells and

water follows it (equilibrium)

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D5WPros:

Treats hypoglycemiaOften used preop

for diabetic patients who are NPOBody needs sugar

for long-term NPO

Cons:No good for

resuscitationCan cause hypo-

osmolarity and water intoxicationMay worsen brain

trauma

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CrystalloidsUsed for fluid deficit, third space losses,

maintenanceEquilibrates in ECF (plasma/interstitial)When infused: about 1/3 stays in

intravascular space, and after ~ 10 minutes, the other 2/3 has diffused out of the plasma

When administering for blood loss, must use 3-5L for every 1L of bloodEx: 3L blood loss = 9-15L of RL!!

So we use other fluids for LARGE replacement!

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CrystalloidsNormal Saline

Hyperosmolar 308 mosm/l Sodium 154 Chloride 154

Acidic relative to the plasma pH 5.0

Excessive administration results in: Hyperchloremic metabolic acidosis

1000 ml NS – redistributed along [Na] Extracellular - ISF 750 ml, only 250 ml

stays intravascular

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CrystalloidsNormal SalinePros:

Good for initial resuscitation Cheap Readily available,

multiple sizes Widely used for OR

maintenance fluid Compatible with all drugs and blood products

Cons: Hyperchloremic,

hypernatremic metabolic acidosis (Use 3L or less) Large sodium load Use care with

heart failure, renal failure, brain injury, old age

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CrystalloidsRinger’s LactateOsmolality 279 mOsm/L

Na+ 130 mmol/L Cl- 110 mmol/L Lactate 27 mmol/L K+ 4 mmol/L Ca++ 3 mmol/L pH 6.5

Closer to physiologic pH and Osmo

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CrystalloidsRinger’s LactatePros:

Good for resuscitation More “physiologic” Contains K Less hyperosmolar

than saline No hyperchloremia

Cons: More expensive Not compatible

with some drugs or blood May worsen brain

swelling (not as bad as NS) Use caution with

elevated K, renal failure

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ColloidsNS based fluidsContain osmotically active particlesLarge molecules unable to cross endotheliumProvide colloid oncotic pressure

Theoretically replenish intravascular volume and stay in this compartment much longer than crystalloids

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ColloidsPentaspan ($70 per

500cc)

○ Normal Saline plus 10 g/100ml pentastarch

○ 250 kDa Protein○ pH 5.0○ High Na load just as with

NS

○ Renal excretion○ 70% cleared in 24 hours

in patients with normal GFR

○ Max dose 28 mL/kg over 24 hours (2 L)

Voluven

Normal Saline plus 6g/100mL hydroxyethyl starch

130 kDa Protein pH 5.0 High Na load just as

with NS

Renal excretion 70% cleared in 72 hours

in patients with normal GFR

Max dose 50 mL/kg over 24 hours (3.5L)

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ColloidsPros:

Smaller infused volume

Replace blood loss 1:1

Prolonged ↑ Intravasc vol

Less edema Pulmonary, peripheral

Cons:No O2 carrying

capacityExpensiveDilutional

coagulopathyLeaky capillaries =

interstitial edemaIncreased

anaphylactoid reactions

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ColloidsAlbumin

Human blood product Purified protein from human blood Large osmotically active protein increases oncotic

pressure Available as 5% and 25% solutions Similar risks to other blood products

Half-life 1.6 hours in plasma = 8 hours plasma elimination 20 days in the body

Increased morbidity compared to other colloids

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Hypertonic solutionsHypertonic Saline

Available as 1.8%, 3%, 7.5%, 10% solutions Increases extracellular osmolality Promotes fluid shift from ICF to ECF

Rare indications: Trauma Symptomatic acute hyponatremia (TURP syndrome)

Unclear benefits – risk acute hypernatremia

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Fluid Therapy ObjectivesIntravenous Access

Sites for Line InsertionAdvantages and DisadvantagesComplication RisksInsertion Techniques

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Sites for Line InsertionPeripheral Intravenous Access

Central Intravenous AccessInternal Jugular (IJ)SubclavianFemoral

Intraosseous Access

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Peripheral IV Access

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Peripheral IV AccessAdvantages

Easy to placeMany points of

accessIf unsuccessful,

compressible siteFewer complications

than central accessLarge bore access

allows rapid infusion of large volumes

DisadvantagesVein may be difficult

to accessNot used for

prolonged administration of vasoactive drugs

Cannot be placed distal to site of surgery or injury

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Central Venous Access

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Central Venous AccessAdvantages

Reliable IV access when peripheral sites not available

Long term IV and vasopressor therapy

Large volume resuscitation

DisadvantagesSpecial equipment

requiredLonger time to

placeHigher complication

rateNeed for special

skill

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ComplicationsMechanical

Arterial puncture (femoral > IJ > subclavian)Hematoma (femoral > SC > IJ)Hemothorax (only seen in SC)Pneumothorax (SC >> IJ)Cardiac Tamponade (SC = IJ)

InfectiousEmbolic

Wire/catheter embolism

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Intraosseous Access

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Intraosseous AccessAdvantages

Venous access when no other sites can be found

Useful if difficult, delayed, or impossible IV access

Used in burns or other injuries preventing alternate access

DisadvantagesNeed for special

equipment and skill

Requires pressure bag to provide reasonable flow of fluids

Osteomyelitis if long term

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Whaddya do now???

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Kelly Shinkaruk, MD FRCPCHLT 123

October 17, 2009

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Blood Therapy ObjectivesBlood Components

Blood TransfusionPros and Cons of Blood Products

Indications for TransfusionAcceptable Blood LossFactors Related to Blood Administration

Complications Related to TransfusionLab and Point of Care TestingAdministration Techniques

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Blood Therapy ObjectivesBlood ComponentsBlood TransfusionPros and Cons of Blood Products



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Blood ComponentsCells:

Red blood cells: carry oxygenPlatelets: imperative for clottingWhite blood cells: removed

Fluid: Plasma: Fluid with proteins (albumin), clotting

factors

Proteins: Clotting factors II-XII

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Blood TransfusionAutologous bloodRecovered bloodPooled blood products

No “whole blood” anymoreRBCsplateletsPlasmaCryoprecipitate, factor VII

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Autologous BloodPros:

Person’s own blood-low risk of transfusion reactions Can donate up to

4 units Whole blood:

coagulation factors, etc.

Cons: Anemic, heart

disease, transmissible diseases not eligible Whole blood only Anemia from

donation Expensive

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Recovered Blood (Cell Saver)Pros:

Person’s own RBCs, washed No transfusion

reaction Can be used for

some Jehovah’s Witnesses

Cons: Expensive Surgical

contaminationBone InfectionCancer?

Not 100% recovery

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Cell SaverWhen?

Major vascular proceduresMajor ortho proceduresMajor traumaSometimes used in neurosurgery/backsScoliosis surgery

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Cell Saver

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Packed RBCsPros:

1 unit = Hb by 10 g/l Best replacement

for excessive blood loss Stays in vascular

compartment Mix with saline for

faster infusion

Cons: Transfusion

reactions Expensive Freshness Risk/benefit ratio Cold

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Frozen PlasmaPros:

Contains all coagulation factors (V and VIII unstable) Use for high

volume/ongoing transfusion or bleeding with coagulopathy used to be given for

elevated INR Now we have

octaplex!

Cons: Can contain

infectious particles Fluid overload

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PlateletsIndications:

Acute thrombocytopenia (platelet deficiency)

Large volume transfusion + bleeding

One unit = increase platelet count by 5-10

Complications:Stored at room

temperatureHigh risk of

bacterial contamination/sepsis

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CryoprecipitateContains

Factor VIIIFactor XIIIVon Willebrand’s FactorFibrinogen (Factor II)

Indications Coagulopathy in massive bleeding and transfusion Actively bleeding patients with Fibrinogen < 0.8-1.0 g/L VWD or Hemophilia A (Factor 8 deficiency)

Only in the absence of specific factor concentrates DDAVP is not available or ineffective

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Indication for TransfusionBlood products administered for

dangerous levels of blood loss Normal Hgb 120-150g/L Healthy patients tolerate >70g/L With systemic disease >90g/L

Start with PRBCsHistorically, transfuse Plts, FP, cryo only

when “indicated” low plts, surgical oozing, etc

Now moving to PRBCs : FP : Plts (1:1:1)

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Acceptable Blood LossDepends on:

Preop HbVolume of blood lossCoexisting disease

Cardiovascular disease

Normal Hb level can be by ~25% with little stress…as long as intravascular VOLUME is maintained!

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Acceptable Blood Loss (ABL)ABL= [ Hgbinitial – Hgbfinal / Hgbfinal ] X EBV

Example:

60 yo female for THR. Preop Hgb 120, Wt 75kg

We will accept Hgb of 75 post-op

EBV = 75kg x 60 cc/kg = 4500cc

ABL = [120-75 / 120] x 4500 = 1688 cc

We will allow her to lose 1700cc blood without transfusing her

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Blood Volume How much blood do we have?

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Preemie 90 ml/kg

Baby 80

Adult male 75 (less for obesity)

Adult female 65 (less for obesity)

“Acceptable loss” = ml/kg blood volume x kg body weight x % decrease in Hb

Factors Related to Blood AdministrationConsent

Discuss options early therefore alternatives can be considered

Ensure all questions answeredType and screen

Jehovah’s WitnessesMost will not accept allogenic productsMust verify what they will/won’t accept DOCUMENT IT IN THE CHART!

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Blood Sparing TechniquesProcedures with high anticipated blood lossPreop techniques

Erythropoietin + Fe – at least 2wks preAutologous donation – at least 1mth pre

Intraop techniquesAntifibrinolytic therapy (tranexamic acid)Cell saverControlled hypotensionTourniquet“damage control” surgery

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Dangers of BloodTransfusion reactions

Clerical error: most common reasonTransmission of infectious particles:

Viruses Bacteria Prions?

Mad cow Kreutzfeld-Jacob

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Dangers of Blood

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1 : 500,000Death from sepsis

1 : 82,000Hepatitis B

1 : 3.1 millionHepatitis C

1 : 4.1 millionHIV transmission

RiskEvent

Risk of sepsis is even higher with autologous blood and platelets!

Complications of Blood Transfusion

Volume overloadheart failure, pulmonary edema

Temperature hypothermia from large amounts of cold

blood/fluidAir

if given under pressure, risk of air entering circulation (air trapping in lung, heart, brain)

Immune suppressionnon-specific suppression with blood product

administration 68


Incompatibilityred blood cell, white blood cell, plasma

antibody reactionsMost common reason: clerical error

Dilutional coagulopathyInfection

blood screened for HIV, Hep C/B, syphilis, others

Not screened for all viruses!

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Biochemical abnormalitiesCitrate: anticoagulant in pRBCs, binds

calcium, may necessitate calcium replacementPotassium: high concentrations in pRBCs, with

low pH. Interreaction of pH and K may mean high or low K after transfusion

Microaggregatestiny clots in pRBCs may lodge in lungs (TRALI)

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Symptoms of Blood ReactionsPain, rash, hives, edemaFever, chills, nausea, vomiting, SOBBP, HR, O2 sat, mental status changesPink or brown urineCirculatory collapse

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TAKE-HOME MESSAGE

Any change in clinical condition after blood transfusion is suspect!! Stop transfusion and treat aggressively!!

Complications: What to DoSTOP blood product IMMEDIATELY!Notify other OR staff, blood bank.Send blood and samples from patient to

lab.O2, drugs as necessary to support vital

signs. Fluids, drugs to flush kidneys.Monitor for coagulation problems, treat as

necessary.72

Transfusing BloodDoes patient want blood?How much of this anemia is acute?Is blood loss more than “acceptable”?Will there be more blood loss? Is there a

coagulopathy causing this?Is the patient at risk from heart or

vascular disease?Have I tried to use other fluids without

success?73





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Lab and Point of Care TestingUsed for intra-op diagnosisRapid assessment of blood measurementsHelps guide ongoing therapyDifferent equipment

Hemocue for HgbHemochron for PTT/INRiStat for ABGs, lytes, Hgb

Traditional lab work also available – but takes far longer!

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Lab and Point of Care TestingHemocue

Used for rapidly checking Hgb

Easy to use, no need for arterial access

Not as accurate as sending a CBC

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Lab and Point of Care TestingHemochron Jr.

Measures coagulation parameters

PTT and INRNo need for arterial

access

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Lab and Point of Care TestingiStat

Rapid assessment of blood gases, Hgb, electrolytes

Need arterial sample

More accurate than Hemocue

Same technology as ABG sampling machines

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Lab and Point of Care TestingACT (activated clotting time)

Used during vascular proceduresMonitors effectiveness of high dose heparin

therapySample from undiluted site not contaminated

by heparin infusionHelps guide further dosing of heparin or

reversal of heparin with protamine

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Administering Fluids and Blood ProductsEnsure at least one functional IVNormal Procedure

IV infusion set upFluid warmer - not necessary, often if >2hr

procedure or possibility of blood transfusionProcedure with anticipated transfusion

IV Blood setFluid warmer essential

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Administering Fluids and Blood ProductsSome physicians now use infusion pumpsOccasionally administer meds by infusion

pumpVancomycinInsulin

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Massive TransfusionDefinition

the replacement of TBV in less than 24 hours or…

more than half the EBV per hour. TOH has a massive transfusion protocol

In the binderIncludes studies/point of care, order of blood

products, factor VIIa, etc.Rapid infusion – Pressure bags, Level 1

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CompatibilityPacked RBCFrozen PlasmaCryoprecipitatePlatelets

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Administration SetFrozen PlasmaPacked RBCCryoprecipitatePlatelets

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Questions???

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Kelly Shinkaruk, MD FRCPC HLT 123 October 17, 2009 1.

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