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Basics of anaesthesia REVISION NOTES ANESTHESIA

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anesthesia machine
PIN index
cylinder
capnography
oxygen therapy
mapleson circuit
stages of anaesthesia
boyles apparatus
rotameter
flow meter
breathing circuits
mapleson circuits
anaesthesia revision notes for neet pg preparation with high

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Basics of anaesthesia REVISION NOTES ANESTHESIA

  1. 1. Basics of anaesthesia TONY SCARIA 2010 KMC
  2. 2. Anaesthesia machine TONY SCARIA 2010 KMC
  3. 3. TONY SCARIA 2010 KMC
  4. 4. Boyles apparatus  Continuous flow system TONY SCARIA 2010 KMC
  5. 5. TONY SCARIA 2010 KMC
  6. 6. Cylinders are made up of molybdenum steel • MOST COMMONLY USED IS SIZE E TONY SCARIA 2010 KMC
  7. 7. TONY SCARIA 2010 KMC
  8. 8. PIN INDEX • TO PREVENT INCORRECT GAS CYLINDER ATTACHMENT TONY SCARIA 2010 KMC
  9. 9. DIAMETER INDEX SAFETY SYSTEM (DISS) FOR CONNECT CONNECTION OF CYINDER TO MACHINE TONY SCARIA 2010 KMC
  10. 10. GAS FILLED AS LIQUID IN CYLINDER • N2O • CO2 • CYCLOPROPANE TONY SCARIA 2010 KMC
  11. 11. O2 therapy • O2 therapy Delivers O2 more than 29 % (at room 0229 %) • Indications • Recovery from GA • a/c respiratory failure • ARDS • a/c severe BA • severe pneumonia • a/c exacerbation of COPD • Pulmonary thromboembolism • CVA IHD ILD • Shock • O2 delivery devices TONY SCARIA 2010 KMC
  12. 12. • Nasal prongs • Simple face mask • Partial rebreather • Non breather • Venturi mask • O2 hood in neonate TONY SCARIA 2010 KMC
  13. 13. TONY SCARIA 2010 KMC
  14. 14. Simple oxygen mask • r TONY SCARIA 2010 KMC
  15. 15. AMBU BAG  mapleson C TONY SCARIA 2010 KMC
  16. 16. TONY SCARIA 2010 KMC
  17. 17. High performance fixed performance TONY SCARIA 2010 KMC
  18. 18. TONY SCARIA 2010 KMC
  19. 19. • Stage III plane 3  surgical anaesthesia TONY SCARIA 2010 KMC
  20. 20. TONY SCARIA 2010 KMC
  21. 21. TONY SCARIA 2010 KMC
  22. 22. TONY SCARIA 2010 KMC
  23. 23. TONY SCARIA 2010 KMC
  24. 24. TONY SCARIA 2010 KMC
  25. 25. Boyles apparatus : anaesthetic machine • High pressure low resistance continuous flow TONY SCARIA 2010 KMC
  26. 26. Rotameter Bobbin flow rate of gases N20 & O2 act as carriers for halothane vapours TONY SCARIA 2010 KMC
  27. 27. Flow meters/Thorpe tube • Variable orifice with smallest diameter at the base TONY SCARIA 2010 KMC
  28. 28. • HEIGHT TO WHICH BOBBIN RISES  FLOW RATE • CAUSES OF INACCURATE READING • STATIC ELECTRICITY • DIRT • NONVERTICAL TUBE • BACK PRESSURE BY VENTILATOR • TONY SCARIA 2010 KMC
  29. 29. LINK 25  TO PREVENT HYPOXIATONY SCARIA 2010 KMC
  30. 30. IN A 3 GAS MACHINE SAFEST CONFIGURATION IS WHEN OXYGEN IS LOCATED IN DOWNSTREAM AFTER BOTH GASES TONY SCARIA 2010 KMC
  31. 31. TONY SCARIA 2010 KMC
  32. 32. PRESSURE SYSTEM TONY SCARIA 2010 KMC
  33. 33. PRESSURE SYSTEM HIGH • FROM CYLINDER TO PRIMARY PRESSURE REGULATOR • cylinder • yoke assembly • oxygen assembly • 1st pressure reducing valve INTERMEDIATE • 1ST PRESSURE REDUCING VALVE TO FLOW CONTROL VALVE • Pipeline source • Flow control valve • 2nd pressure reducing valve LOW • DOWNSTREAM TO FLOW CONTROL VALVE • Rotameter TONY SCARIA 2010 KMC
  34. 34. Fail safe valve in case of hypoxia shuts off & decreases supply of nonoxygen gases  increasing delivery of O2 Oxygen enters downstream TONY SCARIA 2010 KMC
  35. 35. Hypoxia prevention • Oxygen flail valve • Low pressure oxygen alarm • oxygen is located at downstream position TONY SCARIA 2010 KMC
  36. 36. Cylinders • Made of chromium molybdenum steel TONY SCARIA 2010 KMC
  37. 37. Pin index system TONY SCARIA 2010 KMC
  38. 38. TONY SCARIA 2010 KMC
  39. 39. Carbon dioxide 1 ,6 Single central holeTONY SCARIA 2010 KMC
  40. 40. TONY SCARIA 2010 KMC
  41. 41. TONY SCARIA 2010 KMC
  42. 42. Gas Pin index Colour of cylinder Air 1,5 02 2,5 Black body ,white shoulder Nitrous oxide 3,5 blue C02 1,6 Grey Cyclopropane 3,6 Orange Entonox 7 Blue body with Blue Quartered Shoulders Ethylene red halothane Amber helium Brown TONY SCARIA 2010 KMC
  43. 43. TONY SCARIA 2010 KMC
  44. 44. TONY SCARIA 2010 KMC
  45. 45. O2 cylinders • Black with white shoulder • Pressure -2000 psi • As liquid O2 • Size from AA to H • Most commonly used is E TONY SCARIA 2010 KMC
  46. 46. N2O cylinder • Blue • 760 psi • liquid gas TONY SCARIA 2010 KMC
  47. 47. Cylinders TONY SCARIA 2010 KMC
  48. 48. Cylinders TONY SCARIA 2010 KMC
  49. 49. Gas pipes • Seamless copper tubing • Pressure is 50 psi (4 bar) TONY SCARIA 2010 KMC
  50. 50. Breathing circuits TONY SCARIA 2010 KMC
  51. 51. TONY SCARIA 2010 KMC
  52. 52. Mapleson A /magill • System of choice in spontaneous breathing TONY SCARIA 2010 KMC
  53. 53. Mapleson B • Not used clinically TONY SCARIA 2010 KMC
  54. 54. Mapleson c • Operative recovery room • Not used TONY SCARIA 2010 KMC
  55. 55. Mapleson D / bain co-axial system • Best for controlled ventilation TONY SCARIA 2010 KMC
  56. 56. Mapleson E/ Ayres tube • Jackson rees modification of t piece • Best circuit for children in spontaneous and assisted ventilation • Infants & young children TONY SCARIA 2010 KMC
  57. 57. TONY SCARIA 2010 KMC
  58. 58. Circuit type type F (Ja Required fresh gas flow Comments Spontaneous Controlled Type A (magill) Equal to minute volume Very high & difficult to predict • Circuit of choice for spontaneous ventilation • Not used for controlled ventilation Type B 2*minute volume 2-2.5 times minute volume Type C 2* minute volume 2-2.5 times minute volume • AMBU bag • Co-axial system Type D (bain circuit) 2-3 times minute volume 1-2 times minute volume • Circuit used for controlled ventilation • Most commonly used circuit • Can also be used for spontaneous ventilation Type E (Ayre T piece) 2-3 times minute volume 3 times minute volume • Circuit of 2nd choice in children Type F(Jackson rees ) 2-3 times minute volume 2times minute volume • Circuit of choice in children TONY SCARIA 2010 KMC
  59. 59. TONY SCARIA 2010 KMC
  60. 60. Mapleson a • Best for spontaneously breathing patient • Prevent rebreathing Gas from patient is expelled through valve TONY SCARIA 2010 KMC
  61. 61. TONY SCARIA 2010 KMC
  62. 62. Bain circuit /mapleson d best circuit for both controlled & spontaneous breathing TONY SCARIA 2010 KMC
  63. 63. Bain circuit  coaxial system TONY SCARIA 2010 KMC
  64. 64. Mapleson D TONY SCARIA 2010 KMC
  65. 65. TONY SCARIA 2010 KMC
  66. 66. Mapleson f • Used in infant • Jackson rees modification of Ayres t piece • Light weight • Fresh gas flow is close to respiratory tract • No valves  low resistance • High gas flow hence CO2 does not accumalate • Drying of respiratory epithelium TONY SCARIA 2010 KMC
  67. 67. TONY SCARIA 2010 KMC
  68. 68. Mapleson C • Used for emergency resuscitation TONY SCARIA 2010 KMC
  69. 69. TONY SCARIA 2010 KMC
  70. 70. C02 absorbents • Circle systems • From expired gas CO2 is absorbed by C02 absorbents and then recirculated in to the patient • Soda lime • Baralyme • Amsorb plus TONY SCARIA 2010 KMC
  71. 71. TONY SCARIA 2010 KMC
  72. 72. Soda lime • Most commonly used • 94% ca hydroxide • 5% NaOH • 1% KOH • Silica  to provide hardness & prevent alkaline dust formation • Size 4-8 mesh • Clayton yellow  pH indicator • As more CO2 is absorbed colour , pink  yellow/white TONY SCARIA 2010 KMC
  73. 73. Drugs contraindicated in circle systems • Trichloroethylene • Sevoflurane • Methoxyflurane • chloroform TONY SCARIA 2010 KMC
  74. 74. Baralyme • BaOH (instead of NaOH )5% • 80% ca hydroxide • 6% KOH • Less heat caustic and less heat prdn • No silica is necessary to produce hardness • Indicator • Mimiza Z and ethyl red as indicator • Pink  red TONY SCARIA 2010 KMC
  75. 75. Amsorb plus • Calcium hydroxide • Calcium chloride • Water • Hardness  caso4 & polyvinyl pyrrolidine TONY SCARIA 2010 KMC
  76. 76. TONY SCARIA 2010 KMC
  77. 77. Guedels staging of anaesthesia for ether • Stage 1 (stage of analgesia) • Hearing is last sense to be lost • Stage 2 stage of delirium • Stage 3 stage of surgical anaesthesia • Entire relaxation • No muscular rigidity • Deep regular breathing • Satge 4 stage of medullary paralysis (respiratory paralysis) TONY SCARIA 2010 KMC
  78. 78. TONY SCARIA 2010 KMC
  79. 79. TONY SCARIA 2010 KMC
  80. 80. ASA physical scale TONY SCARIA 2010 KMC
  81. 81. MONITORING OF ANAESTHESIA TONY SCARIA 2010 KMC
  82. 82. Monitoring of depth of anaesthesia • Bispectral index : most commonly used • Electrode strip placed on forehead electrical activity recorded in the form of EEG TONY SCARIA 2010 KMC
  83. 83. TONY SCARIA 2010 KMC
  84. 84. BISPECTRAL INDEX TONY SCARIA 2010 KMC
  85. 85. 60-40 surgical anaesthesia TONY SCARIA 2010 KMC
  86. 86. Other methods • Raw EEG • power spectral analysis • Auditory evoked potentials • Tunstalls isolated forearm technique • Lower esophageal contractility TONY SCARIA 2010 KMC
  87. 87. CAPNOGRAPH TONY SCARIA 2010 KMC
  88. 88. 4 PHASE & 2 ANGLES PHASE 1  INSPIRATORY BASELINE  DEVOID O CO2 αANGLE 110*c TRANSITION FROM DEAD SPACE TO ALVEOLI GASES β ANGLE= 90 * DEAD SPCE GAS TONY SCARIA 2010 KMC
  89. 89. ETCO2 • Normal = 35 -45 mmHg • 2-5 mmHg LOWER THAN ARTERIAL PaCO2 • ETCO2 at end expiration • Inversely proportional to alveolar CO2 • Uses • Malignant hyperpyrexia (first indicator) • Degree and adequacy of alveolar ventilation • Correct placement of endotracheal tube (best indicator) • In esophageal intubation • Absence of CO2 in exhaled air or <10 mm TONY SCARIA 2010 KMC
  90. 90. ETCO2 • Circuit Disconnection indicator • Sudden cessation of CO2 in expiratory phase • Indicator of degree of rebreathing (presence of CO2 in inspired air) • Massive fall of ETCO2 • Air embolism • Indicator of cardiac output • Hypovolemia • Pulmonary embolism (following craniotomies major complication) • Cardiac arrest TONY SCARIA 2010 KMC
  91. 91. TONY SCARIA 2010 KMC
  92. 92. TONY SCARIA 2010 KMC
  93. 93. TONY SCARIA 2010 KMC
  94. 94. TONY SCARIA 2010 KMC
  95. 95. TONY SCARIA 2010 KMC
  96. 96. TONY SCARIA 2010 KMC
  97. 97. TONY SCARIA 2010 KMC
  98. 98. TONY SCARIA 2010 KMC
  99. 99. Pulse oximeter • O2 saturation of Hb TONY SCARIA 2010 KMC
  100. 100. Pulse oximeter TONY SCARIA 2010 KMC
  101. 101. Deoxy Hb red light oxy Hb IR light TONY SCARIA 2010 KMC
  102. 102. PRINCIPLE OF PULSE OXIMETRY • AMOUNT OF LIGHT ABSORBED α CONCENTRATION OF LIGHT ABSORBING SUBSTANCE BEERS LAW • LIGHT ABSORBED IS PROPORTIONAL TO DISTANCE TRAVELLED (LENGTH) LAMBERTS LAW TONY SCARIA 2010 KMC
  103. 103. PULSE OXIMETRY DETECTS ONLY PULSATILE BLOOD TONY SCARIA 2010 KMC
  104. 104. Error in SpO2 • COHb • methHb • Intravasular dye(methylene blue) • Low blood volume (hypovolemia) • Nail polish • Ambient pressure • MOVEMENT OF LIMB TONY SCARIA 2010 KMC
  105. 105. Central venous pressure • CVP parallels right atrial P • Normal 5-10 cm of H2o(2-7 mmHg) • Veins used (seldinger technique) • Right internal jugular V*** • Short straight and valveless • Tip of catheter should be at junction of SVC and RA • Subclavian • Femoral • Antecubital TONY SCARIA 2010 KMC
  106. 106. MEASUREMENT OF CENTRAL VENOUS PRESSURE: MANOMETRY When the stopcock is turned to direct flow of fluid to the patient, the manometer is bypassed. TONY SCARIA 2010 KMC
  107. 107. To measure central venous pressure, first turn the stopcock to fill the manometer to 25 cm H2O. TONY SCARIA 2010 KMC
  108. 108. Next, open the stopcock to the patient and the manometer. Allow the column of water in the manometer to fall and stabilize before a reading is taken. Note that the zero mark must be horizontally aligned with the tricuspid valve (which is estimated as the midaxillary line in a supine patient) TONY SCARIA 2010 KMC
  109. 109. Indications for CVP • TPN • Open heart surgeries • Shock (fluid management) • Major surgeries • Apirating air embolus TONY SCARIA 2010 KMC
  110. 110. Increased CVP • Fluid overload • RV failure • Pulmonary embolus • Hemothorax • Cardiac tamponade • Constrictive pericarditis Decreased CVP • Hypovolemia & shock • Venodilaton TONY SCARIA 2010 KMC
  111. 111. Hypothermia • Temp monitoring in skin rectum nasopharynx • Hypothermia causes • delayed metabolism of drugs & delayed awakening • Shivering • Increased o2 consumption • Shift of ODC to left • Temperature is maintained TONY SCARIA 2010 KMC
  112. 112. Neuromuscular blockade is monitored at • Ulnar nerve TONY SCARIA 2010 KMC
  113. 113. By assessing movement of thumb TONY SCARIA 2010 KMC
  114. 114. • No twitches  100 % blockade TONY SCARIA 2010 KMC
  115. 115. TONY SCARIA 2010 KMC
  116. 116. Monitoring of neuromuscular blockade • Tetany: A sustained stimulation (5 s) • Train-of-four (TOF): Four pulses in rapid succession • Double-burst stimulation (DBS): A series of 3 pulses followed after a pause by 2 or 3 pulses. • Post-tetanic potentiation: When a pulse is sent after a tetanic stimulation, it will bring on a stronger twitch than at first. • non-depolarizing muscle blockers, there is a fade phenomenon where twitch amplitude decreases from the first stimulationTONY SCARIA 2010 KMC
  117. 117. TONY SCARIA 2010 KMC
  118. 118. Train of four TONY SCARIA 2010 KMC
  119. 119. Train of four • Used for neuromuscular monitoring • 4 stimuli each of 2 Hz& each for 2second • Ratio of T4 to T1 is taken • With depolarisers all 4 ampitudes are of same in phase I(T4:T1=1) • In phase II & in nondepolarising block • Decrease proportionately in response to T1 • Fading • Raito of 0.3 required for most surgeries • Ratio of 0.7  for reversal TONY SCARIA 2010 KMC
  120. 120. • Adductor pollicis (ulnar nerve) • Used for monitoring • Paralysis of adductor pollicis adequate blockade of laryngeal & pharyngeal muscle  neuromuscular blockade • Absence of activity in orbicularis oculiblockade in laryngeal muscle • Diaphragm requires 90%of recptor occupation while for Sx only 70 - 75 % is needed TONY SCARIA 2010 KMC
  121. 121. Myasthenia gravis • Anaesthesia of choice • Isoflurane,propofol • Muscle relaxant • Atracurium /cisatracurium (1st choice) ,mivacurium,rapacurium • myasthenia is resistant to depolarising muscle relaxant • Myasthenia is sensitive to nondepolarising Contra indicated • Aminoglycosides • Tertacycline • Polypeptide Abx • Procainamide • Pencillamine • B blockerTONY SCARIA 2010 KMC
  122. 122. Porphyrea Safe • Inhalational • N2O,halothane,cyclopropane • IV agents • Propofol • NM blocking agents • dTC ,suxmethonium,pancuronium • NM reversing agents • Atropine,gycopyrrolate ,neostigmine • LA safe • Lignocaine,bupivacaine,prilocaine,tertrac ine Contraindicated • IV agents • barbiturates.,etomidate • LA • Ropivacaine • Analgesic • Pentazocin TONY SCARIA 2010 KMC
  123. 123. Porphyrea Contraindicated • Thiopentone • Methohexitone • Etomidate • Ketorolac • Phenacetin • Pentazocine TONY SCARIA 2010 KMC
  124. 124. Day case surgery • DOC for induction propofol • Muscle relaxant  Sch,mivacurium TONY SCARIA 2010 KMC
  125. 125. Mnemonic day case surgery • Manmohan Singh Is A Prime Minister • Mivacurium • SCh • Isoflurane • Alfentanyl • Propofol • Midazolam TONY SCARIA 2010 KMC
  126. 126. Liver failure Drugs used • Isoflurane (hepatic blood flow is least affected) • NM blockercisatracurium Contraindicated • Halothane TONY SCARIA 2010 KMC
  127. 127. Renal failure Drugs used • Isohurane • Halothane • Desflurane Contraindicated • Methoxyflurane • Morphine • Gallamine TONY SCARIA 2010 KMC
  128. 128. Status asthmaticus • Children halothane • Adults ketamine TONY SCARIA 2010 KMC
  129. 129. Pediarics • Inhalation agent of choice sevoflurane TONY SCARIA 2010 KMC
  130. 130. Malignant hyperthermia drugs used • NODDLE Piza Kake • N20 • Opiate • Diazipine • Droperidol • LA • Etomidate • Propofol • Ketamine TONY SCARIA 2010 KMC
  131. 131. Ischemic heart disease • Barbiturate • Propofol • Etomdate TONY SCARIA 2010 KMC
  132. 132. Opiods TONY SCARIA 2010 KMC
  133. 133. TONY SCARIA 2010 KMC
  134. 134. MORPHINE • Poisoning • Pinpoint pupil • Respiratory depression  death • Rx • Naloxone 0.6mg IV repeated every 3 mins till rr peaks up • No agonistic action and no resp depression • Morphine  tolerance except for miosis & constipation • Morphine withdrawal • Rhinorrhea,hyperhidrosis,sweating,diarrhea,goose flesh • Withdrawal of morphine substitute with oral methadone & gradual withdrawal of methadone TONY SCARIA 2010 KMC
  135. 135. Morphine • IM /IV/SC/epidurally/rectally • Effective against visceral and myocardial ischemic pain TONY SCARIA 2010 KMC
  136. 136. • Opiods  spasm of sphincter of oddi & increase biliary P TONY SCARIA 2010 KMC
  137. 137. • Opiod with high protein binding • Alfentanyl,sufentanyl • Very high lipid solubility • Sufentanyl,fentanyl • With very high ionized fraction • Alfentanyl TONY SCARIA 2010 KMC
  138. 138. Remifentanyl • Ultrashort acting opiod • Metabolised by RBC and tissue esterases • Not influenced by heptic or renal clearance TONY SCARIA 2010 KMC
  139. 139. Oculocardiac reflex • Trigemino vagal reflex • Traction on extraocular muscle  bradycardia • Afferent trigeminal • Efferent vagal TONY SCARIA 2010 KMC
  140. 140. TONY SCARIA 2010 KMC
  141. 141. Ventilation TONY SCARIA 2010 KMC
  142. 142. Modes of ventilation • Non invasive ventilation • Face mask /nasal cannula • Invasive ventilation • Mechanical ventilation • With endotracheal intubation TONY SCARIA 2010 KMC
  143. 143. Mechanical ventilation • Indications • Hypoxemic respiratory failure • Most common indication • ARDS, HF with pulmonary edema ,pneumonia • Hypercarbic respiratory failure • COPD ,neuromuscular disease TONY SCARIA 2010 KMC
  144. 144. • Positive pressure ventilation • Positive • Air pushed in to trachea • Most commonly used • Negative pressure ventilation • Negative pressure is created in alveoli • Air is sucked in to lung • Not used TONY SCARIA 2010 KMC
  145. 145. Ventilator • Volume preset time cycled • Delivers fixed tidal volume at regular intervals • Most commonly used • Pressure preset time cycled TONY SCARIA 2010 KMC
  146. 146. Modes of ventilation • Total ventilator support • Ventilator provides mechanical breath , patients effort is NIL • Patient is passive…ventilator is active • Intermittent positive pressure ventilation • Volume controlled mechanical ventilation (CMV) • Flow delivery is governed by preset flow rate and volume • Pressure controlled ventilation • Flow delivery is governed by preset inspiratory pressure • Partial ventilator support TONY SCARIA 2010 KMC
  147. 147. Partial ventilator support • Assisted mechanical ventilation (AMV) • Ventilator assists a breath initiated by patient • Assist contolled mechanical ventilation • Intermittent mandatory ventilation (IMV) • Synchronised intermittent mandatory ventilation (SIMV) • Pressure support ventilation TONY SCARIA 2010 KMC
  148. 148. Typical ventilator setting • Tidal volume -10 ml/kg • Inspn /expn – 1:2 • Frequency- 10-12 breaths /min • Inspiratory flow rate - 60-80L/min • PEEP – 3-5 cm H2O • FiO2- 50% TONY SCARIA 2010 KMC
  149. 149. Positive airway pressure ventilation • PEEP • Positive pressure applied at the end of expiration • Used during mechanical ventilation • CPAP • During both expiration and inspiration • During spontaneous respiration TONY SCARIA 2010 KMC
  150. 150. Indications for CPAP • Abnormal physical examination • Increased work of breathing, • Substernal & suprasternal retraction,grunting, nasal flaring ,cyanosis , increases RR • Inadequate ABG • Abnormal CXR • Poorly infiltrated/abnormal infiltration TONY SCARIA 2010 KMC
  151. 151. CPAP • Pulmonary edema • Weaning from ventilator • Sleep apnea • Tracheomalacia • Respiratory distress syndrome TONY SCARIA 2010 KMC
  152. 152. Weaning from ventilator • Discontinuing the ventilator support • From any mode possible but not from control mode ventilation • Because in CMV patient support is nil and Tidal volume is delivered by ventilator TONY SCARIA 2010 KMC
  153. 153. Weaning from ventilator • Modes used are • SIMV • IMV • Assisted controlled ventilation(ACV) • Pressure support ventilation (PSV) • SIMV+PSV • T piece • CPAP TONY SCARIA 2010 KMC
  154. 154. TONY SCARIA 2010 KMC
  155. 155. TONY SCARIA 2010 KMC
  156. 156. TONY SCARIA 2010 KMC

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