Intro to ra lausanne 2018

Introduction to
US-Guided
Regional Anaesthesia
Dr Amit Pawa @amit_pawa
THE 4TH
REGIONAL ANAESTHESIA DAY
OF ROMANDIE
6th
October 2018
Lausanne University Hospital, Switzerland
Sempach | Switzerland AK2357_04.2018
OF ROMANDIE
6th
October 2018
Lausanne University Hospital, Switzerland

Guy’s
Hospital
St Thomas’
Hospital

Declaration
I love Ultrasound Guided RA!…
RA-UK President
Consult
Honoraria from
!
Sponsored by:

Learning USGRA
Understanding
Equipment
SonoAnatomy
Technical Skills
@amit_pawa

Purpose of this lecture
Gain Tips On How to…
1. Generate best image
2. Interpret best image
3. Needle best image
4.Achieve best results
@amit_pawa

Hocus #Pocus?
@amit_pawa
Is it

The Future
#POCUS
Airway Breathing Circulation
@amit_pawa

Why Ultrasound for RA?
US Machines everywhere!
Familiarity (CVC)
We know some anatomy
Reliable Non-opiate analgesia
@amit_pawa

Accuracy
Reduce
Less Intraneural Injections
Rapid Block Onset
Quick & Painless
block insertion
Longer Block
Durations
Why Ultrasound for RA?
Reduce LA Dose
Identify Aberrant
anatomy
Avoid “Tiger Territory”
L.A.S.T

The Anatomy Lesson of Dr Nicolaes Tulp - 1632 - Rembrandt
Learning Anatomy

Machines are getting smaller!
@amit_pawa

When did it all begin?…
1994
@amit_pawa

Prince - “The Most Beautiful
Scan in the world”
“Could u be, the most beautiful nerve in the world,
Its plain to see, the body anatomy all told.
When the probe, makes the images of you come to life,
I know I, can remove all the pain of the knife…”
"
# #
"
1994

1. Generate Best Image
Probe Handling
Probe Manipulation - P.A.R.T
Machine Manipulation/Optimisation
Short / Long Axis imaging
Ergonomics
@amit_pawa

Probe Handling
My Hand My 6yr old’s Hand
Not like this…
@amit_pawa

Stable & precise
Probe Handling
Treat it like a paintbrush
My Hand My 6yr old’s Hand
@amit_pawa

Probe Manipulation
Pressure
Alignment
Rotation
Tilting
@amit_pawa

Most Important
Alignment
Tilting
@amit_pawa

Less Clear90
Anisotropy
@amit_pawa

Machine Manipulation/
Optimisation
@amit_pawa

Probe Selection
Superficial
High Frequency
“Resolves”
Deeper
Low Frequency
“Penetrates”
>10 MHz 2-5 MHz

Select the Correct Mode/
Preset
@amit_pawa

Positioning your picture
@amit_pawa

Everything to gain…
@amit_pawa

Add some colour…
• Veins: compressible,
non pulsatile
• Arteries: non-
compressible, pulsatile
• Detects flow
• Red flow towards
probe
• Blue away from
probe
@amit_pawa

Short/Long Axis Imaging
Short Axis = Cross Section
Long Axis = Longitudinal Scan
@amit_pawa

Short/Long Axis Imaging
@amit_pawa

2.Interpret best image
3.Needle best image
@amit_pawa

2. Interpret Best Image
Anatomy
Sonoanatomy - Template
Dynamic - traceback to known
anatomical relations
“Only See what you Look for, Only Look
for what you Know”
Know common anomalies
@amit_pawa

Anatomy
This is the best time to revise your old
anatomy notes
Attend a cadaveric course
Dig out your old text books
Buy an App!!
@amit_pawa

Axilla
Coracobrachialis
MCN
Humerus
Biceps Brachii
Long Head ofTriceps/
ConjointTendon (TM/LD)AA
av
AV
M U
R
L
A
T
E
R
A
L
M
E
D
I
A
L
London Society of Regional Anaesthesia
!"#$%$&'()#*+,(-*.
“Sono”Anatomy
=
Ultrasound Anatomy
@amit_pawa

Nerve
Proximal -
Interscalene
Distal -
Musculocutaneous
Hyperechoic rim
Hypoechoic content
(neural tissue)
Hyperechoic rim
Honeycomb content –
fascicles & connective tissue

Sonoanatomy
Cross sectional anatomy
Schematic
Pattern recognition
Apply to real US
Ultrasound is dynamic!
@amit_pawa

Sternocleidomastoid
Anterior
Scalene
CA
IJV Middle
Scalene
phrenic n
vagus n
Medial
Lateral
Interscalene
@amit_pawa

Sternocleidomastoid
CA
IJV
Needle trajectory
Interscalene
@amit_pawa

Cephalad Caudad
Pec Major
Pec Minor
AA
AVL
P
M
Clavicle
Infraclavicular Block
@amit_pawa

Pec Major
Pec Minor
AA
AVL
P
M
Clavicle
Cephalad Caudad
@amit_pawa

Many more examples…
Axilla
C
oracobrachialis
MCN
Humerus
BicepsBrachii
Long Head
ofTriceps/
ConjointTendon (TM/LD)
AA
av
AVM
U
R
L
A
T
E
R
A
L
M
E
D
I
A
L
!"#$%$&'()#*+,(-*.
Friday, 21 June 2013
E.O.m
I.O.m
T.A.m
Rectus m
skin
Q.L.m
L.D.m
Peritoneum
ABDOMEN
!"#$%$&'()#*+,(-*.
Subgluteal Sciatic
Gluteus Maximus
Quadratus femorisSN
Fat
GT
IT
Lateral
Medial
!"#$%$&'()#*+,(-*.
SFA
Lateral
sartorius
vastus
medialis
adductor
longus
adductor magnus
FV
Adductor Canal
!"#$%$&'()#*+,(-*.
Obturator Block
FV
Pectineus
Adductor Longus
Adductor Brevis
Adductor Magnus
Lateral
Medial
Ant
Post
FA
London Society o
!"#$%$

Ultrasound is Dynamic
Confirm what you think you know
Trace to known anatomical relations -
Forearm peripheral nerves
Scan from antecubital fossa to wrist & back
Nerves follow a characteristic path
@amit_pawa

Ultrasound is Dynamic
Confirm what you think you know
Trace to known anatomical relations -
Infraclavicular brachial plexus
Scan from medial to lateral, the cords rotate
around axillary artery
@amit_pawa

@amit_pawa
You only SEE what you LOOK for
Caution

Caution
@amit_pawa
You only LOOK for what you KNOW
Caution

1st Rib
Pleura
Plexus SCA
Supraclavicular Block
@amit_pawa

Had a pre-procedure doppler been
performed & attention paid to
Pleura(!)...
@amit_pawa

3. Needle Best Image
In-Plane / Out-of-Plane needling
S.T.A.R
Ergonomics again
@amit_pawa

Needling
In-Plane
Out - of - Plane
@amit_pawa

Needling Technique
Out-Of-Plane (OOP)
@amit_pawa

Needling - OOP
Needle tip deeper
than initially seen
Target
Often use hydrolocation to assist here

Needling Technique
In-Plane (IP)
@amit_pawa

Needling - IP
Visualise shaft & tip
@amit_pawa

From Above
NOT in-plane
From In-front
“Looks” in-plane

S.T.A.R.
What about when needling in-plane & not
seeing needle entirely…
Remember P.A.R.T.?
Anything Better?
A Randomized Controlled Trial
Evaluating the See, Tilt, Align, and
Rotate (STAR) Maneuver on Skill
Acquisition for Simulated Ultrasound-
Guided Interventional Procedures
Nicholas C. K. Lam, MD, Steven J. Fishburn, MD, Angie R. Hammer, BS, Timothy R. Petersen, PhD,
Neal S. Gerstein, MD, Edward R. Mariano, MD, MAS
Received August 12, 2014, from the Department
of Anesthesiology and Critical Care Medicine,
University of New Mexico, Albuquerque, New
Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P.,
N.S.G.); Department of Anesthesiology, Perioper-
ative and Pain Medicine, Stanford University
School of Medicine, Stanford, California USA
(E.R.M.); and Anesthesiology and Perioperative
Care Service, VA Palo Alto Health Care System,
Palo Alto, California USA (E.R.M.). Revision
requested August 26, 2014. Revised manuscript
accepted for publication September 1, 2014.
This work was presented in part at the
American Society of Anesthesiologists Annual
Meeting;October2013;SanFrancisco,California.
Dr Lam received support for this project from
the Father Meldon Hickey Memorial Fund
administered by the University of New Mexico
Foundation.DrMarianohasreceivedunrestricted
Objectives—Achieving the best view of the needle and target anatomy when perform-
ingultrasound-guidedinterventionalproceduresrequirestechnicalskill,whichnovices
may find difficult to learn. We hypothesized that teaching novice performers to use 4
sequentialsteps(see,tilt,align,androtate[STAR]method)toidentifytheneedleunder
ultrasoundguidanceismoreefficientthantrainingwiththecommonlydescribedprobe
movements of align, rotate, and tilt (ART).
Methods—Thisstudycompared2instructionalmethodsfortransducermanipulation
including alignment of a probe and needle by novices during a simulated ultrasound-
guidednerveblock.Right-handedvolunteersbetweentheagesof18and55yearswho
hadnopreviousultrasoundexperiencewererecruitedandrandomizedto1of2groups;
one group was trained to troubleshoot misalignment with the ART method, and the
otherwastrainedwiththenewSTARmaneuver.Participantsperformedthetask,con-
sisting of directing a needle in plane to 3 targets in a standardized gelatin phantom 3
times. The performance assessor and data analyst were blinded to group assignment.
Results—Thirty-five participants were recruited. The STAR group was able to com-
pletethetaskmorequickly(P<.001)andvisualizedtheneedleinagreaterproportion
of the procedure time (P = .004) compared to the ART group. All STAR participants
were able to complete the task, whereas 41% of ART participants abandoned the task
ctiveperformanceofallultrasound-guidedproceduresrequires
wledge of relevant sonoanatomy and proficiency in real-time
dle guidance. In ultrasound-guided regional anesthesia, the in-
e technique (directing the needle within the same plane as the
ne | J Ultrasound Med 2015; 34:1019–1026 | 0278-4297 | www.aium.org

wellas the proportion of attempt time in which the needle
was not fully visible. If an attempt lasted 600 seconds,
the participant was offered the option to terminate the
attempt, and its duration was recorded as 600 seconds.
attempt time in which the inserted portion of the needle
was not fully visible on the ultrasound screen and the par-
ticipants’self-reportedfatigueduringandaftertheir3task
attempts.
J Ultrasound Med 2015; 34:1019–10261022
Figure 2. The STAR technique. A, “See,” where the needle is in relation to the probe. B, “Tilt” the probe to optimize the reflected signal from the
target. C, “Align” the probe in the direction of the needle. D, “Rotate” if the needle is partially visualized.
S.T.A.R.
well asthe proportionof attempt time in which the needle
attempts.
J Ultrasound Med 2015; 34:1019–10261022
wellas the proportionofattempt time in which the needle
attempts.
J Ultrasound Med 2015; 34:1019–10261022
wellastheproportionofattempt time in which the needle
attempts.
J Ultrasound Med 2015; 34:1019–10261022
itute of Ultrasound in Medicine | J Ultrasound Med 2015; 34:1019–1026 | 0278-4297 | www.aium.org
See Tilt
Align Rotate

Ergonomics again!
Variations with In-Plane needling
@amit_pawa

Ergonomics In-Plane
Needling Along Visual Axis is better
Novice Learner In-Plane Ultrasound Imaging
Which Visualization Technique?
Melanie Speer, MBChB, FANZCA* Neil McLennan, MBChB, FANZCA† and Chris Nixon, MBChB*†
Background and Objectives: Needle guidance under ultrasound is
an acquired skill requiring fine motor control. Maintaining the image of
an advancing needle in the plane of an ultrasound beam may be per-
formed with the probe and needle orientated along the visual axis
(AL) or across the visual axis (AC). This study was undertaken to deter-
mine if orientation affected task performance.
Methods: Twenty-four relative novices were tasked to perform guided
punctures to a target in a pork phantom using each technique 5 times.
The technique first used was randomly chosen from a sealed envelope.
The time taken to guide the needle to target and the accuracy of needle
imaging were recorded.
Results: The mean time to locate the target was significantly faster for
the AL technique, compared with the AC technique (group AL, 35.7, vs
group AC, 58.6 seconds; P < 0.0001, Wilcoxon matched-pairs signed
rank test). The mean imaging quality score was also significantly better
when needle advancement was along the visual axis (group AL, 1.37, vs
group AC, 1.64; P = 0.05).
Conclusions: Advancing the needle along the visual axis was associ-
ated with improved task completion speed and quality of needle imag-
ing. This ergonomic pattern, therefore, may be the more appropriate
choice for novices learning ultrasound-guided in-plane needle imaging.
(Reg Anesth Pain Med 2013;38: 350–352)
Ultrasound-guided regional anesthesia is widely used for
achieving reliable peripheral nerve blockade with or with-
out nerve stimulation. A block needle may approach a target
from a position perpendicular to the ultrasound beam or parallel
to the ultrasound beam, referred to as “out of plane” and “in
plane,” respectively. The in-plane approach has the advantage
of enabling the user to see the needle shaft and tip as it is di-
rected toward a target but requires skill and may result in a false
The aim of this study was to assess any potential advan-
tage in terms of accuracy or speed to novices performing an
in-plane needle imaging task using these 2 techniques.
METHODS
Ethics approval for this study was obtained from the Northern
X Regional Ethics Committee (NTX/10/EXP/145) in Auckland,
New Zealand.
Medical students and first-year residents in the Department
of Anesthesia were invited to participate in the study. After ob-
taining written informed consent, each subject completed a brief
questionnaire detailing previous ultrasound experience. Those
whose experience was greater than 10 nerve blocks were excluded
from study. Experience of ultrasound-guided vascular access was
not regarded as an exclusion criterion because this is performed
using an out-of-plane technique in our hospital.
Each participant watched an educational presentation (Power-
Point; Microsoft Corp, Redmond, Washington) detailing the study
method and objectives immediately after testing. This included a
brief introduction to ultrasound, a video demonstrating the task re-
quired, and specific instructions to advance the needle only when
the tip was visualized. This standardized the instructions given to
all subjects, reducing instruction bias.
A simulated peripheral nerve block was created using a por-
cine phantom.6
An 18-gauge Tuohy needle (Perican; B. Braun,
Melsungen AG, Germany) embedded in the phantom acted as a
target. It was positioned at a depth of 1 to 3 cm below the surface
of the phantom and imaged in cross-section. The position within
the phantom was changed between subjects to avoid needle tracks
left after previous attempts. A short bevel nonechogenic spinal
needle (Pencan 20 g; B.Braun) was used to approach the target.
ULTRASOUND ARTICLE
was contacted and the buzzer sounded. A 30-second retrospec-
tive video clip of each attempt was recorded immediately after
the buzzer sounded. The video clips were later analyzed for
the quality of needle imaging using a 4-point scoring system
(Table 1) modified from Sites et al.6
Each video clip was scored
independently by 3 investigators, blinded to the technique used
and the subject’s experience.
B, Department of
and City Hospital, Level
ukland, New Zealand
onal Anesthesia and Pain
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, 2013
ional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
matched-pairs signed rank test for time and quality score data
The preferred technique was analyzed using Fisher exact test.
RESULTS
Twenty-four novice ultrasound users were recruited for the
study. Thirteen were medical students, and 11 were first-yea
residents. The 13 medical students had never used ultrasound
previously. All residents had previous ultrasound experience
5 for vascular access only, and 6 had previously performed
ultrasound-guided nerve blocks. Of these 6 participants, 2 had
performed 1 to 5 ultrasound-guided nerve blocks and 4 had per
formed 6 to 10 blocks.
the remaining 234 were analyzed for needle imaging qu
Each clip was given a score from 0 to 3 with a score of 0 r
senting excellent needle imaging, whereas a score of 3
poor. The mean quality score was 1.64 for the AC techn
compared with 1.37 for the AL technique (P = 0.05, Wilc
matched-pairs signed rank).
Each participant was asked which technique they
ferred. Overall, 6 (25%) of the 24 participants preferred techn
AC, and 18 (75%) preferred technique AL. The preferred
nique was not statistically correlated with the technique
formed first (Fisher exact test, P = 0.64).
DISCUSSION
This study demonstrates an improved ability of novic
guide a needle to a target in a pork phantom when the
sound probe and needle were orientated along the visual
This complements a previous ergonomic study by Lan
et al,7
which demonstrated that the position of the ultras
monitor affected the speed and accuracy of ultrasound-gu
needle placement. Poor ergonomics was identified by
et al6
as a key error made by anesthesia residents perfor
ultrasound-guided nerve blocks. This was defined as an arc
torso, nondominant hand holding the needle, or head tu
45 degrees or greater (as estimated by the reviewers). Poor
nomics occurred 31 times and resulted in unintentional p
movement in 70% of cases. A total of 398 errors were
in 520 ultrasound-guided nerve blocks, of which the most
mon was advancing the needle while the tip was not visua
(174 cases, 44%). In our study, of the 234 procedures anal
only 69 (29%) received a score of 0, indicating ideal ima
of the needle tip and shaft. In the remaining 165 (71%),
movement of the needle occurred without the needle an
being fully imaged.
FIGURE 1. Orientation of monitor screen, ultrasound probe,
needle and operator. A, the across technique, B, the
along technique.
@amit_pawa

4. Achieve Best Results
Single/Double/Triple Monitoring
?Self Injection
Volume of LA?
Avoid Wrong Sided Blocks
Document clearly
@amit_pawa

Single/Double/Triple
Single Monitoring - US Only
Double monitoring US plus either Pressure
or PNS
Triple Monitoring - US plus PNS plus
Pressure
Well known to our American colleagues…
@amit_pawa

NYSORA
- Triple Monitoring
@amit_pawa

Why Bother…
Review
A systematic review and meta-analysis of ultrasound versus
electrical stimulation for peripheral nerve location and blockade*
S. Munirama1
and G. McLeod2,3
1 Consultant Anaesthetist, Department of Anaesthetics, Manchester Royal Inﬁrmary, Manchester, UK
2 Consultant Anaesthetist, Department of Anaesthetics, Ninewells Hospital, Dundee, UK
3 Honorary Reader, Institute of Academic Anaesthesia, University of Dundee Medical School, Dundee, UK
Summary
We systematically reviewed peripheral nerve blockade guided by ultrasound versus electrical stimulation. We
included 26 comparisons in 23 randomised controlled trials of 2125 participants. Ultrasound reduced the rate of pain
during the procedure, relative risk (95% CI) 0.60 (0.41–0.89), p = 0.01. Ultrasound with or without electrical stimula-
tion reduced the rate of analgesic or anaesthetic rescue versus electrical stimulation alone, relative risk (95% CI) 0.40
(0.29–0.54) and 0.29 (0.16–0.52), respectively, p < 0.0001 for both. The rate of rescue was unaffected by the addition
of electrical stimulation to ultrasound, relative risk (95% CI) 1.07 (0.54–2.10), p = 0.85. Ultrasound, with or without
electrical stimulation, reduced the pooled rate of vascular puncture, relative risk (95% CI) 0.23 (0.15–0.37),
p < 0.0001. There was no difference in the rate of postoperative neurological side-effects, relative risk (95% CI) 0.76
(0.53–1.09), p = 0.13.
.................................................................................................................................................................
Correspondence to: S. Munirama
Email: shilpa.m@hotmail.co.uk
Accepted: 5 March 2015
*Presented in part at the European Society of Regional Anaesthesia and Pain Therapy’s Annual Congress, Glasgow,
2013.
Anaesthesia 2015 doi:10.1111/anae.13098
Review
A systematic review and meta-analysis of ultrasound versus
electrical stimulation for peripheral nerve location and blockade*
S. Munirama1
and G. McLeod2,3
1 Consultant Anaesthetist, Department of Anaesthetics, Manchester Royal Inﬁrmary, Manchester, UK
2 Consultant Anaesthetist, Department of Anaesthetics, Ninewells Hospital, Dundee, UK
3 Honorary Reader, Institute of Academic Anaesthesia, University of Dundee Medical School, Dundee, UK
Summary
We systematically reviewed peripheral nerve blockade guided by ultrasound versus electrical stimulation. We
included 26 comparisons in 23 randomised controlled trials of 2125 participants. Ultrasound reduced the rate of pain
during the procedure, relative risk (95% CI) 0.60 (0.41–0.89), p = 0.01. Ultrasound with or without electrical stimula-
tion reduced the rate of analgesic or anaesthetic rescue versus electrical stimulation alone, relative risk (95% CI) 0.40
(0.29–0.54) and 0.29 (0.16–0.52), respectively, p < 0.0001 for both. The rate of rescue was unaffected by the addition
of electrical stimulation to ultrasound, relative risk (95% CI) 1.07 (0.54–2.10), p = 0.85. Ultrasound, with or without
electrical stimulation, reduced the pooled rate of vascular puncture, relative risk (95% CI) 0.23 (0.15–0.37),
p < 0.0001. There was no difference in the rate of postoperative neurological side-effects, relative risk (95% CI) 0.76
(0.53–1.09), p = 0.13.
.................................................................................................................................................................
Correspondence to: S. Munirama
Anaesthesia 2015 doi:10.1111/anae.13098
@amit_pawa

Use of PNS
Use PNS as a safety measure - the “Brakes”
Leave on in background at 0.5mA
Not to identify nerve
If get twitches at 0.5mA
Make sure not intraneural - withdraw
Assess injection pressure (manual? or with
device?)
@amit_pawa

Injection pressure
monitoring
Compressed Air Injection Technique
(CAIT)
50% compression ensures pressure < 1 atm

The Injection
Small Aliquots
Low pressure injection
If resistance to injection - STOP
If Spread of LA not visible - STOP
(?DON’T?) Aim for circumferential spread
of target - Scan distal/prox to injection site
You can...
@amit_pawa

Do Self Injection!
Pappin D, Christie I. The Jedi Grip: a
novel technique for administering
local anaesthetic in ultrasound-
guided regional anaesthesia.
Anaesthesia. 2011 Sep; 66(9):845.
Bedforth N, Townsley P.
Single-handed ultrasound-guided
regional anaesthesia.
Anaesthesia. 2011 Sep; 66(9):846.

What Volume of
Depends...
1. Indication
2. Location - peripheral nerve VS plexus
3. Adequacy of LA spread
4.Body Weight
5. Any other blocks?
@amit_pawa

Stop Before
You Block
@amit_pawa

6&':":,-%9'$27%#$;

Stop Before You Block
Dr Craig Johnstone @c_johnstone1980

PLEASE DOCUMENT ANY FURTHER DETAILS OVERLEAF
GUYS AND ST THOMAS’ HOSPITAL NHS FOUNDATION TRUST ANAESTHETIC RECORD SHEET FOR CENTRAL AND PERIPHERAL REGIONAL ANAESTHESIA
6928-tba_Layout 1 27/01/2014 11:39 Page 1

How Will I Know
When I’m Good?

Feasibility of eye-tracking technology to quantify expertise
in ultrasound-guided regional anesthesia
T. Kyle Harrison1,2
· T. Edward Kim1,2
· Alex Kou1,2
· Cynthia Shum1
·
Edward R. Mariano1,2
· Steven K. Howard1,2
· The ADAPT (Anesthesiology-Directed
Advanced Procedural Training) Research Group
Received: 5 August 2015 / Accepted: 21 February 2016
© Japanese Society of Anesthesiologists (outside the USA) 2016
Short communication
Ultrasound-guided regional anesthesia (UGR
an advanced procedural skill set that incorp
sonographic knowledge of relevant anatomy
technical proficiency in needle manipulation
achieve a successful outcome. Arguably, e
accumulate a substantial fund of knowledg
deploy that knowledge through iterative pra
ing, and multiple successive trials until reli
cal performance and successful patient outco
achieved. It is important to determine the
Abstract Ultrasound-guided regional anesthesia (UGRA)
requires an advanced procedural skill set that incorporates
both sonographic knowledge of relevant anatomy as well
as technical proficiency in needle manipulation in order
to achieve a successful outcome. Understanding how to
differentiate a novice from an expert in UGRA using a
quantifiable tool may be useful for comparing educational
interventions that could improve the rate at which one
develops expertise. Exploring the gaze pattern of individu-
als performing a task has been used to evaluate expertise in
many different disciplines, including medicine. However,
the use of eye-tracking technology has not been previously

2.Interpret best image
3.Needle best image

Summary
Sonoanatomy
Learn how to “Drive” US machine
Ergonomics
‘See the Needle’
Double/Triple monitoring
Stop Before You Block
Document clearly
@amit_pawa

Intro to ra lausanne 2018

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Intro to ra lausanne 2018