# What was that device?



## Melbourne MICA (Jun 27, 2009)

Out of interest in a purely clinical sense, in the photograph of the late Michael Jackson when he arrived at hospital, he had a blue attachment to his ETT . Was this just a clamp to secure the tube or was it in fact part of another type of airway device like a combitube. We only secure our ETT's with a cloth tape tie. It works well enough as long as you keep a close eye on your tube so as to stop zealous EMT-B's or firies dislodging it in their haste to run up the hospital ramp or out the door of the pts residence.

Any help?

MM


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## jtb_E10 (Jun 27, 2009)

Melbourne MICA said:


> Out of interest in a purely clinical sense, in the photograph of the late Michael Jackson when he arrived at hospital, he had a blue attachment to his ETT . Was this just a clamp to secure the tube or was it in fact part of another type of airway device like a combitube. We only secure our ETT's with a cloth tape tie. It works well enough as long as you keep a close eye on your tube so as to stop zealous EMT-B's or firies dislodging it in their haste to run up the hospital ramp or out the door of the pts residence.
> 
> Any help?
> 
> MM




That was an endo-lock. They are devices to secure the ET tube in place on a patient.


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## Melbourne MICA (Jun 27, 2009)

*endo-lock*

I take it they attach at the front in the oral cavity (?) with the ETT inserted through a central opening and a cloth tie or the like round the back of the neck to tie it off.

MM


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## Ridryder911 (Jun 27, 2009)

Actually, it looked more like a Thomas Brand.. same concept

Here is a link with all the different brands 


http://online.boundtree.com/store/product_index.asp?keyword=et+tube+holder


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## Melbourne MICA (Jun 27, 2009)

*Ta*



Ridryder911 said:


> Actually, it looked more like a Thomas Brand.. same concept
> 
> Here is a link with all the different brands
> 
> ...



Cheers Ryders  - I'll scope them out. We peasants downunder have no such luxuries!!!!!

MM


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## Ridryder911 (Jun 27, 2009)

Try Boundtree, they are also International. The device is cheap enough to make it available to purchase and they really do work remarkably well. Much more effective than the traditional methods. 

R/r911


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## downunderwunda (Jun 27, 2009)

Melbourne, 

they also fit LMA's, I believe the only reason they are not used here is cost.


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## Scout (Jun 27, 2009)

They also lessen the chance of them using their teeth to bite on the tube.


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## VentMedic (Jun 27, 2009)

The type they were using is probably one of the less secure devices I've seen used. The screw is either tightened too tight or too loose. The medic will use the marking at the screw as the proper number from what they learned which may be 2 - 3 cm too high and the tube becomes a supraglottic device. The hospital has to change out the device in the ED fairly quickly as it damages the soft tissue of the mouth after 2 - 4 hours. It is a pain when the patient vomits since the device covers the whole mouth area. We usually have to get it off on arrival to the ED just to get the vomit out of the mouth from the field. And of course, a cuffed ETT does not protect from aspiration.

There are several better devices on the page linked by Rid.


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## boingo (Jun 27, 2009)

We use cotton trach tape, seems to do the trick.  We carried the Thomas for a bit, no one seemed to care for it, especially the hospitals.


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## AnthonyM83 (Jun 27, 2009)

VentMedic said:


> We usually have to get it off on arrival to the ED just to get the vomit out of the mouth from the field. And of course, a cuffed ETT does not protect from aspiration.


 Happen to know stats on how well they (don't) protect from aspiration? Few minutes after my last intubation, patient vomited. Respiratory was handling him and they insisted that his airway was secure because of the inflated balloon. It still seemed wrong...
Why can't we have "VentMedics" at all the hospitals? I've seen some very shady RTs lately...


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## ADKMedic (Jun 27, 2009)

*It may take a little education on your part.*



boingo said:


> We use cotton trach tape, seems to do the trick.  We carried the Thomas for a bit, no one seemed to care for it, especially the hospitals.



When we started using ET tube holders in our region the medics loved them and the hospital was pretty noncommittal.  Then, the agencies were flooded with complaints from the hospital about their use.  It seems that when patients were brought to the ED the holders were left in place when the patients were taken to ICU or the floor.  Sometimes tissue would be squeezed between the tube holders and the bony structures of the mouth and tissue necrosis would result when they are left in place for a long period of time.  

Please, if you are interested in using these devices educate your hospital that they are emergency use only and should be replaced by whatever means to secure the tube that the hospital respiratory techs feel comfortable using once the patient is under their care.  

For field use, I think these devices are great.  They do not crush the tube, they provide a bite block, and (the ones I have used like the Thomas) provide ample space to suction around.  Most important, they do exactly what they are designed to do, they can quickly be applied and hold the ET tube securely in place.


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## VentMedic (Jun 27, 2009)

AnthonyM83 said:


> Happen to know stats on how well they (don't) protect from aspiration? Few minutes after my last intubation, patient vomited. Respiratory was handling him and they insisted that his airway was secure because of the inflated balloon. It still seemed wrong...


 
Stats? Let me just give you a basic anatomy lesson. The cuff is located *below* the cords. Whatever gets through the cords is considered aspirated. The tube just makes it easier to suction out. The best way is to prevent aspiration by correct use of a BMV or an OG/NG tube.

By understanding this is why we don't have the issues in Peds and Neo with the cuffless tubes. Unfortunately, due to the larger VTs required for adults, a cuff is necessary. So, ensuring the patient is adequately ventilately without much volume loss is the ONLY purpose of a cuff. However, we do have some modes of ventilation and ventilators where we do not use a cuff even for adults. 

BTW, the cuff is also not meant to "hold the tube in place and keep it from falling out" as some are also led to believe.



AnthonyM83 said:


> Why can't we have "VentMedics" at all the hospitals? I've seen some very shady RTs lately...


 
That is because you are in California. CA has a long history of RT mills just like your medic mills. There are still quite a few "techs" in that state who do suck. But, have you met any RRTs from Loma Linda or Long Beach?

As least even (and especially) CA has been doing its best to get rid of the RTs that don't belong in the profession. The increased education standards is helping as well. The profession in CA can not afford to have another Efren Saldivar. The RTs in that state will be paying for his mess for years to come with the mandatory CEUs that essentially is "How thou shalt not kill your patients".


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## AnthonyM83 (Jun 27, 2009)

Gotcha.
And yes, I've met one RT from Long Beach. He was a wealth of knowledge. Him and one other RT from Centinela (who was a contrast to the other ones at that hospital) were the only ones who fit the profile of an RT that I've gotten from my interactions with you. Of course, similar thing has happened with finding paramedics who fit my idea of what one was from posting here since I was in EMT school.


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## VentMedic (Jun 27, 2009)

Anthony, 
This might also be of interest to you.  
http://www.zapvap.com/_pdfs/inservice_poster.pdf

For the last 5 - 10 years, depending on teaching or otherwise, hospitals have been using ETTs with subglottic suction ports to reduce VAP.   Some may already have seen RRTs and/or MDs switching out the tubes in the ED or at least in the ICU if it is suspected the patient will be intubated for over 48 hours.  

Secretions from the oral cavity (and sinuses) will drain to the cuff when the patient is sedated and especially if a paralytic is used.


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## wyoskibum (Jun 29, 2009)

Also, the 2005 AHA ACLS guidelines advocate the use of a commercial endotracheal tube holder.


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## VentMedic (Jun 29, 2009)

wyoskibum said:


> Also, the 2005 AHA ACLS guidelines advocate the use of a commercial endotracheal tube holder.


 
And there are many, many to choose from. We don't use the same method of securing a child as we do an adult nor a burn patient. We also have to use a device that works with the injuries and care of the patient as well as the shape of the person's face for which allowances for deformities must be made. That is also why hospitals have many different ETTs to choose from.

While many things may work emergently, some providers get focused on just the one device they have or have "grown up with" and know no other way to secure a tube. I have even seen tubes come in unsecured "with the cuff inflated real big so the tube won't fall out" because they didn't know how else they could secure the tube.


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## Melbourne MICA (Jul 2, 2009)

*Dohh!!!!*



VentMedic said:


> Stats? Let me just give you a basic anatomy lesson. The cuff is located *below* the cords. Whatever gets through the cords is considered aspirated. The tube just makes it easier to suction out. The best way is to prevent aspiration by correct use of a BMV or an OG/NG tube.
> 
> By understanding this is why we don't have the issues in Peds and Neo with the cuffless tubes. Unfortunately, due to the larger VTs required for adults, a cuff is necessary. So, ensuring the patient is adequately ventilately without much volume loss is the ONLY purpose of a cuff. However, we do have some modes of ventilation and ventilators where we do not use a cuff even for adults.
> 
> BTW, the cuff is also not meant to "hold the tube in place and keep it from falling out" as some are also led to believe.



Blow me away why don't you Venty. Their is a eons old mythological belief amongst the ALS types, (even here) about ETT providing the "best" level of protection from aspiration. It is typically called "securing the airway". If what you are saying is on the mark (and it usually is) I must humbly put up my hand bend over and prepare to take it where it hurts because I have gone along with this concept for ever. I understand the ventilation issues and of course we see them most obviously in arrested pts where the soft bag will fill up very quickly necessitating some weening.

But even today our education still talks about BVM, LMA and ETT in terms of both airway "protection" and of course relative efficiencies for ventilation worst to best. Seems like the old timers who routinely emphasize basic airway protection measures like side position, drainage, suction etc are right on the money and always have been.

I promise I will never look at a nasogsatric tube the same way again.

Stone the crows and call me a platypus!!!!

To be investigated further. 



MM


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## VentMedic (Jul 2, 2009)

A lot of changes in attitudes have had to take place when we started examining our ventilator associated PNA rates. We do not allow NT intubation in the hospital except when there is absolutely no other choice, which in our hospital that should not be the case. Of course in the OR for facial surgery NTI is acceptable (RAE tubes) but if the tube has a chance of staying for more than 72 hours a trach is preferred method of securing the airway. There are two reasons for that: 1. if the tube falls out inadvertently the patient will get an emergent trach. 2. it will reduce the chance of sinus infections leading to bigger badder things.

We also no longer use nasogastric tubes on ventilator patients but go OG for long term placement.  An NG is acceptable in the rescue phase but it had better be gone when the CCM doctors round. 

We are still not using the subglottic suction ports with the trachs yet although that hear those expensive trachs are available more so in Europe. We do postural drainage and if on a vent, cuff deflation with a trendelenburg manuver to clear secretions above the trach.

I am always amazed at how many secretions can be drained by the subglottic suction port. It has also increased patient comfort as they don't feel like they have to cough or be frequently suctioned from the draining secretions.

An ETT is still the definitive method for securing the airway and while the tube can slow the flow of vomit through the cords, it also keeps the cords open for secretions to pass through. They have no other choice but to hang out on the cuff and slowly contaminate the lung fields. The pressure around the cuff also changes with each breath when on a ventilator which can allow for secretions to be introduced. We attach a spring loaded device that attempts to keep consistent pressure in the cuff.

When I was looking for the link to that device I came across this artilce from the ERS. Defeating VAP is global since it is costly for healthcare.

http://erj.ersjournals.com/cgi/reprint/20/4/1010.pdf


Managing an airway is both a science and an art. As I have also stated before, there are over 300 different airway devices and now just as many accessories.


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## VentMedic (Jul 2, 2009)

Here's a couple of links to view some of the many different tubes we work with in a hospital.

This article is 10 years old so some of the new tubes and theories are not listed.

http://www.aarc.org/marketplace/reference_articles/06.99.0661.pdf

Some of these tubes you may see in people at their homes or on the street for a variety of reasons. Some of them do not have a standard 15 mm connector so you may have to get creative. Before pulling any device, make sure it does not have large internal phlanges that will rip the trachea.

http://www.bosmed.com/metanavigation/about-us.html

http://www.bosmed.com/airway-management.html

http://www.bosmed.com/safe-t-tubestm.html

All about trachs
http://www.rcjournal.com/contents/04.05/04.05.0497.pdf

Metal/silver trach tubes (aka Jackson trachs in the U.S. and are now stainless)
http://www.kapitex.com/tracheostomy/negustubes

Shiley trachs (*other good respiratory links on that page also*)
http://www.dhmc.org/webpage.cfm?site_id=2&org_id=116&morg_id=0&sec_id=0&gsec_id=3103&item_id=8169

Portex trachs
http://www.smiths-medical.com/catalog/portex-tracheostomy-tubes/

Bivona trachs
http://www.smiths-medical.com/catalog/bivona-tracheostomy-tubes/

Portex ETT for selective lung ventilation
http://www.smiths-medical.com/catalog/endobronchial-tubes/blue-line-endobronchial-tubes-1.html

Various special purpose ETTs
http://www.smiths-medical.com/catalog/endotracheal-tubes/


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## 8jimi8 (Jul 2, 2009)

VentMedic said:


> Unfortunately, due to the larger *VTs* required for adults, a cuff is necessary. So, ensuring the patient is adequately ventilately without much volume loss is the ONLY purpose of a cuff. However, we do have some modes of ventilation and ventilators where we do not use a cuff even for adults.



Vent did you mean tidal volume?


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## VentMedic (Jul 2, 2009)

8jimi8 said:


> Vent did you mean tidal volume?


 
Yes.

Here is a list of commonly used pulmonary terms and abbreviations which will be found in some of the articles I post or write about.
http://noairtogo.tripod.com/gloss.htm


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## Shishkabob (Jul 2, 2009)

Ah, you're no fun Vent 

Thanks for the list.


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## 8jimi8 (Jul 2, 2009)

Thanks, i didn't realize that VT and TV were the same thing!!


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## Melbourne MICA (Jul 2, 2009)

*Not completely daft*

So Venty at least in the short term an ETT can "secure" the airway (stating the obvious and paraphrasing the accepted notion) or more correctly prevent significant aspiration from hitting the lung fields. 

I have been reading up on cuff pressures and most of the studies I read called for cuff pressures to be measured using a manometer. Even amongst skilled anaesthetists over or under pressure occurred in a surprising percentage of ET placements.

In the field as you know we just inflate the cuff till you hear no leaks. One excellent operator who works on our air wing uses the method whereby rather than just put an arbitrary amount of air via a syringe (which is probably and usually too much) he will put a small amount in, ventilate, add a little more etc until there are no leaks heard.

I like the approach and now use it myself. In the absence of manometers I think this comes closest to providing sufficient pressure to seal the trachea without compromising the perfusion of the tracheal lumen though of course how are we to really know for sure.

In the end however it is clearly a priority to evacuate the stomach with an NG or OG tube and I will certainly give this far more emphasis and a higher place in the chronology of airway management for our tubed Pt's. It makes sense that there can be little passive aspiration if there is nothing or next to nothing in the stomach.

Like I've said before, airway management is a hugely important area for ambos. Keep the great posts on this subject going. All will benefit.

Cheers
MM


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## VentMedic (Jul 2, 2009)

What you described is MLT (Minimal Leak Technique) or MOP (Minimal Occlusion Pressure) which is what RTs do until they can get their gadgets hooked up. A manometer is the best.

Some have a difficult time understanding that it isn't the amount of air placed in the cuff but the fit of the tube in the trachea that varies the pressure. The cuff size will also vary with tube size. And, there are many different cuffs. There is no set recipe or magical number for filling a cuff.

Also, some will claim to see the ETT pass through the cords but what they may not see is the cuff expand and if the tube is just slightly higher than it should be, the cuff will pop back through the cords. If it doesn't go to the esophagus, the cuff may just lie supraglottic giving the provider the false security that the tube is in the correct position.  But when the patient arrives at the hospital, when the RT does a MLT, they will realize they can not make a seal with the usual amount of air.  Correlating that to the tube marking at the gum or lip line will tell them the tube is misplaced.   

The ETT is still a "secure" airway but some will have to remember that it may just slow down the inevitable as secretions will eventually make it to the lungs. Suctioning is not adequately taught in EMT(P) which would also explain why CPAP gets placed on aspirated scrambled eggs and oatmeal each morning by some provider who didn't clear the airway before applying. Usually, one the airway is clear there is not a need for CPAP. However, once CPAP is applied with aspirated secretions, ETI will be needed. 

Another little tidbit is we no longer inflate trach cuffs to prevent patients from aspirating when eating. We found they aspirate more by not being able to equalize the pressures within their chest and the cuff may get over inflated and place pressure against the esophagus causing the food to not be swallowing. 

The best method for swallowing with a trach, whether on a ventilator or not, is cuff deflated with a Passy-Muir Valve in place which helps to create a relatively normal pressure within the chest.

http://www.passy-muir.com/

Christopher Reeve used this device when he was speaking.  It is essentially a one way valve that allows air to enter through the trach but then must exit through the throat and cords.

For nurses and RTs, there are 5 free CEUs on that website.


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## Melbourne MICA (Jul 2, 2009)

*Suction*

I note your point about the almost complete lack of education on suctioning and it is no different here. We have an array of suction tubes in our kit but most of us would miserably fail a pop quiz on their uses and underlying airway pathophysiology specific to their considered use.

Like much of the stuff we carry we could all benefit from some thorough background knowledge on this gear.

I don't come across many trachy pts these days but the info you have given is valuable. 

Just on that point do you have tips on pts who have been criked  re suctioning, airway pressure issues, ventilation technique etc. It's in our failed intubation drill as it stands but there is little in the way of the technicalities should we have to employ one. We are taught about jet ventilation but not much else. 

This will become of greater concern and relevence as there is the possibility of an expansion in our airway management guidelines for paeds in particular the under 12's including RSI, SFI (we can already do this now in some paeds emergency categories) and crike for kids. We already carry paeds LMA's but haven't as yet been updated on the particulars.

There's a fair bit there I realise so just a few basic tips would suffice for now if you feel so inclined. Info at your leasure of course and citations are always a good alternative.

I will keep an eye on the thread or perhaps you might like to start a new one with input from some of the other quality Paras on the forum.

Love your work.
MM


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## AnthonyM83 (Jul 3, 2009)

Could you elaborate on the comment on that few clear the airway before CPAP and that once the airway is clear there usually isn't a need for CPAP?

Are we talking CPAP for an unconscious patient (which I'm not familiar with)?
Or for a CHF'er in pulmonary edema crisis? (In which case, how would I clear an airway to the point they don't need CPAP)


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## VentMedic (Jul 3, 2009)

AnthonyM83 said:


> Could you elaborate on the comment on that few clear the airway before CPAP and that once the airway is clear there usually isn't a need for CPAP?
> 
> Are we talking CPAP for an unconscious patient (which I'm not familiar with)?
> Or for a CHF'er in pulmonary edema crisis? (In which case, how would I clear an airway to the point they don't need CPAP)


 
I would not put CPAP on an unconscious patient who can not control their own airway. 

If the patient appears to have just eaten or was being feel or a misplaced feeding tube, the gurgles and crackles you hear may be aspirated material.  A quick NT suction through the nares may stimulate a cough or suction enough stuff to know what you are dealing with.  Sometimes the gurgles and crackles disappear.  However of course NT suctioning is not without some risks but then again an airway full of secretions or food also presents with some risks.


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## Markhk (Jul 3, 2009)

Hey Vent,
What's the rationale behind OG vs. NG tubes? Is it because of easier placement? Or risks like of nasal tube cranial placement?


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## VentMedic (Jul 3, 2009)

Markhk said:


> Hey Vent,
> What's the rationale behind OG vs. NG tubes? Is it because of easier placement? Or risks like of nasal tube cranial placement?


 
For inhospital, it is part of our VAP (Ventilator Associated Pneumonia) protocol. We have already banished NTI, except for surgical situations, in our hospitals since the CDC recommendation about 10 - 15 years ago. Sinus infections give rise to PNAs and other systemic infections. Insurers such as Medicare will no longer pay for hospital acquired infections. 

http://www.zapvap.com/guidelines.aspx

These same guidelines are now observed by all of our Specialty and hospital based Flight teams (or those with ICU RNs on board) where possible regardless of what county, state or country they are picking up from. But then they are just continuing their practice from the ICUs to transport so it is nothing out of the norm since these protocols and awareness education has been in effect for 10 years at least.

Of course, prehospital EMS will not have access to the meds and intubation assist gadgets the hospital or Specialty teams have so NTI may be your only choice for some situations. The NG may also be better tolerated prehospital due to lack of adequate sedation ability.


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## maxwell (Jul 3, 2009)

On a purely sensationalist note...the individual who took that picture...hope he/she get fried.  That's so wrong.


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## AnthonyM83 (Jul 3, 2009)

maxwell said:


> On a purely sensationalist note...the individual who took that picture...hope he/she get fried.  That's so wrong.



Huh?
Of Michael Jackson? No, dude that paparazzi either got good commission or heck even got a job because of the picture. (There's no way it was EMS..."Hold on guys, I'm gonna stop doing helping so I can take this picture. No one tell".... yeah right)


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## Markhk (Jul 3, 2009)

Hey Vent,

Thanks for the explanation. I think it's amazing that with all the concerns with VAP - and the people making ET tubes that are lined with silver and all the other crazy tech - one simple way was just to put a hole above the pilot balloon to suction the gunk out periodically.


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## VentMedic (Jul 3, 2009)

Markhk said:


> Hey Vent,
> 
> one simple way was just to put a hole above the pilot balloon to suction the gunk out periodically.


 
Actually it is hooked up to continuous suction at -20 cm H2O for the duration of the tube.

Silver and copper are both known for their bacterial static properties. Silver trachs have been used for centuries and not the silver lined ETTs are gaining popularity. Copper mesh used to be part of the ventilator humification systems until disposable circuits came along. 

Silver coated ETT - hard to miss with the purple although the King Airway looks similar with it dark reddish connector.
http://www.bardmedical.com/products/loadProduct.aspx?prodID=391


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