珍屯医学

标题: 心肺复苏(CPR) [打印本页]

作者: 大江    时间: 2018-7-13 00:31
标题: 心肺复苏(CPR)
[attach]2560[/attach]
心肺复苏术(CPR)是一种紧急程序,它将胸部按压与人工通气相结合,以手动保持完整的大脑功能,直到采取进一步措施恢复心脏骤停患者的自发血液循环和呼吸。建议那些没有反应,没有呼吸或呼吸异常的人,例如,无自主呼吸。[1]

CPR涉及成人胸部按压,深度为5厘米(2.0英寸)至6厘米(2.4英寸),速度至少为每分钟100至120分钟。[2]救助者还可以通过向对象的口腔或鼻子呼出空气(口对口复苏)或使用将空气推入受试者肺部的装置(机械通气)来提供人工通气。目前的建议强调早期和高质量的胸部按压超过人工通气;对于未经训练的救援人员,建议采用仅限胸部按压的简化CPR方法。[3]然而,在儿童中,仅进行按压可能会导致更差的结果。[4]成人的胸部按压与呼吸比率设定为30比2。

单靠CPR不太可能重新开始。其主要目的是恢复部分氧合血液流入大脑和心脏。目标是延迟组织死亡并延长成功复苏的简短机会窗口,而不会造成永久性脑损伤。通常需要对受试者的心脏施加电击,称为除颤,以恢复可行的或“灌注的”心律。除颤仅对某些心律有效,即心室颤动或无脉性室性心动过速,而不是心搏停止或无脉搏电活动。建议在适当时进行早期休克。心肺复苏可能成功诱导可能易受打击的心律。一般来说,CPR一直持续到该人恢复自发循环(ROSC)或被宣告死亡为止。[5]

视频1:↓心肺复苏术
https://cache.tv.qq.com/qqplayerout.swf?vid=h0719l39ama

视频2:↓ 如何做CPR
https://cache.tv.qq.com/qqplayerout.swf?vid=u0719c588z0

视频3:↓传统CPR概述
https://cache.tv.qq.com/qqplayerout.swf?vid=z07198xvo35

[attach]2561[/attach]
假人每分钟100次胸部按压。

目录:

1 医疗用途
1.1 有效性
2 并发症
3 方法
3.1 带有救援呼吸的压缩
3.2 仅限压缩
3.3 容易发生心肺复苏术
3.4 怀孕
3.5 家庭存在
3.6 其他
4 病理生理学
5 附加设备
5.1 定时装置
5.2 手动辅助装置
5.3 自动装置
5.4 移动应用程序
6 流行
6.1 接受心肺复苏的机会
6.2 及时收到心肺复苏的机会
7 社会与文化
7.1 描绘的有效性
7.2 阶段心肺复苏术
7.3 自我CPR恶作剧
7.4 从视频中学习
7.5 仅手动CPR描绘
8 历史
9 其他动物
10 研究
11 参阅
12 参考

医疗用途
CPR适用于任何没有反应但没有呼吸或呼吸的人,只会偶尔发生心脏骤停,因为他们最有可能是心脏骤停。[6]:S643 如果一个人仍有脉搏但没有呼吸(呼吸停止) 人工通气可能更合适,但是,由于人们难以准确评估脉搏的存在与否,CPR指南建议不应指示非专业人员检查脉搏,同时让医护人员选择检查脉搏。脉搏。[7] 在因创伤而心脏骤停的患者中,CPR被认为是徒劳的,但仍被推荐。[8] 纠正诸如气胸或心包填塞等根本原因可能会有所帮助。[8]

效用
类型ROSC生存来源
目睹院内心脏骤停52%19%[9]
未经证实的院内心脏骤停33%8%[9]
院外心脏骤停总体占59%10%[10]
未经证实的院外心脏骤停21%4%[10]
见证了院外心脏骤停41%15%[10]
与旁观者CPR见证和“可震撼”53%37%[10]
旁观者仅压缩复苏 - 13%[11]
旁观者常规CPR - 8%[11]

CPR是成功进行心肺复苏的基础,可保护身体进行除颤和高级生命支持。即使在“不可电击”节律的情况下,例如没有指示除颤的无脉电活动(PEA),有效的CPR也同样重要。单独使用,CPR将导致几乎没有完全恢复,但没有CPR的结果几乎是致命的。[12]

研究表明,在突然的VF心脏骤停后3-5分钟内立即进行CPR随后除颤可显着提高生存率。在西雅图这样的城市,CPR培训很普遍,EMS工作人员的除颤很快,所有原因的存活率约为20%,如果目睹“可电击”的逮捕,则高达57%。[13]在纽约这样的城市,没有这些优势,目睹可靠的逮捕,生存率只有5%。[14]

在成人中,旁观者的仅压缩CPR似乎比使用救援呼吸的胸部按压更好。[15]仅限压缩的CPR在儿童中的效果可能低于成人,因为儿童心脏骤停更可能是非心脏原因。在一项关于儿童(1-17岁)心脏骤停的非心脏病的2010年前瞻性研究中,旁观者提供常规心肺复苏术与挽救呼吸在一个月内产生的有利神经学结果比单纯压缩心肺复苏更常见(或5.54)。对于这个队列中有心脏病原因的逮捕,两种技术之间没有区别(OR 1.20)。[16]这符合美国心脏协会对父母的指导。[17]

当由训练有素的应答者完成时,两次呼吸中断的30次按压似乎比连续胸部按压稍微好一点,并且在按压持续时进行呼吸。[15]

实现自发循环(ROSC)的患者比例较高,他们的心脏再次开始自我跳动,最终生存至医院出院(见上表)。这可能是由于医务人员最终无法解决心脏骤停的原因,其他合并症,或者患者严重不能以多种方式解决。最终,只有5-10%的心脏骤停患者在尝试复苏后仍然存活。[18]

并发症
虽然心肺复苏术是最后的手段干预,没有脉搏,没有脉搏的人肯定会死亡,但心肺复苏术的实际性质确实会导致可能需要纠正的并发症。 CPR引起的常见并发症有肋骨骨折,胸骨骨折,前纵隔出血,心脏挫伤,[19]心包积血,[20] [21] [22]上呼吸道并发症,腹部脏器损伤 - 肝脏撕裂和脾脏,脂肪栓塞,肺部并发症 - 气胸,血胸,肺挫伤。[23] [24]

CPR最常见的损伤是肋骨骨折,文献报道发生率为13%~97%,胸骨骨折发生率为1%~43%[25]。 虽然这些医源性损伤可能需要进一步干预(假设患者幸免于心脏骤停),但只有0.5%的患者本身就有生命危险。[24]

受伤的类型和频率可能受性别和年龄等因素的影响。 例如,女性胸骨骨折的风险高于男性,肋骨骨折的风险随着年龄的增长而显着增加。[26] 儿童和婴儿在心肺复苏期间肋骨骨折的风险较低,发生率低于2%,但是,当它们确实发生时,它们通常是前牙和多胎。[25] [27] [28]

如果旁观者错误地进行心肺复苏,对于非心脏骤停的人,约2%的人会因此受伤(尽管12%的人感到不适)。[29]

方法

[attach]2562[/attach]
CPR技术如假人所示

[attach]2564[/attach]
口对口复苏

[attach]2563[/attach]
心肺复苏培训:正在进行心肺复苏术,而第二个救助者准备除颤。

2010年,美国心脏协会和国际复苏联络委员会更新了他们的心肺复苏准则。[6]:S640 [30]强调了高质量心肺复苏的重要性(足够的速度和深度,没有过度通气)。[6]:S640除了新生儿从气道,呼吸,胸部按压(ABC)到胸部按压,气道,呼吸(CAB)之外,所有年龄组的干预顺序都有所改变。[6]:S642这项建议的一个例外是那些被认为是在呼吸停止(气道阻塞,药物过量等)。[6]:S642心肺复苏最重要的方面是:胸外按压中断少,压迫速度和深度足够,按压之间压力完全放松,不通气得多。[31]目前尚不清楚除颤前几分钟的心肺复苏是否会导致与立即除颤不同的结果。[32]

有救援呼吸的压缩
建议成人通用压缩与通气的比例为30:2 [33]:8对于儿童,如果至少有2名训练有素的救援人员,则优先采用15:2的比例。[33]:8新生儿的比例为建议3:1,除非已知心脏原因,在这种情况下15:2的比例是合理的。[6]:S647

如果气管插管或喉罩气道等先进的气道就位,则应以每分钟8-10的速度进行人工通气而不会出现压力暂停。[34]在大多数情况下,建议的干预顺序是胸部按压,气道,呼吸或CAB,[6]:S642,所有组的压缩率至少为每分钟100次。[33]:8成人和儿童的推荐压缩深度为至少5厘米(2英寸),在婴儿中它是4厘米(1.6英寸)。[33]:8截至2010年,复苏委员会(英国)仍然为儿童推荐ABC。[35]由于确定是否存在脉搏可能很困难,因此医疗服务提供者的脉搏检查已被删除,医疗服务提供者不应超过10秒。[33]:8在成人中,救援人员应使用两个用于胸部按压的手,而在儿童中,他们应该使用一个,并且婴儿用两个手指(食指和中指)。[36]

仅限压缩
对于心脏骤停的成人,建议使用仅限压缩(仅限手部或心脑复苏)的CPR,其中包括无人工通气的胸部按压,作为未经训练的救援人员的选择方法或不熟练的人员,因为它更容易执行和说明通过电话更容易通过电话。[6]:S643 [6]:S643 [33]:8 [37]在院外心脏骤停的成年人中,外行公共压缩CPR等于或高于成功率高于标准心肺复苏术。[37] [38]希望使用仅压缩递送将增加公众提供心肺复苏的机会。[39]

仅限压缩CPR对于更有可能因呼吸原因导致心脏骤停的儿童不太好。两篇评论发现仅压缩CPR没有比没有CPR更成功。[38] [6]:S646儿童,特别是婴儿的呼吸呼吸应该相对温和。[38]对于儿童来说,压缩与呼吸的比例为30:2或15:2都会有更好的效果。[40]儿童和成人每分钟应接受100次胸外按压。除儿童外的其他例外情况包括溺水和药物过量的情况。在这两种情况下,如果旁观者接受过训练并愿意这样做,建议进行按压和救援呼吸。

根据美国心脏协会的说法,Bee Gees歌曲“Stayin'Alive”的节拍提供了一个理想的节奏,以每分钟节拍数用于仅用于手部的CPR。[41]人们还可以哼唱女王的“另一个叮咬尘埃”,即每分钟110次[42]并且包含令人难忘的重复鼓模式。[43]对于因非心脏相关原因而心脏骤停的人和年龄小于20岁的人,标准CPR优于仅限压缩CPR。[44] [45]

容易发生心肺复苏术
标准CPR由仰卧位人员执行。通过将头部转向侧面并压缩背部,对俯卧在胸部的人进行CPR或CPR反向CPR。由于头部被转动,吸入性肺炎引起的呕吐和并发症的风险可能会降低。[46]

美国心脏协会目前的指南建议在仰卧位进行心肺复苏术,并将患者的CPR限制在患者无法转动的情况。[47]

怀孕
在怀孕期间,当一名妇女仰卧时,子宫可压迫下腔静脉,从而减少静脉回流。[8]因此,建议将子宫推到女性的左侧;如果这是无效的,要么将女性推倒30°,要么医护人员应考虑紧急复苏子宫切开术。[8]

家庭存在
证据通常支持家庭在心肺复苏术期间出现。[48]这包括儿童心肺复苏术。[49]

其他
插入腹部按压可能对医院环境有益。[50]没有证据表明院前或儿童有益。[50]

正在研究CPR期间的降温,因为目前尚不清楚其是否能改善预后。[51]

内部心脏按摩是手动挤压暴露的心脏本身通过手术切口进入胸腔,通常当胸部已经开放进行心脏手术。

使用胸部机械减压的主动压缩 - 减压方法尚未显示可改善心脏骤停的结果。[52]

病理生理学
CPR用于心脏骤停的人,以便为血液充氧并维持心输出量以保持重要器官存活。需要血液循环和氧合作用将氧气输送到组织。 CPR的生理学涉及在动脉和静脉血管床之间产生压力梯度; CPR通过多种机制实现这一目标[53]大脑可能会在血流停止约4分钟后受到损害,并在大约7分钟后受到不可逆转的损害。[54] [55] [56] [57] [58]通常,如果血流停止一到两个小时,则身体细胞死亡。因此,一般来说,只有在血流停止后7分钟内进行CPR才有效。[59]心脏也迅速失去维持正常节奏的能力。较低的体温,有时在近溺水中可见,延长了大脑存活的时间。心脏骤停后,有效的心肺复苏能够使足够的氧气到达大脑以延迟脑干死亡,并使心脏能够对除颤尝试保持敏感。

附加设备
虽然有几种辅助装置可供使用,但除了2010年之外,一直发现除了标准的心肺复苏外,其余的除外。[6]:S644这些装置可分为三大类:定时装置;帮助救援者获得正确技术的装置,特别是压缩的深度和速度;和完全接管过程的设备。

定时装置
定时装置可以具有节拍器(由许多救护人员携带的物品),以帮助救助者达到正确的速率。有些单位还可以提供进行压缩,通风和更换操作员的计时提醒。[60]

手动辅助装置
机械胸部按压设备目前不推荐广泛使用。[61]目前还没有进行足够的高质量研究来确定与使用传统手动压缩技术相比,使用机械辅助装置进行胸部按压可以挽救更多生命。[61]

听觉和视觉提示可以提高心肺复苏的质量,防止疲劳时自然发生的压缩率和深度的降低,[62] [63] [64] [65] [66] [67]并解决这一潜在的改善,已经开发了许多设备来帮助改进CPR技术。

这些物品可以放置在胸部顶部,救援者的手越过设备,显示器或音频反馈提供有关深度,力或速率的信息,[68]或以可穿戴格式(如手套) 。[69]一些已发表的评估显示,这些装置可以改善胸部按压的表现。[70] [71]

除了在心脏骤停受害者的实际心肺复苏术中使用时,它依赖于携带设备的救援人员,这些设备也可以用作训练计划的一部分,以提高进行正确胸部按压的基本技能。[72]

自动设备
机械心肺复苏术与机械通气的用途并不多。市场上的设备包括在Lund大学医院开发的LUCAS-2,[73]并且自发循环恢复。[74]和AutoPulse。两者都使用胸部带,LUCAS-2使用气动活塞和马达驱动的收缩带。

自动化设备有几个优点:它们允许救援人员专注于执行其他干预措施;它们不像人类那样疲劳并开始进行效率较低的按压;他们能够在有限空间的环境中进行有效的按压,例如空中救护车,手动按压很困难,并且它们可以让救护人员安全地绑在一起,而不是站在超速驾驶车辆的病人身上。[75]然而,缺点是购买成本,培训应急人员使用它们的时间,实施CPR的中断,不正确应用的可能性以及对多种设备尺寸的需求。

一些研究显示存活率很少或没有改善[76] [77] [78],但承认需要更多的研究。[79]

移动应用
为了支持培训和事件管理,移动应用程序已在最大的应用程序市场上发布。对61个可用应用程序的评估显示,大量的应用程序不遵循国际基本生命支持指南,许多应用程序的设计并非以用户友好的方式进行。[80]因此,红十字会更新并批准了其应急准备应用程序,该应用程序使用图片,文本和视频来协助用户。

英国复苏委员会有一个名为Lifesaver的应用程序,它展示了如何进行心肺复苏术。[81]

流行
接受心肺复苏的机会
各种研究表明,在户外心脏骤停中,美国的旁观者尝试CPR的时间在14%[82]和45%[83]之间,中位数为32%。[84]在国际上,旁观者CPR的比率据报道低至1%,高达44%。[85]然而,这种心肺复苏术的有效性是多变的,研究表明只有大约一半的旁观者心肺复苏术是正确的。[86] [87]一项研究发现,过去接受过心肺复苏培训的公众缺乏拯救生命所需的技能和信心。该报告的作者建议,需要更好的培训,以提高对心脏骤停的反应意愿。[84]影响院外心脏骤停的旁观者心肺复苏的因素包括:

经济实惠的培训。
针对潜在心脏骤停的家庭成员进行CPR培训
应简化和缩短CPR课程。
提供有关心肺复苏的保证和教育。
提供有关特定地区法律影响的更清晰信息。
专注于减少围绕提供旁观者心肺复苏术的耻辱和恐惧。[88]
年龄与心肺复苏开始的机会之间存在关系。在紧急医疗服务到来之前,年轻人更有可能对他们进行心肺复苏术。[82] [89]旁观者通常在公共场合进行心肺复苏术,而不是在家中进行心肺复苏术,尽管医疗保健专业人员负责超过一半的院外复苏尝试。[83]与此人无关的人比他们的家庭成员更有可能执行心肺复苏术。[90]

逮捕原因与旁观者开始心肺复苏的可能性之间也存在明确的关系。当有医疗事业时,非专业人士最有可能在公共场所对心脏骤停的年轻人进行心肺复苏术;那些因创伤,放血或中毒而被捕的人不太可能接受心肺复苏术。[90]

据信,如果旁观者被告知仅执行复苏的胸部按压元件,则执行心肺复苏的可能性更高。[39] [91]

及时接收心肺复苏的机会
CPR很可能仅在血流停止后6分钟内开始有效[92],因为当新鲜血液在此时间后注入细胞后会发生永久性脑细胞损伤,因为大脑细胞在4到4之间就会休眠。在缺氧的环境中6分钟,因此,在传统的复苏中不能再次引入氧气。使用心脏停搏输注的研究导致79.4%的存活率,心脏停搏间隔为72±43分钟,相比之下,传统方法在这种情况下达到15%的存活率。目前需要开展新的研究,以确定CPR,电击和新的先进逐步复苏技术在这一新知识中的作用。[93]

一个值得注意的例外是心脏骤停与暴露于极冷的温度一起发生。低温似乎通过减缓代谢和生理过程来保护,大大降低了组织对氧气的需求。[94]有些情况下,CPR,除颤和先进的加温技术在长时间体温过低后使受害者复活。[95]

社会与文化
描绘效果
CPR在电影和电视中经常被严重歪曲,因为它非常有效地复苏没有呼吸且没有血液循环的人。

1996年发表在“新英格兰医学杂志”上的一项研究显示,电视节目的CPR成功率为75%,即时流通,67%的存活率。[96]这使一般公众对成功结果抱有不切实际的期望。[96]在了解实际存活率时,60岁以上需要心肺复苏的患者的比例应该是心脏骤停从41%下降到22%。[97]

阶段心肺复苏术
胸部按压能够引起明显的局部钝性创伤,包括胸骨或肋骨的瘀伤或骨折。[98]对健康人进行心肺复苏可能会或可能不会破坏正常的心律,但是由于存在创伤的风险,不管是否应该对健康人进行技术。

电视和电影中CPR技术的描绘往往是故意不正确的。模拟CPR性能的演员可能会在弯曲时弯曲肘部,以防止力量到达描绘受害者的演员的胸部。

自我心肺复苏术骗局
被称为“咳嗽心肺复苏术”的一种形式的“自我心肺复苏术”是一个恶作剧连锁电子邮件的主题,题为“如何独自生存心脏病”,错误地引用“ViaHealth Rochester综合医院”作为该技术的来源。罗彻斯特综合医院否认与该技术有任何联系。[99] [100]

在复苏自己意义上的“咳嗽心肺复苏术”是不可能的,因为心脏骤停的显着症状是无意识,[101]这使得咳嗽不可能。在心肌梗塞(心脏病发作)的情况下,在此期间,人可能仍然保持清醒,但这本身并不是一种逮捕形式,尝试“咳嗽CPR”会增加心脏的负担,并可能证明是有害的。

美国心脏协会(AHA)和其他复苏机构[102]并不认可“咳嗽CPR”,因为它不是一种复苏形式,所以它称之为用词不当。 AHA确实认识到咳嗽技术的有限合法使用:“这种在短暂性心律失常期间保持血流的咳嗽技术在医院中是有用的,特别是在心脏导管插入期间。在这种情况下,患者的心电图被连续监测,并且医生是“[103]当咳嗽用于医院训练有素的受监护病人时,已证明只有90秒有效。[102]

从视频中学习
至少在一起案件中,据称从电影中学到的心肺复苏术被用来挽救一个人的生命。 2011年4月,有人声称9岁的Tristin Saghin在堕入游泳池之后通过CPR对她的妹妹的生命进行了挽救,他只使用了他从电影中收集到的CPR知识,Black Hawk Down 。[104]

仅限手部的CPR写照
在家中,工作场所或公共场所心脏骤停的人中,只有不到1/3的人进行了心肺复苏术。大多数旁观者担心他们可能会做错事。[105] 2009年10月28日,美国心脏协会和广告委员会发布了一项仅限于手的CPR公共服务公告和网站,作为解决这一问题的手段。[106] 2011年7月,该网站增加了新内容,其中包括一个数字应用程序,可帮助用户了解如何执行仅限手动CPR。[107]

历史
主要文章:心肺复苏的历史
在19世纪,医学博士西尔维斯特描述了一种人工通气方法(西尔维斯特方法),其中患者仰卧,双臂抬高头部以帮助吸气,然后按压胸部以帮助呼气。 [108]该过程每分钟重复十六次。在20世纪初期制作的电影中偶尔会出现这种人工通风。

第二种技术,称为Holger Nielsen技术,在1911年美国手册的第一版中描述,是一种人工通气的形式,人们面朝下躺着,头朝下,靠在双手掌心。在患者肘部施加的向上压力使上身抬起,而背部的压力迫使空气进入肺部,实质上是西尔维斯特法,患者翻转过来。这种形式可以追溯到20世纪50年代(它在20世纪50年代中期用于Lassie的一集),并且在当时的戏剧漫画中经常使用,有时用于喜剧效果(参见汤姆和杰瑞的“猫与猫”) Mermouse“[1949])。出于历史目的,这种方法将继续与童子军手册中的现代心肺复苏并排显示,直到1979年的第九版。该技术后来被禁止在英国的急救手册中使用。

类似的技术在20世纪早期的ju-jutsu和柔道书中被描述,可以追溯到17世纪初。 “纽约时报”记者报道,这些技术于1910年在日本成功使用。在ju-jutsu(以及后来的柔道),这些技术被称为Kappo或Kutasu。[109] [110] [111] [112]

然而,直到20世纪中叶,更广泛的医学界开始以口对口复苏的形式开始识别和促进人工通气,并将胸部按压作为心脏骤停后复苏的关键部分。这个组合首次出现在1962年由James Jude,Guy Knickerbocker和Peter Safar创作的名为“The Life of Life”的培训视频中。 Jude和Knickerbocker以及William Kouwenhoven和Joseph S. Redding最近发现了外部胸部按压的方法,而Safar曾与Redding和James Elam合作证明了口对口复苏的有效性。在约翰霍普金斯大学,最初开发了CPR技术。 Redding,Safar和JW Pearson对狗的测试进行了第一次测试。不久之后,这项技术被用来挽救儿童的生命。[113]他们的综合发现于1960年9月16日在大洋城举行的年度马里兰医学会会议上公布,并在接下来的十年中得到了广泛认可,并得到了他们所进行的视频和演讲之旅。彼得·萨法尔于1957年写了“复苏ABC”一书。在美国,它首次被推广为一种让公众在20世纪70年代学习的技巧。[114]

口腔复苏与胸部按压相结合,假设主动通气是保持循环血液氧合所必需的,并且在不将其有效性与胸部按压单独比较的情况下接受该组合。然而,过去十年的研究表明假设是错误的,导致AHA单独确认胸部按压的有效性(参见本文中的压缩)。[115]

心肺复苏术继续发展,最近的发展包括强调持续,快速的心脏刺激,以及不再强调呼吸方面。研究表明,那些接受快速恒定心脏胸部按压的人比那些接受呼吸的传统心肺复苏术的人存活率高22%。更重要的是,因为人们往往不愿做口对口,胸部CPR几乎使整体生存的机会增加一倍,通过增加首先接受心肺复苏的几率。[116]

其他动物
对包括猫和狗在内的动物进行心肺复苏是可行的。除了复苏通常通过动物的鼻子而不是嘴巴进行复苏之外,其原理和实践类似于人类的心肺复苏术。 CPR只应在无意识的动物身上进行,以避免被咬伤的风险;有意识的动物不需要胸部按压。动物,取决于物种,可能具有比人类更低的骨密度,因此CPR可以导致骨骼在进行后变弱。[117]

研究
脑性能类别(CPC得分)被用作描述“好”和“差”结果的研究工具。 1级是有意识和正常功能的警报。 2级只是轻微的残疾。 3级是中度残疾。 4级是严重残疾。 5级是昏迷或持续的植物人状态。 6级是脑死亡或其他原因造成的死亡。[118]

参阅
阻抗阈值装置
Lazarus综合征,自发性自动复苏,试图进行人工复苏失败

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