How do you guys feel about ECMO?

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Data is conflicting for adults as far as utility goes and it's still a growing field, but I've seen it work and now I'm a little biased towards it in certain situations we used it a record time in this past flu season.
There was this young healthy 32 y/o in ards due to the flu that I just couldn't ventilate, heliox didn't work much( upped sats to 88-89 though) and he went on ecmo and... Well he's alive and on rehab now, but expected to make a good recovery.

You guys use it or have any experience with it?

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Usual progression CMV->PCV->Rotoprone->iNO->ECMO->CMO

It works well, until ya have a complication....
Which is not very uncommon after it gets to ecmo.
My place is not big on rotoprone( attending preference mostly) and the nurses becomes a pita.
And our ecmo program is good and it needs using!

:)
 
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Data is conflicting for adults as far as utility goes and it's still a growing field, but I've seen it work and now I'm a little biased towards it in certain situations we used it a record time in this past flu season.
There was this young healthy 32 y/o in ards due to the flu that I just couldn't ventilate, heliox didn't work much( upped sats to 88-89 though) and he went on ecmo and... Well he's alive and on rehab now, but expected to make a good recovery.

You guys use it or have any experience with it?

I think it's great in the abstract. The biggest problem with ECMO is 1) experience (you really to be doing more than a couple cases a year) and this can be tough to come by if its considered a "salvage", and 2) clotting/bleeding monitoring.

I think in the next 5 to 10 years the big ECMO centers will publish data showing improved outcomes in cases where conventional mechanical ventilation was failing to oxygenate.

I like it. I think it's the future provided some kinks can be worked out. Just bypass the trashed lungs. It remains to be seen if all we end up with is a bunch of saved pulmonary cripples this way. It also remains to be seen if this will be a tertiary/quaternary critical care referral or if this begins to replace more and more convention mechanical ventilation entirely everywhere. It's an interesting time to be In critical care.

One of the side areas of interest for me is ECOR and doesn't require a surgeon or flouro or echo to deal with catheter placement. Though still fairly cost prohibitive for the once a year ZOMFG asthma or the lung protective ventilation acidotic.
 
I think it's great in the abstract. The biggest problem with ECMO is 1) experience (you really to be doing more than a couple cases a year) and this can be tough to come by if its considered a "salvage", and 2) clotting/bleeding monitoring.

I think in the next 5 to 10 years the big ECMO centers will publish data showing improved outcomes in cases where conventional mechanical ventilation was failing to oxygenate.

I like it. I think it's the future provided some kinks can be worked out. Just bypass the trashed lungs. It remains to be seen if all we end up with is a bunch of saved pulmonary cripples this way. It also remains to be seen if this will be a tertiary/quaternary critical care referral or if this begins to replace more and more convention mechanical ventilation entirely everywhere. It's an interesting time to be In critical care.

One of the side areas of interest for me is ECOR and doesn't require a surgeon or flouro or echo to deal with catheter placement. Though still fairly cost prohibitive for the once a year ZOMFG asthma or the lung protective ventilation acidotic.

Great post man!
I agree with you that as more data will become available in the near future it's true utility will be more clear.
It is an amazing time for critical care!

It's impossible now to imagine small/medium hospitals or non academic centers doing this in the future, in reality you may only need one big referral center to deal with the not so frequent cases( 1 or 2 per state or so?),
Unless ECOR proves to be as effective and takes away the army of people needed to do it.

We will be telling our kids and students anecdotes about this in the future ... In a good or a bad way.
 
We use quite a bit of ECMO in our SICU and CVICU.

I'm a huge fan of ECMO when used in patients with reversible/temporary disease states and good recovery potential. We put many on ECMO for this winter's run of H1N1, and had great success with it. Dedicated teams of ECMO specialists (RNs, RTs, and Perfusionists with advanced training) help a ton, and the RNs here are outstanding - we prone with it.

The complications are real (and often devastating), so it's not to be taken lightly. Patient selection is, to me, the biggest factor for success.
 
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We use quite a bit of ECMO in our SICU and CVICU.

I'm a huge fan of ECMO when used in patients with reversible/temporary disease states and good recovery potential. We put many on ECMO for this winter's run of H1N1, and had great success with it. Dedicated teams of ECMO specialists (RNs, RTs, and Perfusionists with advanced training) help a ton, and the RNs here are outstanding - we prone with it.

The complications are real (and often devastating), so it's not to be taken lightly. Patient selection is, to me, the biggest factor for success.

What's the rationale behind proning on ECMO?
 
Jdh -

Does a couple of things for us/them: we tend to see profound secretion clearance when proned, so that may help clear the lungs more quickly than when patients remain supine; there are also a group of patients that we cannot get enough flow through our membrane lungs, so proning may improve oxygenation as we try to squeeze out more native lung function.
 
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Jdh -

Does a couple of things for us/them: we tend to see profound secretion clearance when proned, so that may help clear the lungs more quickly than when patients remain supine; there are also a group of patients that we cannot get enough flow through our membrane lungs, so proning may improve oxygenation as we try to squeeze out more native lung function.

We have never proned on ecmo here, but Good to know!
Thanks!
 
Jdh -

Does a couple of things for us/them: we tend to see profound secretion clearance when proned, so that may help clear the lungs more quickly than when patients remain supine; there are also a group of patients that we cannot get enough flow through our membrane lungs, so proning may improve oxygenation as we try to squeeze out more native lung function.

Hm. Ive only been involved in one proned ECMO case. I was ambivalent about it then and I'm still ambivalent about it now. I suppose its like anything whenever we come up with a modality to keep someone alive, people who would have just died stay alive and push the new modality to its new edge and then we have to do something more outside the box.

I doubt ill ever personally have a patient on ECMO again, though its definitely a trick to file away if practice changes a lot in the future.
 
Agreed...there's a bit of a "Okay - what's next?" feeling when proning on ECMO. The last guy we had proned was cannulated by our service at this tiny OSH, and he had a short 23F cannula as his femoral vein draining line...we just couldn't get enough flow thru the ECMO lung, so we proned to get more oxygenation from his native lung...it was either that or do a second draining line.

The guy was just transferred back toward home, sans cannula or ETT.

Pretty neat stuff, when it works.
 
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Agreed...there's a bit of a "Okay - what's next?" feeling when proning on ECMO. The last guy we had proned was cannulated by our service at this tiny OSH, and he had a short 23F cannula as his femoral vein draining line...we just couldn't get enough flow thru the ECMO lung, so we proned to get more oxygenation from his native lung...it was either that or do a second draining line.

The guy was just transferred back toward home, sans cannula or ETT.

Pretty neat stuff, when it works.
What oxygenator were you using and how much flow did you need? We generally get great flow through the adult sized Quadrox, though we have added a second oxygenator once. With a 23 Fr venous cannula, you should be able to provide pretty good support. Our practice is to add a femoral venous catheter if more flow is needed, and I wouldn't be thrilled with the idea of proning. What are your 'resting' vent settings? As JDH alluded to, eCOR requires much less flow and may also be a compromise on a patient that you can at least oxygenate, provided you're not beating up the lungs.

Are you guys doing ECPR as well?

My peds center does over 50 ECMO runs a year, and some of those are older teens with flu. Volume is important, as is having an institution invested in training the RTs/RNs who run the circuit. Again, I agree with JDH in that I think this technology will be used more and more and the trick will be figuring out how to appropriately anticoagulate. The guys in the Duke PICU are actually extubating their CF patients on VV ECMO, and getting them out of bed to walk around. Their as yet unpublished data that I saw at ELSO suggested that they were cutting their post lung transplant recovery time and post op vent days nearly in half.
 
We did more runs this year because of H1N1. Some good some bad one ICH, one never improved and two others came off and were discharged to rehab (last month). We had a case of massive PE in a young patient that survived and was discharged home (this was ECPR). I think ECPR will be up and coming on the horizon pending the CHEER trial and I'm hoping to set up an ECPR shop in the my dual role ED/ICU. I only know of two ED's that are currently performing ECPR.

We use the cardiohelp by maquet which has a quadrox oxygenator and our protocol has a perfusionist at the bedside and 1:1 nursing, I know of others where the perfusionist is not required to be at bedside. (despite all these resources this is still the 2nd most profitable intervention in the hospital next to cardiac surgery? or so I was told)

The columbia guys don't intubate their severe COPDers, and pts with CF awaiting lung tx, and instead have them ambulate and work with PT/OT while having the avalon catheter in place. This way they aren't getting debilitated and going to a SNF bouncing back and forth at the end of their days. Apparently the dyspnea is markedly improved in the aforementioned patient population, although my limited experience has been in patients with IPF/ILD who still felt miserable with "normal" PCO2s and PaO2s.

I've drank the kool-aid, so to speak, and feel there is a place for it in the adult world.
 
I think it has it's place and is a great option for certain patients. I am a believer in it's utility but patient selection has to come into play. As we have seen in 2009 and this year, it can truly save some of these H1N1 ARDS patients that would otherwise certainly die. Our program is new but we have some good saves using it. Recently had a pt that developed severe TRALI coming out of the OR after cardiac surgery. Complete lung opacification. Placed on V-V ECMO. Lungs completely recovered in about 3 days and he was decannulated. Great save and great utility of ECMO in a patient that otherwise would have died. I think that it is becoming easier to manage patients as the technology improves. It does have it's place in adult critical care but it is not a panacea and patient selection is a big part of it. It does not 'cure' anyone. Patients must have a reversable process. I feel like some referring physicians don't realize this and get frustrated when you tell them "no" when they call about wanting ECMO for a patient. I think it's a great therapy for the right patient.
 
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It does not 'cure' anyone. Patients must have a reversable process. I feel like some referring physicians don't realize this and get frustrated when you tell them "no" when they call about wanting ECMO for a patient. I think it's a great therapy for the right patient.
100% agree. You as the intensivist and as an ECMO center need to be able to say 'no' sometimes. It will not benefit every patient, and may even make things worse. I've found it's useful to have the discussion early. Is this patient an ECMO candidate? We had a patient with terrible cardiomyopathy from chemo. Since this is a known non reversible process, we felt that there was little point in putting him on ECMO (he wasn't a transplant or VAD candidate). There would be no end point. Heme/onc was furious with us for it at first, but ECMO would not have helped his already damaged, failing heart.
 
This is probably going to draw out fire from gutonc but I detest the oncologists in my area for these types of patients. When your CM is so bad from chemo that you need ECMO to prolong life....you should probably be being enrolled into hospice, not cannulated for ECMO. So many of the sickest patients at the final stages of life, if you can even call it life, end up in the unit requiring massively laborious, expensive and often painful invasive procedures that in no way will affect there 30-60 day mortality. Most often I have found, these patients have never had a true sitdown and explanation of just how sick they are. Or they cant comprehend anymore because they are just too sick and they have a family member making decisions who has no idea how sick they are.

I am sure it has a lot to do with the individuals at my place but I have found the heme/onc skillset of our docs is great...for pts that need aggressive therapy and treatment to try and extend their lives in a meaningful way. IE if my otherwise healthy 65 y/o mother was diagnosed with lunc ca....I would want her aggressively treated and they would do great here.

Conversely if my decrepit 92 y/o grandmother with 3 prior MIs, 2 strokes, artificial hips and knees, an EF of 20 andhorrible functional status, was found to have colon ca with mets....theyd also be guiding her towards full code and chemo/rads/sx. The palliative care is very much lacking here. and more often then not, the old, sick cancer pts who are nearing the end of their lives are the pts that end up in MICU sick as death with no chance of meaningful recovery and yet thousands of dollars of labor and services pumped into them for them to suffer theire last few days. I think this is an area of medicine that really needs to be addressed.

the ECMO example is the epitomy of this. not a VAD candidate, not a tranplant candidate. failing maximal medical therapy. well, then its the end. ecmo is a bridge. and if there is nothing at the end of the bridge then the pt should not be offered it. I approach the vent the sameway to a degree. If your a gold stage 4 copd'r, still smoking, with an ef of 5-10%, horrible dyspnea at rest on 02 24/7 and virtually bipap dependent, and NOT a heart/lung transplant candidate, vad candidate, bypass candidate, "enter therapy X candidate here"...the vent will do nothing but keep you alive long enough for a family member to have to painfully terminally extubate you. I have found it is much easier on the family to make the decision to not initiate rather than to withdraw. they feel less resonsible for the inevitable death.

anyway, that last post really triggered my palliative care thoughts. sorry to derail the convo.
 
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This is probably going to draw out fire from gutonc but I detest the oncologists in my area for these types of patients. When your CM is so bad from chemo that you need ECMO to prolong life....you should probably be being enrolled into hospice, not cannulated for ECMO. So many of the sickest patients at the final stages of life, if you can even call it life, end up in the unit requiring massively laborious, expensive and often painful invasive procedures that in no way will affect there 30-60 day mortality. Most often I have found, these patients have never had a true sitdown and explanation of just how sick they are. Or they cant comprehend anymore because they are just too sick and they have a family member making decisions who has no idea how sick they are.

I am sure it has a lot to do with the individuals at my place but I have found the heme/onc skillset of our docs is great...for pts that need aggressive therapy and treatment to try and extend their lives in a meaningful way. IE if my otherwise healthy 65 y/o mother was diagnosed with lunc ca....I would want her aggressively treated and they would do great here.

Conversely if my decrepit 92 y/o grandmother with 3 prior MIs, 2 strokes, artificial hips and knees, an EF of 20 andhorrible functional status, was found to have colon ca with mets....theyd also be guiding her towards full code and chemo/rads/sx. The palliative care is very much lacking here. and more often then not, the old, sick cancer pts who are nearing the end of their lives are the pts that end up in MICU sick as death with no chance of meaningful recovery and yet thousands of dollars of labor and services pumped into them for them to suffer theire last few days. I think this is an area of medicine that really needs to be addressed.

the ECMO example is the epitomy of this. not a VAD candidate, not a tranplant candidate. failing maximal medical therapy. well, then its the end. ecmo is a bridge. and if there is nothing at the end of the bridge then the pt should not be offered it. I approach the vent the sameway to a degree. If your a gold stage 4 copd'r, still smoking, with an ef of 5-10%, horrible dyspnea at rest on 02 24/7 and virtually bipap dependent, and NOT a heart/lung transplant candidate, vad candidate, bypass candidate, "enter therapy X candidate here"...the vent will do nothing but keep you alive long enough for a family member to have to painfully terminally extubate you. I have found it is much easier on the family to make the decision to not initiate rather than to withdraw. they feel less resonsible for the inevitable death.

anyway, that last post really triggered my palliative care thoughts. sorry to derail the convo.

I feel somewhat relieved reading this as I thought this happened only in my institution!
Hem Onc docs should be more direct talking about outcomes in some cases.
Sometimes they go as far as telling the family" we may give more chemo if they recover from this ( renal/ respiratory etc) failure and come out of the Icu..." And you are stuck with a family full of false hopes on a patient that had little to no chances to begin with.
Some even get upset if you talk with their patients about advanced directives.

But in ECmo, I've seen it work on the right set of patients and I'm an advocAte for some patients on it, but as said before, prognosis should be acceptable to even consider ECMO.
 
Look, heme/onc sells hope. It's what they do. I know that it creates a moral hazard for those of us that pick up the pieces and YES they probably could often be better about setting expectations, but let's not get too hostile about of heme/onc colleagues.
 
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Look, heme/onc sells hope. It's what they do. I know that it creates a moral hazard for those of us that pick up the pieces and YES they probably could often be better about setting expectations, but let's not get too hostile about of heme/onc colleagues.

See that's the thing I wasn't trying to be hostile. It's just my anecdotal experience there needs to be more palliative care and end of life conversations initiated at an earlier stage in the game
 
Look, heme/onc sells hope. It's what they do. I know that it creates a moral hazard for those of us that pick up the pieces and YES they probably could often be better about setting expectations, but let's not get too hostile about of heme/onc colleagues.

No hostility, frustration!
 
Coming from the Peds world, ECMO is one of the few things we sent to the adult world rather than the other way around (which is how things usually happen). Personally I love ECMO, but the mindset matters a ton. Call it patient selection or a bridge or whatever, the key is to remember that in the original ECMO studies in neonates, they were reducing mortality from >80% to about 50%. Repeat: more than 50% of patients in the "proof of concept" studies died. It really is a last ditch effort, and the "complications" are occurring in patients with a grim prognosis anyways. While the numbers are not near that level now, death should still be a major consideration. And as I often tell families, so much of what we do in the ICU simply buys ourselves time so the body can heal, ECMO is the ultimate example of that.
 
Coming from the Peds world, ECMO is one of the few things we sent to the adult world rather than the other way around (which is how things usually happen). Personally I love ECMO, but the mindset matters a ton. Call it patient selection or a bridge or whatever, the key is to remember that in the original ECMO studies in neonates, they were reducing mortality from >80% to about 50%. Repeat: more than 50% of patients in the "proof of concept" studies died. It really is a last ditch effort, and the "complications" are occurring in patients with a grim prognosis anyways. While the numbers are not near that level now, death should still be a major consideration. And as I often tell families, so much of what we do in the ICU simply buys ourselves time so the body can heal, ECMO is the ultimate example of that.

It's interesting that you bring this up because at my shop, they been playing around with ECMO as a bridge to lung transplant a few cases have gone very well and a few others not so well. The big difference in those that went well versus those that didn't? Appear to be age. People over the age of 50 just don't seem to bridge well . . . however, I would also say the numbers are not huge enough yet to say that definitely with an statistical significance . . . HOWEVER, our transplant surgeons, who are a rather conservative lot, have kind of washed their hands of consideration for ECMO as a bridge to any lung transplant in 55 or older.
 
What I'm really interested in right now also is the ECPR. I think in order for ECMO to really move into prime time, we will need to remove the onus of catheter placement from the surgeons (now I know this isn't uniformly who places the catheters everywhere) and train the bedside clinician to place the catheters, at least the V-V, and then we need some people who are NOT perfusionists trained in running the machine. Catching folks between cases is not ideal for patient, primary treatment team, or the surgeons.
 
What I'm really interested in right now also is the ECPR. I think in order for ECMO to really move into prime time, we will need to remove the onus of catheter placement from the surgeons (now I know this isn't uniformly who places the catheters everywhere) and train the bedside clinician to place the catheters, at least the V-V, and then we need some people who are NOT perfusionists trained in running the machine. Catching folks between cases is not ideal for patient, primary treatment team, or the surgeons.

Lots of places and people are interested in this. It is coming soon to centers with strong EM-CCM.

http://edecmo.org/

HH
 
I've had 3 echo cases as a resident 1 vv for a 40 year old with a persistent air leak from a wedge bx he got for DAD at an osh didn't go well. I also had 3 va cases 1 36 yo women with massive pe and coronary dissection s/p labor she walked away the other 2 were a last ditch trying to stabilize someone to get them to vad those didn't go well. Really interesting physiology in the vv case.

As a medicine trained person how many of the pulm/ccm people here would say they feel comfortable running the circuit if they were the service attending right out of fellowship. I hear Michigan and Columbia are the big adult places in the states and maybe Pittsburgh. Would I need to do an extra year of ecmo training or would it be sufficient to go to a ecmo center and complete fellowship there. I'm trying to feel out what niche I want to fill in academic medicine which will influence fellowship choice certainly and ecmo seems appealing to me as well as up and coming ( or one big study away from being thrown on the scrap heap :).
 
I think the vv ecmo catheters are being placed by non surgeons routinely. Was at acoi conference last week and spoke with a presenting intensivist (EM/IM/CC trained) he places his own vv catheters, the dual lumen catheter via right IJ and he does his own tee to guide it so caudal port is in IVC. I've seen multiple people doing this and am looking to be trained in this manner. We don't have va Ecmo so can't speak on that point.

Agree with JDH though, at our shop, ecmo will continue to be a last ditch, initiate then ship mentality until we get I house people who can run the machine, as we don't have continuos in house perfusionists.
 
Some peds intensivists are doing their own VV (Avalon) catheters as well and having success. If you're doing ECPR though, you really need to go VA. Some EM docs are doing their own cannulation for VA ECPR, and I think they are generally using bilateral femoral caths. There's significant risk of losing the leg where the arterial catheter is due to lack of distal perfusion, so the very few I've seen had booster arterial catheters placed in the posterior tibial artery by a surgeon. In kids <15 kg you won't get good enough flow for support, so we almost always go through the neck (neckMO so to speak), but I realize that's not a problem most of you would have. Some australian studies showed that cracking the chest enabled them to get very high flows in adults with sepsis, but that's a pretty big ordeal, and isn't our general practice unless they had their chest open for recent cardiac surgery.

Our ECPR times for in house arrest are just over 20 minutes from chest compressions to full flows, but there are a lot of moving parts and it's surgeon dependent. Our general surgeons take call but we also have three cardiac surgeons who are available to help. Outside of ECPR you often have some planning time to go on pump and can wait for surgeon availability as long as they are taking it seriously and making it a priority.

We actually don't use perfusionists to man the pumps. There's quite a bit of difference between the bypass circuit and the ECMO circuit, so we specially train a group of PICU nurses and RTs to run the pump. They do an amazing job of it too.

As I (and others) have said, patient selection is key to success, but I also think that leaving it as a 'last ditch' has its dangers. There has to be recoverable lung that can heal. We've moved to putting people on relatively early, before you wreck the lungs and before they crash. Of course our substrate/pathology is a bit different than adult stuff, so I understand it may not work in the same manner. But generally speaking if a patient's OI is in the high 20s for any period of time, we're considering it.
 
The avalon catheter is nice in that it is a single stick, but even with TEE it can be a BI*** to keep in the right place. Also we have had several H1N1 who had the avalon placed, and then had to crash onto VA because of RV failure. In other cases a little oxygen and CO2 removal reduced the need for any vasoactives once on V-V, so again patient selection is critical.

Placing the catheters isn't rocket science, but you need a surgeon to back you up as you will have complications that you cannot fix if you do enough of cases even with V-V.

As JDH mentioned ECPR is where some of the ED/CC guys are trying to move to, especially in those refractory VF/VT patients who you know have a culprit lesion as the cause of the arrest and maybe ECMO can buy time for cath lab and ventricular stunning recovery in a few days, preferable >>> than 10 000 mg of epi given during a 45 min code.

In the peds world ECMO is used more frequently and so there are enough cases for most nurses and RT's to be comfortable running the pumps and complications, where in MOST adult centers 15 runs/year seems about avg. and it can be harder to keep staff up to speed.
 
Saw ECMO done on one person this winter for H1N1. Couldn't get her sats above 60% while paralyzed and on maximum vent settings. Proning actually brought her up to the 90s and got the FiO2 down to about 60%, but after a few days it failed. Now off ECMO and transferred back to home ICU, not sure what her ultimate outcome was.
 
Saw ECMO done on one person this winter for H1N1. Couldn't get her sats above 60% while paralyzed and on maximum vent settings. Proning actually brought her up to the 90s and got the FiO2 down to about 60%, but after a few days it failed.

And that's the reason my friends from residency and I coined the term "ECMO stable" - it's a unique feeling to see a patient you struggle with for hours making no progress in the matter of minutes be well saturated, clearing lactate and ventilating adequately.
 
The institution I'm at does exclusively adult ECMO (about 70 last year). Adult ECMO didn't quite take off here until about 10 years ago (although in general it took longer to become popular compared to paediatric ECMO anyway).

Basically the intensivists here stress the importance of patient selection in ECMO (just like any other medical intervention). Although this is hard to learn and seems to be based on a lot of experience of our consultants. Although the success of ECMO at our institution may mean we're putting some people who don't need it on ECMO. Although this is very hard to say since there really aren't many good studies looking at who benefits from ECMO.

Most of our ECMO cannulation is done as percutaneously as peripheral ECMO by the intensivists (compared to the kid's who do loads of central ECMO). The occasional ones done by surgeons are usually for failure to wean after cardiopulmonary bypass or for central ECMO.

I agree with the idea that ECMO-CPR seems to be where adult ECMO is heading. The other area some intensivists are interested in exploring here is ECMO before transplantation although this is hard since it's hard to predict when organs will become available.
 
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