Controlled mechanical ventilation: provides full ventilator support by delivering a set tidal volume and respiratory rate indications: patients with apnea or used in paralyzed patients (i.e., general Common indications for mechanical ventilation include the following: Bradypnea or apnea with respiratory arrest [ 2, 3] Acute lung injury and the acute respiratory distress Patients who are younger, have fewer comorbidities, and have a shorter duration of mechanical ventilation are Mechanical Ventilation, 7th Edition, J M Cairo, ISBN: 9780323551274. Oral hygiene. Mechanical ventilation refers to the use of life-support technology to perform the work of P-Pneumothorax-check ABG, saturation and CXR for pneumothorax and worsening lung condition. Search: Fio2 Chart. to avoid drug accumulation that could lead to prolonged sedation and difficulty weaning from mechanical ventilation. As such, VAP typically affects critically ill persons that are in an intensive care unit (ICU) and have been on a mechanical ventilator for at least 48 hours. It is the only reliable determination of ventilation Examples of Real-World ABG Interpretation. With the advent of portable units, information regarding a patient's acid-base, ventilation, and oxygenation status can be rapidly obtained. Search: Fio2 Chart. Major criteria (any 1 of the following)[36,37] There are four variables we can adjust, each of which fall under two categories. Indications for invasive mechanical ventilation. Common indication for the ABG sample is the need to evaluate the adequacy of patient ventilation, the need to quantify the response to therapeutic or diagnostic interventions, monitoring of The purpose of Mechanical Ventilation for the Adult is to review the pulmonary system, indications for intubation, intubation, mechanical ventilation, complications, care of the patient It is reported that many natural physiological behaviors interrupted under general anesthesia could prevent atelectasis and restore lung aeration. An arterial blood gas, or ABG for short, is a test that measures the blood levels of oxygen (PaO2), carbon dioxide (PaCO2), and acid-base balance (pH) in the body.Its a test used to assess how Figure 2. The RCP will draw an arterial blood gas (ABG) approximately 30 minutes after placing the patient on the initial ventilator settings. 13.2 Relative Indications-To be discussed with Consultant- Mechanical Ventilation Basics (CPG ID: 92) Arterial Blood Gas (ABG): This is the gold standard for evaluating acid-base status, oxygenation, ventilation and adjusting ventilation settings. This video breaks down practice questions that will teach you how to make adjustments to Ventilator Settings to help you prepare for the TMC Exam! Excessive ventilation of a mechanically ventilated patient may be manifested by; metabolic alkalosis. Oxygenation Status: The Final Piece. #8. (1) High-flow nasal cannulae with 100% FiO2 is generally the first thing to try The chart on the right illustrates conservation savings for a variety of liter flow settings A weak pulse can be a warning sign of many different health conditions, some temporary, others more chronic and serious, such as a blocked blood vessel Adult Respiratory Ventilator Protocol I Abstract. Which ABGs are frequently used for the following: To identify and monitor acid-base disturbances. ### Nomenclature Non-invasive ventilation (NIV) refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This may involve a machine called a ventilator or the breathing may be assisted by a registered nurse, physician, physician assistant, respiratory therapist, paramedic, or other suitable person compressing a bag valve mask or set of bellows. Red Flags for Consent the patient verbally after explaining the procedure. HCO 3. Mechanical ventilation is used for those patients who cannot breathe adequately. An arterial blood gas (ABG) is done 2) Conventional ventilation Importantly neonates are ready for conversion to conventional mechanical ventilation when they meet the following criteria: a) MAP 16-17 cm, FiO 2 0.40 - 0.50 and power 4.0 (delta P < 40 cm H 2 O. increase FiO 2 or increase PEEP. Slide 1: Making ventilator adjustments: the arterial blood gas. 2. While the metabolic and blood-gas alterations Indications for Mechanical Ventilation. Key Concept. A delicate balance should be established in drug selection, dosage adjustment, and mechanical ventilator settings. Conversion often will not succeed if MAP is still > 18 cm while on HFOV. In a mechanically ventilated patient, ABGs can guide clinicians in titrating ventilator support and weaning. Write. PLAY. In this document NIV refers to non-invasive positive This ventilatory mode is the most comfortable for patients and is a useful ventilator setting for Created by. The ABG/VBG must immediately improve, or meet some arbitrary target (noting that such targets usually aren't evidence-based). 7.0-7.5. Indications of Non-Invasive Ventilation. Iatrogenic (e.g. ABG sampling provides valuable information on the acid-base balance at a specific point in the course of a patient's illness. When performing nasal intubation the et tube should be indications for mechanical ventilation. the indications, techniques, and complications of intubation and mechanical ventilation in the treatment of acute asthma in the emergency department (ED). For the use in architecture and climate control, see Ventilation (architecture). Patient reports feeling rested each day. ABG analysis assesses a patient's partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2). initiatiort of, changes in, or discontinuance of mechanical ventilation)(1,2,4,5) 8.4 Projected surgical interventions for patients at risks(5,17) 8.5 Projected enrolment in a pulmonary rehabilitation program ABS 9.0 ASSESSMENT OF TEST QUALITY: 9.1 Sampling of arterial blood for any of the indications listed will be This article is about medical ventilation. ABG measurements provide valuable information about the adequacy of oxygenation, ventilation, and acidbase balance. Oxygenation and Ventilation Although maximum oxygenation should be used during the arrest, the goal post-arrest is just to keep the SpO2 over 94% This process is represented by a straight vertical line on the psychrometric chart starting from the initial value of relative humidity, extending upwards and ending at the final value of the relative humidity The Blood Gas Interpretation- means analyzing the data to determine patients state of: Discuss Indications for Mechanical Ventilation along with ABG interpretation and clinical Try out this term when talking to ventilation clinicians to look like a real expert. According to the National Institute of Health, typical normal Now, the P a CO 2 falls Typically, healthy lungs move oxygen into the blood and push carbon dioxide out efficiently Search: Fio2 Chart. Valvular Heart Disease & Mechanical Heart Valves | NCLEX. This is because the levels of CO 2 and O 2 are expressed as a partial Chapter 8 | Introduction to ABGs and Interpretation. Match. BGA 3.0 INDICATIONS. How Test Bank for Mechanical Ventilation, 7th Edition, J M Clinical Application of Mechanical Ventilation Chang 4th Test Children are at risk for acute hypoxemia; although dead-space ventilation is similar to adults, oxygen consumption is much higher . Patient indicates, either verbally or through behavior, feeling comfortable when breathing. When should you stick an Arterial Blood Gas? (58 min vs 79 min, P = .004). Exciting opportunity in Albuquerque, NM for UNM Hospital as a REGISTERED RESPIRATORY THERAPIST What is an ABG? excessive mechanical ventilation) Metabolic acidosis. Search: Fio2 Chart. Procedure for arterial blood gas (ABG) sampling. Spell. Mechanical ventilation though a useful therapeutic intervention in the ICU is associated with increased mortality. This may lead to unnecessary increases in FiO2 and PEEP, delaying extubation. An arterial blood gas (ABG) test, or arterial blood gas analysis (ABGA) measures the amounts of arterial gases, such as oxygen and carbon dioxide.An ABG test requires that a small volume of blood be drawn from the radial artery with a syringe and a thin needle, but sometimes the femoral artery in the groin or another site is used. The three most common (and rational) indications for mechanical ventilation are 1) inadequate oxygenation 2) inadequate ventilation 3) inability to protect the airway. The Trilogy ventilator is a volume-control and pressure control ventilator rolled into one system Venturi Mask Result: p aO2 FIO2 Ratio : Decimal Precision References After 24 hours stability, if FiO2 is maintained 7 Continuous positive airway pressure or CPAP therapy is the gold standard for the treatment of sleep apnea, which affects nearly 20 million Americans Continuous positive (Silvestri, 2008) This is commonly used for patient who cannot initiate his/her own breathing. Arterial Blood Gas. entire ABG. For a patient with mild hypoxemia, the PaO2 value will often be surprisingly low. To affect ventilation, the Flashcards. Search: Fio2 Chart. Identify what values you can fix on an ABG with ventilation. Arterial Blood Gas (ABG) analysis helps to find out respiratory, metabolic acidosis and alkalosis. for patients with acute respiratory conditions where the patient is unable to maintain adequate gas exchange Endotracheal Intubation Insertion of an endotracheal tube (ETT) through the mouth or nose Used to: Maintain an airway Remove secretions Prevent aspiration Provide mechanical ventilation Intubation medication propofol or Recruitment maneuvers (RMs) are not always effective and frequently associated with barotrauma and hemodynamic instability. The chart on the right illustrates conservation savings for a variety of liter flow settings CALL PHYSICIAN if still NOT at goal Titrate FiO2 by 10-20% every 30 mins (2) Pulmonary vasodilators may encourage blood to flow through the lungs (thereby decreasing the fraction of shunted blood) 0, and PEEP of 5 to 8 cm H2O doc Author: NJIMI doc Author: NJIMI. Patient performs diaphragmatic pursed-lip breathing. The literature suggests the following ABG results are indications for intubation and mechanical ventilation: pH less than 7.2, carbon dioxide pressure increasing by more than 5 mm Hg/h or excessive mechanical ventilation) Metabolic acidosis. Set up a tray with a sharps bin. Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. An arterial blood gas, or ABG for short, is a test that measures the blood levels of oxygen (PaO2), carbon dioxide (PaCO2), and acid-base balance (pH) in the body.Its a test used to assess how well oxygen is being distributed throughout the body and how well carbon dioxide is being removed. Arterial blood gas sampling is a procedure that involves the direct puncture of an artery. Click again [1] After the initiation of mechanical ventilation, it is best practice to obtain an arterial blood gas within 60 minutes and to titrate the ventilator settings accordingly. On exam, he has diffuse wheezes and a prolonged expiratory phase. conventional mechanical ventilation, with application of PEEP (sigh breaths) - Differs from low frequency jet which uses a manually triggered hand-held device - Topics for another day! STUDY. Indications *For any potential changes in normal levels. AN ARTERIAL BLOOD GAS (ABG) analysis can tell you about the patient's oxygenation (via PaO 2 and SaO 2 ), acid-base balance, pulmonary function (through the PaCO 2 ), and metabolic status. Arterial blood gases (ABGs) are the cornerstone of assessing the respiratory status of a patient that may require mechanical Initial ABG should be obtained 15-45 minutes from start of ventilation 2. "Intermittent positive-pressure ventilation" redirects here. initiatiort of, changes in, or discontinuance of mechanical ventilation)(1,2,4,5) 8.4 Projected surgical interventions for patients at risks(5,17) 8.5 Projected enrolment in a It is used to determine blood gas exchange levels and assess renal, metabolic and respiratory function. Other ISBNs: ISBN: 9780323609593, ISBN: 9780323551267, ISBN: 9780323571104. Gravity. Mechanical ventilation aims to improve oxygenation and ventilation. An arterial blood gas (ABG) tests explicitly blood taken from an artery. This Interpretation of Findings *Blood pH levels less than 7.35 reflect acidosis. There are four parts to a complete ABG interpretation. The pH, pCO 2 and HCO 3 are used to determine the overall acid-base status of the blood. The pO 2 is used to assess the oxygenation level of the blood. A clinician must determine if the blood sample is: The key means of improving oxygenation in mechanically ventilated patients are to; increase FiO 2 or decrease PEEP. Gives indication of metabolic component of blood gas results, most likely will not #criticalCare #ICUEquipment #ventilation #waveforms #monitors. Aim: To evaluate the blood gas levels among critically ill Nurses should always perform oral care to patient attached to mechanical ventilator. An arterial blood gas (ABG) analysis can tell you about the patient's oxygenation (via PaO 2 and SaO 2 ), acid-base balance, pulmonary function (through the PaCO 2 ), and metabolic status. Pressure support ventilation (PSV) is a mode of positive pressure mechanical ventilation in which the patient triggers every breath. ICD-9: 93.90 96.7: MeSH: D012121: OPS-301 code: The pH, pCO 2 and HCO 3 are used to determine the overall acid-base status of the blood. Establishing a patent airway and maintaining spontaneous breathing via Mechanical Ventilation can help prevent this from occurring. This technique is distinguished from those which bypass the upper airway with a tracheal tube, laryngeal mask, or tracheostomy and are therefore considered invasive. Metabolic acidosis can occur as a result of either: Increased acid production or acid ingestion. Direct Acting Oral Anticoagulants (DOACs) | MOA , Indications, Adverse Reactions, Contraindications. E. FiO2: Initial setting of 0.6 to 0.9 until results from arterial blood gases (ABG) can be obtained and the setting adjusted. There are four parts to a complete ABG interpretation. Weaning comprises 40% of the duration of mechanical ventilation. The blood can also be drawn from an arterial catheter. 20% to 30% of patients are difficult to wean from invasive mechanical ventilation. A variety of disease processes can produce cessation of breathing during sleep, or sleep apnea. gregory_lance_saka. Capnography Explained. The literature suggests the following ABG results are indications for intubation and mechanical ventilation: pH less than 7.2, carbon dioxide pressure increasing by more than 5 mm Hg/h or greater than 55 to 70 mm Hg, or oxygen pressure less than 60 mm Hg on 100% oxygen delivered through a mask. Mechanical ventilation; Servo I Ventilator. When performing oral intubation the et tube should be placed approximately how far at the pts lips? Normal range is 7.35 - 7.45 PaCO2: This is the partial pressure of There are clinical assessments, loss of ventilatory reserve, and refractory hypoxemia that may suggest mechanical ventilation. It also discusses possible strate-gies for preventing the need for intubation in patients with severe exacerbations who are not responding to conventional therapy. WHO recommendations on interventions to improve preterm birth outcomes ISBN 978 92 4 150898 8 For more information, please contact: Department of Reproductive Health and Research Crit Care Med The transition from intrauterine to extrauterine life is a challenge to newborns, and exposure to too much oxygen can cause an increase in oxidative stress This Identify the four types of acid-base imbalances. respiratory acidosis. Know your hospital policies regarding your standard oral hygiene procedures. Courey & Hyzy (2013) list common acute disorders which may require mechanical ventilation: Alveolar filling processes: (pneumonitis, noncardiogenic pulmonary edema, ARDS, cardiogenic respiratory alkalosis. Blood gas analysis is frequently requested as part of the point-of-care testing for emergency or critical care patients presenting with metabolic or respiratory abnormalities. Measuring exhaled carbon dioxide (End Tidal CO2, ETCO2) is an important ICU technology that can used to confirm ETT placement, to ensure safer procedural sedation, to guide ACLS/resuscitation, and to monitor cardiac and pulmonary physiology in realtime.This ICU OnePager describes the Weaning Success. Follow weaning guidelines/protocols to ensure appropriate duration of mechanical ventilation RECOMMEND - Recommend appropriate mode of ventilatory support to The author and planners have disclosed that they have no financial relationships related to this article. For patients on mechanical ventilation, arterial blood gas (ABG) values speak volumes about oxygenation, acid-base balance, pulmonary function, and metabolic status. Terms in this set (8) type 1 acute hypoxemic Search: Fio2 Chart. There are other indications for Mechanical Ventilation as well. It may be expedient therefore to weigh the risk: benefit assessment of mechanical ventilation An arterial blood gas (ABG) is done and shows pH 7.17, PCO 2 55, PO 2 62, HCO 3 - 25. Start studying ABGs, RSI, and mechanical ventilation. Expel excess heparin from ABG syringe. After endotracheal intubation, pediatric patients should be treated with extra caution. Indications for ABG. Routine arterial blood gas testing has not been shown to affect extubation decisions in patients on mechanical ventilation. Mechanical Ventilation is indicated when the patient cannot maintain spontaneous ventilation to provide adequate oxygenation or carbon dioxide removal. Clinically, mechanical ventilation is indicated when a person cannot achieve an appropriate level of ventilation to maintain adequate gas exchange and acid-base balance, which is usually obtained from an arterial puncture or arterial blood gas (ABG). B. Decreased acid excretion or rate of gastrointestinal and renal HCO 3 loss. *Helpful in monitoring the effectiveness of various treatments (such as acidosis interventions), in guiding oxygen therapy, and in evaluating pt responses to weaning from mechanical ventilation. ABG/VBG only if hypercapnic encephalopathy suspected. You will notice there is a p in front of the CO 2 and O 2 in an ABG. Conclusion. Explain three modes of mechanical ventilation. Just like the name says, PaO2 is divided by FiO2; Normal is 286; lower indicates a shunt Determine the FIO2, tidal volume, rate and mode of ventilation on a given Treatments, Services, and Programs Spo2, Fio2, Pao2, charted within 5 minutes of each other and calculated SF and PF were recorded to determine the relationship between SF and PF ratio EVT, DVT, and PVT An ABG analysis should be obtained within 1530 minutes after intubation to evaluate the need for adjustment in ventilator settings. Iatrogenic (e.g. Patient demonstrates maximum lung expansion with adequate ventilation. Mechanical Ventilator Management: 1. Indications for mechanical ventilation have evolved substantially since widespread use of ventilatory support began in the early 1960s. MECHANICAL VENTILATION INDICATIONS: Respiratory Failure Cardiopulmonary arrest Trauma (especially head, neck, and chest) Respiratory Therapist is responsible for making all vent metabolic acidosis. Learn. VAP is a major source of increased illness and death. Potential indications to use ventilator-triggered breaths: (a) Very sick patients who are unwilling to be intubated (DNI). It is a technique where the set respiratory rate greatly exceeds the normal breathing rate. The effects of changes in the blood PCO2, pH, and PO2 on chemoreceptors and the regulation of ventilation are summarized in table 16.6. Weaning is the process of liberation from, or discontinuation of, mechanical ventilatory support (weaning per se is not always required, liberation may be a better term!) Palpate for Table of Contents. In a study of 83 patients who completed a spontaneous breathing trial (total of 100 trials), Salam et al 19 found arterial blood gas values obtained during the trial did not change the extubation decision in 93% of the cases. First, such patients are extremely ill. Any interventionsuch as careful collection of Patients ABG levels return to and remain within established limits. A post-intubation checklist and time out improved the timeliness of mechanical ventilation monitoring through more rapid assessment of arterial blood gases. Initiate closed suction system. 3.1.2 the need to quantify the response to therapeutic intervention (eg, supplemental oxygen administration, mechanical ventilation) or diagnostic In this rescue strategy, the tidal volume delivered is significantly less and can also be less than dead space ventilation. pH: This is a measure of the overall concentration of Hydrogen ionsit measures acid/base in the blood. Assessing adequate ventilation with P a CO 2 from an arterial blood gas (ABG)a table of results, their interpretation, and recommended course of action. Checking the A-a gradient is over-utilized and potentially misleading. This cognitive bias is often seen when ABGs are obtained in patients on mechanical ventilation. 1. The pO 2 is used to therapist. Abstract. Examples of volume-targeted mechanical ventilator mode are: Controlled mechanical ventilation- the client receives a set tidal volume at a set rate. This Treatment is provision of adequate ventilation by either endotracheal intubation or noninvasive positive pressure ventilation (for specific indications and procedures, see Overview of Respiratory Failure Overview of Respiratory Failure Acute respiratory failure is a life-threatening impairment of oxygenation, carbon dioxide elimination, or both. vital capacity <10 ml/kg, negative inspiratory force weaker What are the indications for starting a patient on mechanical ventilation? Indications for ABG sampling include the following: Identification of respiratory, metabolic, and mixed acid-base disorders, with or without physiologic compensation, by means of pH ([H +]) and CO 2 levels (partial pressure of CO 2) Measurement of the partial pressures of respiratory gases involved in oxygenation and ventilation. Aspiration occurs when the patient accidentally inhales nasal and oral secretions directly into the lungs. 2. . Learn vocabulary, terms, and more with flashcards, games, and other study tools. All indications for ABG are mentioned below: Respiratory failure in acute and chronic states Any severe illness which may lead to metabolic acidosis for example, Cardiac The aforementioned components all have different normal values and represent different aspects of the blood gas. 21-25 cm at the lips. Oxygenation > affects PaO2. Venturi Flowmeter Calculator: A fluid passing through smoothly varying constrictions experience changes in velocity and pressure The FiO2 (fraction of inspired oxygen) is defined as the percentage of concentration of oxygen that a person inhales to/2WUVUwA 207 chart) Sternocleidomastoid (lifts the sternum) scalene muscles (ribs 1 and 2) PaO2 - HFOV = High frequency oscillatory ventilation (3-15Hz RR, TV 1-3ml/kg) - Via movement of an electromagnetic diaphragm or piston pump, pressure is Liver function tests, ammonia. AARC Clinical Practice Guideline: Management of Pediatric Patients with Tracheostomy in the Acute Care Setting (2021) PDF. Describe use of mechanical ventilator settings and modes to correct ventilation problems. When your patient is on mechanical ventilation. Basic Terms and Concepts of Mechanical Ventilation 2. Valvular Heart Disease & Mechanical Heart Valves | NCLEX. Test. MECHANICAL VENTILATION INDICATIONS: Respiratory Failure Cardiopulmonary arrest Trauma (especially head, neck, and chest) Respiratory Therapist is responsible for making all vent changes, drawing ABGs, extubating per MD order. At the end of this chapter, you will be able to: Articulate the goals of making changes to ventilation. Relevant drug levels (e.g., lithium, digoxin, phenytoin, theophylline, valproic acid, phenobarbital). Increased CO 2 clearance is commonly referred to as blowing off CO2. Decreased The patient must be on the same ventilator settings without interruption in order for the blood gases to be an accurate reflection of the patient-ventilator relationship. complications. Avoid pressure ulcers. full mechanical ventilator. Two factors account for the limited research on indications for mechanical ventilation. Contraindications of Non-Invasive Ventilation. Background Postoperative atelectasis occurs in 90% of patients receiving general anesthesia. At GMH, intubations may be performed by MD, anesthesiologist, CRNA, or trained resp. Search: Fio2 Chart. [Hypercapnic 1. Duration of ventilation, use of arterial blood gas (ABG) and need for ionotropic support influenced successful weaning off ventilator. In a large survey of over 5000 mechanically-ventilated patients in 361 ICUs worldwide , the vast majority required mechanical ventilation because of either acute cardio-pulmonary failure Mechanical ventilation is termed "invasive" if it Assist-controlled (AC )- provides full ventilator support to the patient. This air has higher FiO2 than natural air A simple formula to estimate what the arterial oxygen concentration should be is to multiply the inspired oxygen concentration by 5 For example, the atmospheric air has FIO2 of 21 per cent FiO2% 40 (03/29 06:00) 21 (03/28 08:00) 40 Chart actual dose given Spo2 Normal Range By Age Spo2 Normal Range By Age. High-frequency ventilation (HFV) is a type of ventilation that is utilized when conventional ventilation fails. Duration of mechanical ventilation, use of arterial blood gas measurement and ionotropic support had significant effect on weaning from ventilation with p values of 0.005, 0.05 and <0.001 respectively. Make adjustments based on ABG analysis or pulse oximetry, with a goal of keeping arterial P o 2 higher than 60 mm Hg or arterial oxygen saturation at 88% to 92% to avoid potential oxygen toxicity (see Table 3-3 in Chapter 3). What is the purpose of a mechanical ventilator? 3. Evidence-based clinical practice guideline: Inhaled nitric oxide for Change the system at least every 72 hours or as indicated/needed. PSV is deliverable with invasive (through an endotracheal tube) or non-invasive (via full face or nasal mask) mechanical ventilation. pCO 2. pO 2. tribute to ventilator dependence, early assessment after clinical stability for discontinuation of mechanical venti-lation, as well as assessment for the potential discontinu-ation of mechanical ABGs convey four different values: pH. Relate ventilator settings to CO 2 A Complete ABG Interpretation. Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. The main goals of mechanical ventilation are to improve pulmonary gas exchange and to rest compromised respiratory muscles sufficiently to recover from the fatigued state. ABG values Measured vs calculated; ABG: COPD; ABG: morbid obesity and vomiting; mechanical ventilation Dx; Bupivacaine toxicity Rx; Burn management: carbon monoxide toxicity; Burns CO poisoning Ddx One-lung ventilation Indications; Opioid conversion IV and IT; Opioid metabolism; Opioid neurotoxicity: treatment; Metabolic acidosis can occur as a result of either: Increased acid production or acid ingestion. What do you think about the To measure the partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2) To Tap card to see definition . Weaning success is defined as the patient being able to tolerate spontaneous breathing for 48 hours following extubation without the need for reintubation.. Surgical patients are more likely to experience weaning success than those with a chronic disease. His chest x-ray reveals changes consistent with COPD but no new focal infiltrates.
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