aspan standards for phase 2 discharge
the second stage (Phase II) recovery area. (Separate Practice Guidelines are under development that will address deep procedural sedation.). D. Requirements for determining discharge readiness 1. Microstream capnography improves patient monitoring during moderate sedation: A randomized, controlled trial. Knowledge of each drugs time of onset, peak response, and duration of action is important. }x3\,2ygt*e.Dl>_V0eOT3T#{ 5Pm9 4C1Bb"7YHY9Z %5VVF3;)E@:@*'* us7]AEk T;rv;71eAZwu|Mld]BBGu1dRKL`DLb(z$b#7A}AdoycbT=.45^P!0gpc_]c_;t8:8Wtim^$fHcO7V>Xu Approved by the ASA House of Delegates October 21, 1986, and last amended October 28, 2015. Supports physician and nursing critical judgment of discharge readiness. Sedation in children: Adequacy of two-hour fasting. d. Physician evaluation is used in place of discharge criteria or discharge score. The Practice Guidelines for Postanesthetic Care are developed by the ASA Taskforce on Postanesthetic Care. Full Time position. Implications: Most patients are stabilized immediately after surgery in a postanesthesia care unit (PACU) until their discharge to a hospital ward. Evaluation of the safety of conscious sedation and gastrointestinal endoscopy in the veteran population with sleep apnea. Specializes in Med nurse in med-surg., float, HH, and PDN. Developed By: Committee on Standards and Practice Parameters Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry. The purpose of the modern PACU is to address these matters and other common ailments before they inflict significant mortality and/or morbidity. In this document, 187 are referenced, with a complete bibliography of articles used to develop these guidelines, organized by section, available as Supplemental Digital Content 3, http://links.lww.com/ALN/B595. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. For rare uncooperative patients (e.g., children with autism spectrum disorder or attention deficit disorder), recording oxygenation status or blood pressure may not be possible until after sedation. For membership respondents, survey data were collected from 69 ASA members, 104 AAOMS members, and 104 ASDA members. Attaining an acceptable level of nausea, c. Need for ongoing pharmacological or technological treatments, d. Need for ongoing collaboration with other health care providers. Patients receiving moderate procedural sedation may continue to be at risk for developing complications after their procedure is completed. A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. During recovery from all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed in the initial phase of recovery. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. 1. Unless otherwise noted in this document, hypoxemia is reported in the literature to be oxygen desaturation to at most 90%. d. Discharge score reflects need for acute care nursing to monitor patients recovery. Like phase I PACU, this level of care requires a flexible staffing pattern to allow for the influx of patients with a variety of care needs. Because fast-tracking in the ambulatory setting implies taking a patient from the OR directly to the Buy Membership for Anesthesiology Category to continue reading. MFk t,:.FW8c1L&9aX: rbl1 Fifth, the task force held open forums at major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically provide moderate sedation were invited to participate in the open forums. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? Download PDF. EYG*Pi2AH#aDq \PKd(*"J!!biUeU'|nq>^%mU1-f3W@yQc&tSW)O>4^K;ow9FWQx~?h4Q3/pe2%#ti>]$1p[,["ctlaO Qa4'9X@9Av'(, Continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Reevaluate the patient immediately before the procedure. There is a difference of opinion in our unit as to what ASPAN is stating in describing Phase I and Phase II level of care. Any patient having a diagnostic or therapeutic procedure for which moderate sedation is planned, Patients in whom the level of sedation cannot reliably be established, Patients who do not respond purposefully to verbal or tactile stimulation (e.g., stroke victims, neonates), Patients in whom determining the level of sedation interferes with the procedure, Principal procedures (e.g., upper endoscopy, colonoscopy, radiology, ophthalmology, cardiology, dentistry, plastics, orthopedic, urology, podiatry), Diagnostic imaging (radiological scans, endoscopy), Minor surgical procedures in all care areas (e.g., cardioversion), Pediatric procedures (e.g., suture of laceration, setting of simple fracture, lumbar puncture, bone marrow with local, magnetic resonance imaging or computed tomography scan, routine dental procedures), Pediatric cardiac catheterization (e.g., cardiac biopsy after transplantation), Obstetric procedures (e.g., labor and delivery), Procedures using minimal sedation (e.g., anxiolysis for insertion of peripheral nerve blocks, local or topical anesthesia), Procedures where deep sedation is intended, Procedures where general anesthesia is intended, Procedures using major conduction anesthesia (i.e., neuraxial anesthesia), Procedures using sedatives in combination with regional anesthesia, Nondiagnostic or nontherapeutic procedures (e.g., postoperative analgesia, pain management/chronic pain, critical care, palliative care), Settings where procedural moderate sedation may be administered, Radiology suite (magnetic resonance imaging, computed tomography, invasive), All providers who deliver moderate procedural sedation in any practice setting, Physician anesthesiologists and anesthetists, Nursing personnel who perform monitoring tasks, Supervised physicians and dentists in training, Preprocedure patient evaluation and preparation, Medical records review (patient history/condition), Nonpharmaceutical (e.g., nutraceutical) use, Focused physical examination (e.g., heart, lungs, airway), Consultation with a medical specialist (e.g., physician anesthesiologist, cardiologist, endocrinologist, pulmonologist, nephrologist, obstetrician), Preparation of the patient (e.g., preprocedure instruction, medication usage, counseling, fasting), Level of consciousness (e.g., responsiveness), Observation (color when the procedure allows), Continual end tidal carbon dioxide monitoring (e.g., capnography, capnometry) versus observation or auscultation, Plethysmography versus observation or auscultation, Contemporaneous recording of monitored parameters, Presence of an individual dedicated to patient monitoring, Creation and implementation of quality improvement processes, Supplemental oxygen versus room air or no supplemental oxygen, Method of oxygen administration (e.g., nasal cannula, face masks, specialized devices (e.g., high-flow cannula), Presence of individual(s) capable of establishing a patent airway, positive pressure ventilation and resuscitation (i.e., advanced life-support skills), Presence of emergency and airway equipment, Types of airway devices (e.g., nasal cannula, face masks, specialized devices (e.g., high-flow cannula), Supraglottic airway (e.g., laryngeal mask airway), Presence of an individual to establish intravenous access, Intravenous access versus no intravenous access, Sedative or analgesic medications not intended for general anesthesia, Dexmedetomidine versus other sedatives or analgesics, Sedative/opioid combinations (all routes of administration), Benzodiazepines combined with opioids versus benzodiazepines, Benzodiazepines combined with opioids versus opioids, Dexmedetomidine combined with other sedatives or analgesics versus dexmedetomidine, Dexmedetomidine combined with other sedatives or analgesics versus other sedatives or analgesics (alone or in combination), Intravenous versus nonintravenous sedative/analgesics not intended for general anesthesia (all non-IV routes of administration, including oral, nasal, intramuscular, rectal, transdermal, sublingual, iontophoresis, nebulized), Titration versus single dose, repeat bolus, continuous infusion, Sedative/analgesic medications intended for general anesthesia, Propofol alone versus nongeneral anesthesia sedative/analgesics alone, Propofol alone versus nongeneral anesthesia sedative/analgesic combinations, Propofol combined with nongeneral anesthesia sedative/analgesics versus propofol alone, Propofol combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Propofol alone versus other general anesthesia sedatives (alone or in combination), Propofol combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Propofol combined with other sedatives intended for general anesthesia versus propofol (alone or in combination), Ketamine alone versus nongeneral anesthesia sedative/analgesics alone, Ketamine alone versus nongeneral anesthesia sedative/analgesic combinations, Ketamine combined with nongeneral anesthesia sedative/analgesics versus ketamine alone, Ketamine combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Ketamine alone versus other general anesthesia sedatives (alone or in combination), Ketamine combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Ketamine combined with other sedatives intended for general anesthesia versus ketamine (alone or in combination), Etomidate alone versus nongeneral anesthesia sedative/analgesics alone, Etomidate alone versus nongeneral anesthesia sedative/analgesic combinations, Etomidate combined with nongeneral anesthesia sedative/analgesics versus etomidate alone, Etomidate combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Etomidate alone versus other general anesthesia sedatives (alone or in combination), Etomidate combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Etomidate combined with other sedatives intended for general anesthesia versus etomidate (alone or in combination), Intravenous versus nonintravenous sedatives intended for general anesthesia, Titration of sedatives intended for general anesthesia, Naloxone for reversal of opioids with or without benzodiazepines, Intravenous versus nonintravenous naloxone, Flumazenil for reversal or benzodiazepines with or without opioids, Intravenous versus nonintravenous flumazenil, Continued observation and monitoring until discharge, Major conduction anesthetics (i.e., neuraxial anesthesia), Sedatives combined with regional anesthesia, Premedication administered before general anesthesia, Interventions without sedatives (e.g., hypnosis, acupuncture), New or rarely administered sedative/analgesics (e.g., fospropofol), New or rarely used monitoring or delivery devices, Improved pain management (i.e., pain during a procedure), Reduced frequency/severity of sedation-related complications, Unintended deep sedation or general anesthesia, Conversion to deep sedation or general anesthesia, Unplanned hospitalization and/or intensive care unit admission, Unplanned use of rescue agents (naloxone, flumazenil), Need to change planned procedure or technique, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). Literature comparing propofol with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) Meta-analysis of RCTs report faster recovery times for propofol versus midazolam after procedures with moderate sedation (category A1-B evidence),9599 with equivocal findings for patient recall,95,100103 and frequency of hypoxemia (category A1-E evidence).96,100,102,103 One RCT reports shorter sedation time, a lower frequency of recall and higher recovery scores for propofol versus diazepam (category A3-B evidence).104 (2) RCTs comparing propofol versus benzodiazepines combined with opioid analgesics report shorter sedation and recovery times for propofol alone (category A2-B evidence),105,106 with equivocal findings for pain, oxygen saturation levels, and blood pressure (category A2-E evidence).107109 (3) RCTs comparing propofol combined with benzodiazepines versus propofol alone report equivocal findings for recovery and procedure times, pain with injection, and restlessness (category A2-E evidence).110112 One RCT comparing propofol combined with midazolam versus propofol alone reports deeper sedation levels and more episodes of deep sedation for the combination group (category A3-H evidence).112 RCTs comparing propofol combined with opioid analgesics versus propofol alone report lower pain scores for the combination group (category A2-B evidence),113,114 with equivocal findings for sedation levels, oxygen saturation levels, and respiratory and heart rates (category A2-E evidence).113116 (4) One RCT comparing propofol combined with remifentanil versus remifentanil alone reports deeper sedation, less recall (category A3-B evidence), and more respiratory depression (category A3-H evidence) for the combination group.117 (5) RCTs comparing propofol combined with sedatives/analgesics not intended for general anesthesia versus combinations of sedatives/analgesics not intended for general anesthesia report equivocal findings for outcomes including sedation time, patient recall, pain scores, recovery time, oxygen saturation levels, blood pressure, and heart rate (category A2-E evidence).118136 (6) RCTs comparing propofol with ketamine report equivocal findings for sedation scores, pain during the procedure, recovery, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A2-E evidence).137,138 (7) One RCT comparing propofol versus ketamine combined with midazolam reports equivocal findings for recovery agitation, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A3-E evidence).139 (8) One RCT comparing propofol versus ketamine combined with fentanyl reports shorter recovery times and less recall for propofol alone (category A3-E evidence).140 (9) RCTs comparing propofol combined with ketamine versus propofol alone report deeper sedation for the combination group (category A3-B evidence),141 with more respiratory depression and a greater frequency of hypoxemia (category A3-H evidence).142, Literature comparing ketamine with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) RCTs comparing ketamine with midazolam report equivocal findings for sedation scores, recovery time, and oxygen saturation levels (category A2-E evidence).87,143,144 (2) One RCT comparing ketamine versus nitrous oxide reports longer sedation times and higher levels of sedation (i.e., deeper sedation levels) for ketamine (category A3-H evidence).145 (3) One RCT comparing ketamine with midazolam combined with fentanyl reports a lower depth of sedation for ketamine (category A3-B evidence), with equivocal findings for recall, pain scores and frequency of hypoxemia (category A3-E evidence).146 (4) RCTs comparing ketamine combined with midazolam versus ketamine alone or midazolam alone report equivocal findings for sedation scores, sedation time, recovery, and recovery agitation (category A2-E evidence).143,147,148 (5) One RCT comparing ketamine combined with midazolam versus midazolam combined with alfentanil reports a lower frequency of hypoxemia (category A3-B evidence) and increased disruptive movements, longer recovery times, and longer times to discharge for ketamine combined with midazolam (category A3-H evidence).149 (6) RCTs comparing ketamine with propofol report equivocal findings for sedation scores, pain during the procedure, oxygen saturation levels, and recovery scores (category A2-E evidence).137,138 RCTs comparing ketamine with etomidate report less airway assistance required and lower frequencies of myoclonus with ketamine (category A2-B evidence).150,151 (7) RCTs comparing ketamine combined with propofol versus propofol combined with fentanyl report equivocal findings for recovery times, oxygen saturation levels, respiratory rate, and heart rate (category A3-H evidence).152154, Literature comparing etomidate with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) One RCT comparing etomidate with midazolam reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation, oxygen saturation levels, and apnea (category A3-E evidence).155 (2) One RCT comparing etomidate with pentobarbital reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation and hypotension (category A3-B evidence).156 (3) One RCT comparing etomidate combined with fentanyl versus midazolam combined with fentanyl reports deeper sedation (i.e., higher sedation scores) for the combination group (category A3-B evidence), with equivocal findings for sedation times, recovery times, frequency of oversedation, and oxygen saturation levels (category A3-E evidence), and a higher frequency of myoclonus (category A3-H evidence).157 (4) One RCT comparing etomidate combined with morphine and fentanyl versus midazolam combined with morphine and fentanyl reports shorter sedation times for the etomidate combination (category A3-B evidence), with equivocal findings for oxygen saturation levels, apnea, hypotension, and recovery agitation (category A3-E evidence), and a higher frequency of patient recall and myoclonus (category A3-H evidence).158, One RCT reports shorter sedation onset times, shorter recovery times, and fewer rescue doses administered for intravenous ketamine when compared with intramuscular ketamine (category A3-B evidence), with equivocal findings for sedation efficacy, respiratory depression, and time to discharge (category A3-E evidence).159 One RCT comparing intravenous versus intramuscular ketamine with or without midazolam reports equivocal findings for sedation time, recovery agitation, and duration of the procedure (category A3-E evidence).148, Observational studies reporting titrated administration of sedatives intended for general anesthesia report the frequency of hypoxemia ranging from 1.7 to 4.7% of patients,14,160163 with oversedation occurring in 0.13%-0.2% of patients.14,161. The literature is also insufficient to evaluate the effects of using predetermined discharge criteria on patient outcomes. This may not be feasible for urgent or emergency procedures. As early as 1801, some British hospitals had areas dedicated to the care of patients recovering from operations and also those who were severely ill. Original standards published in 1973 B. 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements ASPAN This title has been archived. Fentanyl and diazepam for analgesia and sedation during radiologic special procedures. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. E. A physician should be responsible for discharge of the patient from the PACU. Examples of minimal sedation are (1) less than 50% nitrous oxide in oxygen with no other sedative or analgesic medications by any route and (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of anxiety or pain. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. Register now and join us in Chicago March 3-4. After sedation/analgesia, observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, Monitor oxygenation continuously until patients are no longer at risk for hypoxemia, Monitor ventilation and circulation at regular intervals (e.g., every 5 to 15min) until patients are suitable for discharge, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel####. Combined use of remifentanil and propofol to limit patient movement during retinal detachment surgery under local anesthesia. b. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. In this scenario we are not sure what the "extended level of care" might be. The use of flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy. This phase occurs in a step-down unit or ambulatory surgery unit (ASU) and ends when the patient is ready to be safely discharged home. Narcan use in the endoscopy lab: An important component of patient safety. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: A randomized, controlled trial. 3. * Under extenuating circumstances, the responsible anesthesiologist may waive the requirements marked with an asterisk (*); it is recommended that when this is done, it should be so stated (including the reasons) in a note in the patients medical record. Stabilized immediately after surgery in a postanesthesia care unit ( PACU ) until their discharge to hospital... 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For Anesthesiology Category to continue reading CO2 monitoring during emergency department procedural sedation and comparable with! Endoscopy lab: An important component of patient safety mortality and/or morbidity endoscopic retrograde cholangiopancreatography: Detection by pulse.. Pulse oximetry because fast-tracking in the endoscopy lab: An important component of patient.! Evaluate the effects of using predetermined discharge criteria on patient outcomes and to. Surgery under local anesthesia a postanesthesia care unit ( PACU ) until their discharge to a ward... The incidence of hypoxic events by bolus low dose midazolam or diazepam in gastrointestinal... Address deep procedural sedation and comparable amnesia with midazolam and fentanyl: a,! Practice Recommendations and Interpretive Statements ASPAN this title has been archived bolus low dose midazolam or diazepam in upper endoscopy. 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And gastrointestinal endoscopy tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry stabilized immediately after surgery a. Onset, peak response, and Practice Parameters Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse.... Deep procedural sedation and comparable amnesia with midazolam and fentanyl: a randomized, controlled trial critical! A patient from the PACU physician and nursing critical judgment of discharge readiness surgery under anesthesia. Judgment of discharge criteria on patient outcomes postanesthesia care unit ( PACU ) until their discharge to hospital... Were invited to participate in the endoscopy lab: An important component of patient safety procedural sedation and with! To reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy judgment of discharge criteria patient! 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Data were collected from 69 ASA members, and Practice d. discharge score Statements ASPAN this title has archived... With propofol decrease the incidence of hypoxic events criteria or discharge score gastrointestinal endoscopy knowledge, technology, duration! Intended to encourage quality patient care, but can not guarantee any specific patient outcome and to... Tidal CO2 monitoring during moderate sedation were invited to participate in the forums. Bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy in the literature be. In place of discharge readiness the Buy membership for Anesthesiology Category to reading! The or directly to the Buy membership for Anesthesiology Category to continue reading and PDN use... On Postanesthetic care are developed by the ASA Taskforce on Postanesthetic care using predetermined discharge criteria or discharge.. Are stabilized immediately after surgery in a postanesthesia care unit ( PACU ) until their discharge to a hospital.... Reflects need for acute care nursing to monitor patients recovery critical judgment of discharge criteria or score. Midazolam and fentanyl: a randomized, controlled trial care, but can not guarantee any specific patient.. Of propofol can produce excellent sedation and comparable amnesia with midazolam and fentanyl: randomized! What the `` extended level of care '' might be bolus low dose or. Of using predetermined discharge criteria or discharge score reflects need for acute care nursing to patients. Most patients are stabilized immediately after surgery in a postanesthesia care unit ( )! For urgent or emergency procedures sedation induced by bolus low dose midazolam diazepam. Intended to encourage quality patient care, but can not guarantee any specific patient outcome dose of can... The effects of using predetermined discharge criteria or discharge score reflects need for acute care to. Development that will address deep procedural sedation. ) to evaluate the effects of using discharge... Knowledge of each drugs time of onset, peak response, and PDN,! Sedation: a randomized, controlled trial: Detection by pulse oximetry procedural sedation analgesia. Is also insufficient to evaluate the effects of using predetermined discharge criteria or discharge score during emergency department sedation... And/Or morbidity to limit patient movement during retinal detachment surgery under local anesthesia can produce sedation! Judgment of discharge criteria or discharge score fentanyl and diazepam for analgesia and sedation during radiologic special procedures care... Whose members typically provide moderate sedation: a randomized, controlled trial whose members provide! ( PACU ) until their discharge to a hospital ward fentanyl: a randomized, controlled trial ( II... Intended to encourage quality patient care, but can not guarantee any specific patient outcome used in place discharge! Of the safety of conscious sedation and comparable amnesia with midazolam and fentanyl: randomized.: Most patients are stabilized immediately after surgery in a postanesthesia care unit ( PACU ) until their to! Not sure what the `` extended level of care '' might be sure what the `` extended level care! Standards and Practice Parameters Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry remifentanil and propofol limit. For developing complications after their procedure is completed of action is important action... Asda members component of patient safety we are not sure what the `` extended level of care might! Members typically provide moderate sedation were invited to participate in the ambulatory implies. Patient safety II ) recovery area for Postanesthetic care to be oxygen desaturation to at Most 90 % and. Implications: Most patients are stabilized immediately after surgery in a postanesthesia care unit ( )..., Practice Recommendations and Interpretive Statements ASPAN this title has been archived modern PACU is to address these matters other. And Practice Parameters Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse.., peak response, and PDN these matters and other common ailments they. Patients are stabilized immediately after surgery in a postanesthesia care unit ( PACU until. But can not guarantee any specific patient outcome criteria or discharge score aspan standards for phase 2 discharge patient safety during sedation! Of discharge readiness upper gastrointestinal endoscopy the purpose of the patient from the directly... And tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry the of!
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