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Common reasons for ICU admission, explained by your child’s doctors

What is asthma?

Asthma is the most common chronic illness in children. It is disorder of the small airways in the lungs, where too much, poorly-controlled inflammation produces swelling and mucous buildup. This makes it difficult to moving air into and out of the body, and patients often have to use extra muscles and a great deal of effort to breathe. In addition, their airways may be at risk for spasms, where the already-clogged airways also get very narrow, making it even harder to move air. Certain things can trigger a spike in the inflammation, such as cigarette smoke, animal dander, or viruses, leading to a worsening of symptoms that can be difficult to control without medication.    

What are some signs that my child has asthma?

Symptoms of asthma are the result of blockages and narrowing of the small airways in the lungs. Some patients will only have symptoms when there is a trigger (such as a viral infection); others always have some degree of inflammation that they need medication to help manage. Regardless, patients with asthma are prone to acute exacerbations, or “attacks,” where their symptoms get worse quite quickly. Attacks can be set off by things like viruses, exercise, or smoke. Patients will often cough, wheeze, and feel short of breath. They can feel pain or tightness in their chest, and may not feel like eating or drinking. In addition, working very hard to breathe can make them very tired, and they may feel like they have less energy or, in severe cases, may be lethargic and difficult to awaken or keep awake.

How is asthma treated?

Asthma shows itself differently in different patients, and as a result, the day-to-day treatment varies. Some patients, who only have symptoms when they come into contact with a trigger, can feel better simply by using a rescue inhaler. The medication inside, albuterol, is an inhaled muscle relaxer that works on the muscles inside the lungs that wrap around the small airways. As described above, the smaller airways in patients with asthma are prone to “spasms,” which are a product of those airway muscles squeezing when they are not supposed to. This makes the airway very narrow, and difficult to move air through. Albuterol relaxes these muscles, helping to break the spasm and allowing the airway to open back up again. Patient who have symptoms most days, if not every day, regardless of whether they meet a trigger, are usually on a “controller” medication, most often an inhaled steroid. This steroid helps to “quiet down” the inflammation in the lungs on a daily basis.

Sometimes patients with asthma, regardless of their day-to-day symptoms, present with a more serious attack that cannot be managed with a rescue inhaler. These patients may need albuterol to be given more often than every 4 to 6 hours, more aggressive treatment with steroids, or other medications to break the cycle of airway spasm and mucous plugging.

Why is my child in the ICU?

A severe asthma attack, known as status asthmaticus, requires admission to an intensive care unit. These patients often need their albuterol to be given continuously, and receive their steroids through an IV. In addition, their breathing troubles may be helped by different devices that provide better flow of air, such as through prongs in the nose or a facemask. Giving extra and/or better air flow with these devices can help to take some of the stress off of a patient’s own breathing muscles, which are working very hard.  If this support is not enough, patients may be started on other medications, given through their IV, that are aimed at relaxing their airway muscle spasms. Sometimes several of these medications are used for serious cases, since they each work in slightly different ways. Occasionally, patients may not be able to breathe safely despite all of these therapies, and it becomes necessary to put them to sleep, place a breathing tube into their lungs, and support them on a breathing machine. Fortunately, this is a relatively rare occurrence, and most patients will start to feel the positive effects of their steroids and other medications within a few hours. However, because of their breathing difficulties, these patients are not permitted to eat or drink while on these therapies, and they receive hydration through the fluids in their IV.

How long do we need to stay in the ICU?

While patients do not need to be off all medications for their asthma to transfer out of the ICU, they do need to be safe and stable off of those medications that need to be given continuously. This includes their inhaled albuterol, which (aside from their steroids) is often the last thing to be weaned down. Once patients are able to be taken off of albuterol given continuously, and changed to a dosing schedule where it is given only every few hours, this is usually a sign that the patient is recovering well and stable enough to leave the ICU. It is also a sign that the child is ready to start eating and drinking normally again. The intensive care team will review your child’s progress and plan with you each day.

What is bronchiolitis? 

Bronchiolitis is an infection, usually from a virus, that affects the ‘bronchioles’ - small, branching tubes that carry air to and from the lower part of the lungs. When these tubes become infected, they can get swollen and full of mucus. This will partly or completely block them and make it difficult for the air to move in and out. 

Bronchiolitis usually affects children younger than 2 years of age. In most patients, the infection is self-limited, and the symptoms go away on their own. However, in some children, the infection is severe and can make it very difficult to breathe. These children need to be seen by a doctor and, in some cases, require admission to the hospital and, occasionally, an intensive care unit.

The most common causes of bronchiolitis are viruses, especially Respiratory Syncytial Virus or “RSV.”  

What are the symptoms of bronchiolitis? 

Bronchiolitis usually begins like a common cold, with:

  • A stuffy or runny nose
  • A mild cough
  • A fever (temperature higher than 100.4ºF or 38ºC)
  • Decreased appetite

As the disease progresses, children can start to have more severe symptoms, including:

  • Fast breathing (more than once a second) or labored breathing (using extra ribcage or belly muscles)
    • Some infants can have long pauses in their breathing (‘apnea’ spells), lasting for over 15 seconds
  • Wheezing (whistling sounds, especially when exhaling)
  • Severe cough
  • Troubles eating and drinking (usually because of breathing too fast or too hard)
  • Flaring of the nostrils with breathing

Who is at risk of needing to come to the PICU? 

Bronchiolitis can cause very serious illness in some children, including the following:

  • Very young infants
  • Children born prematurely and/or who need time in the Neonatal ICU after they are born
  • Children who already have heart or lung disease
  • Children who have trouble fighting infections

However, even infants and young children who have not had any health problems before can get very sick from bronchiolitis, and will need admission to the PICU.

How is bronchiolitis treated? 

The main goals of treatment for bronchiolitis are to support your child while they are sick, and to help make sure their body gets enough oxygen while their lungs recover.

This support can include the following:

  • IV fluids to help make sure your child stays well-hydrated, especially if they are breathing too hard or too fast to be able to eat and drink safely
  • Extra oxygen, delivered through tubing to prongs that sit just inside the nose
  • Suctioning of the nose and mouth, by the nurse or respiratory therapist, to help get rid of mucus
  • Chest physiotherapy, delivered by hand or sometimes by machines, by the respiratory therapists to help loosen up mucus that gets stuck in the lungs
  • Albuterol, an inhaled medicine that can help open the airways and get the child to cough up the mucus that is plugging them

Sometimes this is not enough, and your child’s lungs may be too sick to support him or her without more help.  This can include things such as:

  • Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP)
  • RAM Cannula
  • Chest cuirass
  • Breathing tube inserted into the mouth and down into the windpipe, connected to a breathing machine (ventilator)

If any of these are needed, please ask your child’s doctor to explain how they work and why they are needed.  They are happy to help!

The doctors will probably not prescribe antibiotics because bronchiolitis is caused by viruses, and antibiotics do not work on viruses.

How long do we have to stay in the PICU?

This will all depend on how quickly your child’s lungs start to heal. Usually, viruses that cause bronchiolitis tend to stay in a child’s system for 7-10 days, and children can get worse before they start to get better.

Some children may be feeling better in a day or two, especially if this is their first visit to the ICU. Others, who have more chronic health problems, who need a breathing tube to help support them, or who get sick with a particular type of virus, can be sick for much longer.

Typically, once your child is breathing more comfortably, and the doctors begin decreasing the amount of extra support they are receiving, the team will discuss with you plans for transfer out of the PICU.

How did my child get bronchiolitis?

Bronchiolitis is caused by viruses that spread easily from person to person. These viruses live in the droplets that go into the air when a sick person coughs or sneezes. You can help reduce the chances of getting sick by:

  • Good hand washing with soap and water, or using alcohol hand rubs
  • Avoiding others who are showing signs of being sick
  • Getting a flu shot every year for your child (if they are old enough) and all caregivers

What is diabetic ketoacidosis?

Diabetic ketoacidosis, also known as DKA, is a serious complication of diabetes (usually insulin-dependent, or Type 1, diabetes). It is the result of missing or ineffective insulin, which can cause significant derangements in the body’s chemistry and lead to severe disease.

Insulin is a powerful hormone produced by specialized cells in the pancreas, and has a role in many important processes. One of its main purposes is to help the organs and tissues get access to the sugar (glucose) that is circulating in the bloodstream. Insulin helps glucose cross over out of the bloodstream and into the cells of the body, where it can be used as energy. If insulin is not present, or is not working properly, too much glucose stays in the blood, and not enough makes it into the tissues. This can lead to, among other things, an “energy shortage,” to which the body responds by activating several backup systems, which breakdown muscle and fat into chemicals called ketones that can serve as substitute energy molecules. Unfortunately, these backup systems are not as effective or efficient, and can have side effects and consequences that contribute to making patients sick. 

Patients in diabetic ketoacidosis are almost completely dependent on these backup energy systems.  As a result, they can have very high levels of glucose and acid in their blood, which affects the way their organs function. They are usually quite dehydrated and nauseous, and can become more and more lethargic the worse their body chemistry becomes. Left untreated, this state can prove to be extremely damaging and, in some cases, even deadly.

What are signs that my child may have DKA?

Signs and symptoms of diabetes and DKA include:

  • Increased thirst
  • Weight loss
  • Increased urination
  • Nausea, vomiting
  • Fatigue
  • Lethargy
  • Fruity smell on their breath
  • Bedwetting, especially in a child who has finished toilet training

How is DKA diagnosed?

DKA is diagnosed by a series of blood and urine tests. Blood sugar levels are usually very high, and a patient’s electrolytes will usually show the effects of low insulin levels and dehydration. Levels of acid in the blood are high, sometimes dangerously so, in DKA, which will be reflected on the tests. Urine tests will show a high amount of sugar and ketones. After the diagnosis is made, blood and urine testing are continued very few hours to ensure that the treatment is working.

How is DKA treated?

Treatment of DKA, especially in younger and/or sicker patients, usually occurs in the intensive care unit. It involves a combination of careful hydration with fluids and replacing insulin, both things done continuously through an IV. As patients get hydrated and the insulin they are given starts to work, their blood chemistry and sugar levels will gradually return to normal. The body will once again start using glucose for energy, and stop breaking down muscle and fat tissue into acids and ketones. Lab tests, on both blood and urine, will continue as the patient improves, since these will tell us when the body is ready to come off the IV fluids and the continuous insulin infusion. For all patients with DKA, the pediatric endocrinology team (who specialize in, among other things, diabetes management) will be contacted and works with the ICU team to guide therapy.

Once the patient has been cleared of their high acid levels, he or she is usually ready to stop receiving their insulin through the IV. At that time, they will start getting insulin injections, just like they would at home, and are permitted to start eating and drinking again. It may still be necessary to keep their IV hydration going for some time after this, if the urine tests have not yet normalized. However, patients who are eating and drinking, and off their IV insulin, can still transfer out of the ICU. On the pediatric ward, the endocrinologists will continue to follow the patient, as will special diabetes nutritionists and educators.

How long do we need to stay in the ICU?

The exact amount of time will vary with each individual patient. But, as a general rule of thumb, if patients have recovered to the point where they can now eat and drink, and are no longer receiving continuous insulin, they are stable to transfer to a general pediatrics ward.

What is a seizure?

The brain contains millions of nerve cells that send and receive electrical signals, allowing them to communicate with one another. A seizure occurs when this electrical activity becomes disorganized, abnormal, or chaotic. This can be seen by others as changes in awareness or behavior, or as unusual movements (shaking of the arms and legs, for example). It can be as brief as a few seconds, or it can last for hours. Fortunately, even though they can be frightening to witness, seizures are rarely life-threatening, and most can be controlled with medication.

What is epilepsy?

Epilepsy is not a specific disease; instead, it describes a tendency to continue to have seizures over a period of time. This does not include patients with certain circumstances, such as traumatic head injuries, who are considered more at risk for seizures. Even though they may develop many, hard-to-control seizures, these usually stop once the patient has recovered from their injury. Patients like these are not considered to have epilepsy.

Also, having one seizure does not mean that a child will be diagnosed with epilepsy. This diagnosis is usually made after multiple seizures - with an understanding of the circumstances around them. 

What are the different types of seizures?

A seizure may be mild or severe, and there are many forms that they can take. Doctors and nurses can talk about seizures by describing what the patient was doing and/or by describing how the patient’s brain electrical activity looked.  

A common type of seizure is a "generalized tonic-clonic" or "grand mal" seizure. This consists of alternating stiffening and jerking movements, and there may be biting of the tongue or incontinence. Oftentimes, when television or movies show someone having a seizure, this is the type that we see. It can be very disturbing to watch, but fortunately patients are always unconscious and not in pain or aware of what their body is doing.

Other types of seizures are more “focal,” and do not involve the entire body. They may involve only one arm, leg, or part of the face.

One kind of seizure that may be difficult to spot, even if you look carefully, is called an “absence seizure.” This used to be known as a “petit mal” seizure, and usually seems like little more than a child staring off into space for a few seconds. When absence seizures are “simple,” this staring spell lasts for less than 10 seconds. Unfortunately, they can occur many, many times per day, and school-aged children with this type of seizure may have a lot of difficulty with their work, and can be mislabeled as “daydreamers.” More complicated absence seizures, referred to as “complex absence” seizures, will have some unusual movements that accompany the staring spell, such as blinking or chewing motions.

“Atonic” seizures occur when the normal muscle tone in the body is lost. These are also known as “akinetic” seizures, and patients with this type may drop their head or things they are holding, or may collapse to the ground as their legs lose muscle tone.

"Myoclonic” seizures are brief, shock-like muscle jerks lasting a few seconds at most. Patients often can have many short jerks in a row.

“Febrile” seizures are a special category seen in patients 3 months to 6 years old, who may have a generalized tonic-clonic seizure when they get a fever. These tend to run in families, and it is common for parents to report that they too used to have seizures when they got sick. Most children do not need daily seizure medication, and the seizures usually stop when they recover from their illness. However, about half of patients with a febrile seizure before their first birthday will get another if they get sick again. Despite this, their long-term outlook remains excellent. 

What happens after a seizure?

The time following a seizure is called the “postictal” period.  Patients may seem sleepy, lethargic, confused, and complain of a throbbing headache. While this usually lasts only minutes, it can persist for hours, and sometimes even days. In the postictal period, some patients may not be able to move an arm, leg, or even an entire side of the body. This is called a “Todd’s paralysis,” and is a result of parts of the brain that were especially involved in the seizure needing more time than the others to recover. It is not permanent, although it can last for up to 36 hours. It can also affect vision and speech, although these effects will also go away with time. 

What caused the seizure?

There are many common seizure triggers, including:

  • Fatigue, poor sleep, stress
  • Fever
  • Viruses and other illnesses
  • Flashing or bright lights
  • Low blood sugar, poor diet
  • Certain medications, especially in combination

How do we diagnose seizures?

Medical history
Parents can be very helpful in describing what they saw, what things seemed unusual, and what happened around the time of the episode. Sometimes a good, thorough history is enough to make a diagnosis.
Physical examination
Children who come in to a hospital with seizures need a full, head-to-toe examination by a doctor. Sometimes, depending on the circumstances, or by what doctors find on their examinations, a brain/nerve specialist (neurologist) is consulted to help with the case.
An electroencephalogram (EEG) measures electrical activity in the brain using electrodes placed on the scalp, much like an EKG measures the electrical activity of the heart using electrodes placed on the chest. It searches for abnormal patterns that can be seen with seizures. An EEG is not painful and does not cause harm to the brain. Some patients may get an EEG test that lasts for a matter of minutes; others may need to stay connected to the EEG for longer periods if there are concerning patterns that the neurologists see on the monitors.
Lumbar puncture
Also known as a spinal tap, this test involves getting a sample of the spinal fluid that bathes the brain and spinal cord, and sending it to the lab for testing. Doctors trained to do this test will use a special needle placed into the lower back to obtain the sample. They will often use medicine to relax the patient, numb the area that the needle will go into, and occasionally put the patient to sleep altogether so that they will not need to be awake for the procedure. Samples are tested for sugar and protein levels, as well as for blood cells and infection, and can determine a specific course of treatment if they are positive.
Imaging studies
Sometimes seizures are caused by changes in the structure of the brain, or by imbalances among the things inside the skull. Too much spinal fluid (hydrocephalus), for example, can cause pressure to build up inside the head, which can cause seizures. To look for these changes or imbalances, patients may get a CT scan or an MRI of their brain. MRI scans give much more detail, but they take much longer to perform than a CT scan, and young children may need medicine to put them to sleep in order for them to keep still enough to get the right amount of detail. Because of this, doctors may order one scan or the other at different times, depending on how stable the patient is.

How do we treat seizures?

Seizures can be treated differently, depending on the age of the patient, whether or not they have a history of seizures, and how sick the rest of their body is. For most patients, however, the first treatment is almost always an AED (anti-epileptic drug). This is something that, depending on the specific type of AED, can be given at home, in an ambulance, in an emergency room, or in an intensive care unit. For many patients, especially if they do not have a history of having multiple seizures per day, AEDs are given repeatedly until the seizure stops.

Some AEDs, especially if they need to be combined together and/or given within a short time, can slow the body’s breathing rate, so that its oxygen and carbon dioxide levels become dangerous. In this case, patients may be put to sleep and given a breathing tube and mechanical ventilator to keep them safe. Other patients may have seizures that are so powerful, or that go on for so long, that they start to choke on their own saliva or vomit, or simply cannot breathe effectively through the convulsions. In this case, doctors may again put their whole body to sleep and put in a breathing tube to keep them safe.

Why is my child in an ICU?

Patients who seize for a long time, especially if the reason why is unknown, often will get admitted to an intensive care unit. Most commonly, this is for more careful monitoring of their neurological status, breathing, and circulation. For many patients, as long as the brain is seizing, it cannot do the other tasks it normally does, including grow and develop. Therefore, it is very important to get the seizures to stop as soon as possible, so the brain can go back to doing these things. This almost always involves the aggressive use of AEDs, which, as stated earlier, can have their own effects on breathing and wakefulness, and so it is prudent to watch the patients more closely if aggressive treatment is needed.

Also, as described above, seizures can be so long-lasting or so strong that they put a patient’s breathing and, therefore, their safety at risk. Patients who require a breathing tube and breathing machine to keep them safe always get admitted to the ICU. And depending on how sick the rest of their body is, these patients may need medicine to help support their blood pressure and heart rate, as well as strong antibiotics and medications to keep them asleep while their breathing tube is in place. While in the ICU, a neurologist usually consults to guide the use of anti-seizure medications and to help interpret the results of the EEG monitoring so we have a better idea of when the seizures have stopped or if they have come back.

When can we leave the ICU?

Usually, when a patient’s seizures have stopped and they are back to acting normally, they are ready to leave the intensive care unit. This recovery process can have several steps, especially if children are sick enough to need a breathing tube or blood pressure support. However, a good rule of thumb is that once a child is able to breathe and eat without help from the ICU team, they are getting close to a transfer. Depending on the likely cause for the seizures, they may still need medication, like antibiotics or anti-seizure medications, or small amounts of oxygen support, once they leave the unit. The specifics of the plan will be discussed with you each day by the ICU team. 

What is Sepsis?

Sepsis is a life-threatening complication of inflammation and infection. It develops when the body is actively trying to fight an infection, and some of the proteins and chemicals it uses cause inflammation and tissue damage in other parts of the body.

Severe cases of sepsis can cause shock, with proteins of inflammation causing significant problems with the body’s natural blood-clotting system, as well as with the tone and “tightness” of its blood vessels. This can lead to small clots forming in the wrong places and blood vessels becoming too “floppy” and “leaky”. A patient’s blood pressure can fall to dangerously low levels, which starves their body’s important organs of the blood flow they need to do their jobs. The end result can be a state where the important organs, like the brain, heart, and kidneys, do not get enough oxygen and nutrients to function, and start to fail.

Children with any of the following can be at increased risk for developing sepsis:

  • Very young age (especially babies less than 3 months old)
  • Weak immune systems (such as those receiving chemotherapy)
  • Kidney problems (such as nephrotic syndrome)
  • Sickle cell anemia
  • Cystic fibrosis
  • Liver disease
  • Medical tubes and equipment already in the body, such as a tracheostomy tube, shunt in the brain, or central line for medications

What does sepsis look like?

Sepsis is a problem of both inflammation and infection. Many times the body’s own inflammatory response to an infection can cause more problems than the actual infection itself. As a patient starts to get sick, he or she usually follows a progression that goes through several stages:

SIRS (Systemic Inflammatory Response Syndrome)

This is a state where inflammation spreads all over the body, usually but not always because of an infection.  Patients can have signs and symptoms such as:

  • Temperature that is either too high or too low
  • Heart that is beating faster than normal
  • Breathing that is faster than normal
  • White blood cells numbers that are not normal – there are too many, too few, or they are too young/immature to be there normally

Patients who have SIRS as well as an infection (either known or suspected) are considered to have sepsis.

Severe sepsis

This is a state of sepsis where the heart and blood vessels, lungs, or other organs start to become affected.  Patients can have signs and symptoms like:

  • Low blood pressure
  • Buildup of acid in the blood
  • Very little urine being made
  • Change in level of wakefulness, lethargy
  • Skin discoloration, rashes
  • Difficulties breathing
Septic shock
This is a state of severe sepsis where patients continue to have problems with low blood pressure, low urine output, and high acid levels despite aggressively giving them fluids through an IV. Patients often will have to move to intensive care unit for even more aggressive treatment at this point, if they have not already done so.

Why did my child get so sick?

SIRS, sepsis, and septic shock can be caused by an infection from a virus, bacteria, or fungus. There are some types of infections that we know are more likely to cause sepsis than others, such as:

  • Pneumonias, either from a bacteria or a virus
  • Gut infections, such as appendicitis
  • Kidney infections
  • Bloodstream infections

However, children can get sepsis can come from almost any kind of infection. Why some children do, and some children do not, is likely related to things like their individual genetics, and is an area that scientists are researching. 

How do you know which infection they have?

While in the hospital, the medical team may run a number of different tests on a child’s blood, urine, and nasal secretions/mucus to try and find out which infection they have, and where in the body it is located. They might also run blood tests to look at how well the body’s organs are functioning. These can include:

  • Blood and urine cultures
  • Complete blood count, looking at how many and what kinds of blood cells there are
  • Metabolic panels, looking at the levels of different electrolytes
  • Kidney and liver function tests
  • Clotting tests, looking at how well or poorly the blood is making clots
  • Blood gas tests, looking at the way the lungs, red blood cells, and kidneys are working together to bring in oxygen, get rid of waste, and keep blood acid levels stable
  • Urine analysis, looking at how the kidneys are working

The team may also want to look for the source of an infection with the help of imaging equipment, especially if that source is not clear from other tests. This may include:

  • X-ray
  • CT scan (or CAT scan)
  • Ultrasound
  • MRI

How do you treat sepsis and septic shock?

As stated above, children with severe sepsis and shock are managed in the pediatric intensive care unit (PICU), where they can be supported in many different ways. They will likely receive medications and interventions to fight infection, support their organs, and give their bodies time to heal. These can include things like:

  • Antibiotics
  • Fluids and nutrition through an IV
  • Medication to increase blood pressure and support the heart function
  • Placement of a breathing tube, use of a ventilator (breathing machine) to support the lungs
  • Medication to take away pain, keep the child asleep
  • Inhaled medication to help the lungs bring in oxygen or get rid of mucus
  • Dialysis, to help do the job of the kidneys if they are not working well

In cases where children are very sick, and will need most of these interventions, the PICU team will usually place something called a central venous line, or central venous catheter. This is like a normal IV, except it is placed in blood vessel that is larger than one found in the hand, arm, or foot. Most often the vessels used are found in the groin or the neck. There are a few reasons to place this line, including the ability of the team to take small blood samples for testing more easily, and the ability to give some of the stronger medications.  Most of the medicines used to support the heart and blood pressure, for example, will cause damage to the small blood vessels used with a regular IV, and can only be given safely through a larger catheter.

In some very sick patients who need a lot of blood pressure support, the team may also place an arterial line, which is similar to an IV except that it is placed in an artery (not a vein), usually in the wrist or foot. This allows the team to continuously see the child’s blood pressure on a monitor, just like their heart rate or breathing rate, without using an inflatable cuff.

How long will we need to stay in the ICU?

This will depend on many factors, including the type of infection your child has and how many of their organs were affected. Some patients, who did not have a severe infection or who did not need a great deal of medical or mechanical support, recover quickly and leave the ICU in a few days. Others, with more severe infections or shock, usually have breathing tubes and central lines placed to help their lungs and heart. These patients can take weeks to heal. Usually, when a child is ready to have their breathing tube taken out, it is a sign that they will soon be ready to leave the ICU.  

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