2. Lesson Outline
• Key concepts of anaesthetic complications
• Causes of anaesthetic complications
• Strategies to prevent anaesthetic complications
• General management of anaesthetic complications
• Legal aspects of anaesthetic complications
• Summary
• Student Activities
• References
• Next Lecture
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3. Learning Objectives
• To know the key concepts of anaesthetic complications.
• To identify the common causes of anaesthetic complications.
• To distinguish between preventable and unpreventable anaesthetic
complications.
• To develop strategies to prevent anaesthetic complications.
• To plan the general management of anaesthetic complications.
• To know how to deal with the legal aspects of anaesthetic
complications.
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4. KEY CONCEPTS
•Complications are unexpected and unwanted
events.
•Complications related to the delivery of
anaesthesia care are inevitable.
•Even the most experienced, diligent, and careful
practitioners will have to manage complications
despite acting well within the standard of care
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5. KEY CONCEPTS
•These complications will range from minor (eg,
infiltrated intravenous line) to catastrophic (hypoxic
brain injury or death).
•Every complication has the potential to cause
lasting harm to the patient.
•Therefore, deviations from the norm must be
recognized and managed promptly and
appropriately.
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6. KEY CONCEPTS
•Anaesthetic mishaps can be categorized as preventable or
unpreventable.
•The preventable incidents, are associated with human error.
•Death and permanent neurological damage as complications of
anaesthesia are related to adverse cardiovascular and
respiratory events.
•A reduction in adverse respiratory events is believed to be due
to the widespread adoption of pulse oximetry and capnography
as standard monitors.
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7. KEY CONCEPTS
•Many anaesthetic fatalities occur only after a series of
coincidental circumstances, misjudgments, and technical
errors (mishap chain).
•Although the mechanisms differ, anaphylactic and
anaphylactoid reactions can be clinically
indistinguishable and equally life-threatening.
•Cardiovascular and cutaneous manifestations are more
common features of anaphylaxis than bronchospasm
during anaesthesia.
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8. KEY CONCEPTS
•True anaphylaxis due to anaesthetic agents is rare;
anaphylactoid reactions are much more common.
•Muscle relaxants have emerged as the most common cause of
anaphylaxis during anaesthesia.
•Latex allergy is the second most common.
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9. KEY CONCEPTS
•Anaesthesiology is a high-risk medical specialty for
drug addiction.
•The two most important methods of minimizing
radiation exposure are using proper barriers and
maximizing one's distance from the source of
radiation.
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10. KEY CONCEPTS
•Every complication has the potential to cause
lasting harm to the patient.
•Therefore, deviations from the norm must be
recognized and managed promptly and
appropriately.
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11. Incidence
•There are several reasons why it is difficult to accurately
measure the incidence of adverse outcomes, also
referred to as anaesthetic mishaps.
•First, it is often impossible to assign the responsibility
for a poor outcome to the patient's inherent disease,
the surgical procedure, or the anaesthetic management.
In fact, all three can contribute to a poor outcome.
•It is also difficult to define a measurable event.
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12. Incidence
•Death is a clear end point, but because anaesthesia related
perioperative death is rare, a very large series of patients
must be studied to assemble conclusions that have statistical
significance.
•Nonetheless, many studies have attempted to determine the
incidence of complications due to anaesthesia.
•Unfortunately, studies vary in criteria for defining an
anaesthesia related adverse outcome.
•Finally, medicolegal fears hinder accurate reporting.
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13. Incidence
• They occur in approximately 10% of anaesthetics. Only the minority of these
complications cause lasting harm to the patient.
• Death complicates five anaesthetics per million given in the UK (0.0005%).
• Perioperative mortality is usually defined as death within 48 hours of surgery. It
is clear that most perioperative fatalities are due to the patient's preoperative
disease or the surgical procedure.
• The mortality rate attributable primarily to anaesthesia appears to have
dropped during the past 30 years from one or two deaths per 3000 anaesthetic
experiences to a current rate of one or two deaths per 20,000 experiences.
• However, these statistics should be viewed with considerable skepticism, as
they are derived from different countries using different methodologies.
• What is the incidence of anaesthetic mortality in Ghana?
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14. Incidence
•Recent studies indicate that the anaesthetic mortality
rate in some institutions may be even less than
1:20,000.
•This decline may be due to the availability and use of
new monitoring equipment, greater knowledge of
anaesthetic physiology and pharmacology, and
improved surgical and medical care.
•Indeed, in one large study, the mortality rate attributed
solely to anaesthesia was 1 in 185,000.
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15. COMMON ANAESTHETIC COMPLICATIONS
The most frequent complications during anaesthesia are;
arrhythmia,
hypotension,
adverse drug effects and
inadequate ventilation of the lungs.
Inadequate ventilation may be caused by;
poorly managed or difficult tracheal intubation,
pulmonary aspiration of gastric contents,
breathing system disconnections or
gas supply failure.
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16. COMMON ANAESTHETIC COMPLICATIONS
•These complications are also the major causes of
anaesthetic mortality, preventable intraoperative cardiac
arrest and permanent neurological damage.
•Hypotension and hypoxaemia are implicated consistently
in studies of adverse outcome from anaesthesia.
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17. Classification of Anaesthetic Complications
•Anaesthetic mishaps can be categorized as preventable or
unpreventable.
•Studies of anaesthetic-related deaths or near misses suggest
that most accidents are preventable.
•Preventable incidents commonly involve human error.
•During the 1990s, the top three causes for claims in the ASA
Closed Claims Project were death (22%), nerve injury (18%),
and brain damage (9%).
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18. American Society of Anaesthesiologists (ASA) Closed Claims
Project
The goal of the ASA Closed Claims Project is to identify major areas of
loss in anaesthesia, patterns of injury, and strategies for prevention.
It is a collection of completed malpractice claims that provides a
"snapshot" of anaesthesia liability rather than a study of the incidence
of anaesthetic complications.
The most recent analysis spans more than four decades and includes
5803 claims.
These claims are grouped by subject area (eg, awareness and eye injury)
and were independently reviewed to determine patterns of causation
and liability.
Claims for dental injury as well as those in which the sequence of events
or nature of injury could not be reconstructed were excluded.
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19. Inevitable Complications
• There exists a subgroup of complications which may be classed as
‘inevitable’.
• Despite excellent surgical and anaesthetic practice, the patient may still
experience a complication that brings morbidity or even death.
• While we must, at all times, make stringent efforts to save our patients
from harm, it is also important to recognize that it is not always
necessary to place the blame for a complication on a healthcare
provider.
• Examples of such include sudden death syndrome, fatal idiosyncratic
drug reactions, or any poor outcome that occurs despite proper
management.
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20. PREVENTABLE CAUSES
Human Error Human error is a common contributor to
anaesthetic complications. It is often in association with;
poor monitoring,
equipment malfunction,
organizational failure,
poor training,
fatigue,
inadequate experience,
poor preparation of the patient and
Poor work environment.
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21. Human Error Human
•When complications do occur, effective monitoring and
vigilance allow a greater period for action before the
complication grows in severity.
•During this ‘window’, when the complication is apparent but
has not yet damaged the patient, the anaesthetist must act
with precision.
•Such precision of action may be obtained through the use of
‘action plans’ or ‘drills’ that have been rehearsed previously.
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22. Human Error Human
•Errors in drug administration also primarily involve human
error.
•It has been suggested that as much as 20% of the drug doses
given to hospitalized patients are incorrect.
•Errors in drug administration account for 4% of cases in the ASA
Closed Claims Project, which found that errors resulting in
claims were most frequently due to either incorrect dosage or
unintentional administration of the wrong drug (syringe swap).
•In the latter category, incorrect use of epinephrine proved to be
particularly dangerous.
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23. Human Error Human
Communication Failure
•Failure of communication is frequently implicated in the
generation of complications in the perioperative period.
•Poor working relationships, varying levels of training
amongst staff and poor working conditions make such
failure more likely.
•Team training and simulation-based training are effective
in reducing the incidence of this type of error.
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24. Equipment Failure
• Equipment failure may result in significant risk to the patient.
• In particular, failures of breathing systems, airway devices and gas
supplies have resulted in several deaths in recent years.
• In addition, malfunction of mechanical infusion pumps and infusion
pressurizing devices have caused injury and death in several cases.
• Meticulous checking of equipment before use is mandatory.
• The anaesthetist must not only ensure the correct functioning of
items of equipment that may be life-saving or of critical importance
but must also ensure that alternative devices are available should the
primary device fail.
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25. Adapted from Morgan & Mikhail, 2013
FACTORS ASSOCIATED WITH HUMAN ERRORS AND EQUIPMENT MISUSE
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26. Coexisting Disease
•Some complications stem from the deterioration of the
patient’s medical condition, which may have existed before the
anaesthetist’s involvement.
•While such deterioration may be coincidental, it must be
recognized that anaesthesia and surgery frequently introduce
altered conditions into a patient’s finely balanced combination
of pathology and compensatory physiology.
•This may be sufficient to generate instability in the patient’s
condition and result in sudden worsening of an apparently
stable pathology .
•Typical examples include diabetes mellitus, angina,
hypertension and asthma.
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27. Prevention of Anaesthetic Complications
• Strategies to reduce the incidence of serious anesthetic complications
include better monitoring and anesthetic technique, improved
education, more comprehensive protocols and standards of practice,
and active risk management programs.
• Better monitoring and anesthetic techniques imply closer patient
contact, more comprehensive monitoring equipment, and better
designed anaesthesia machines and workspaces.
• The fact that most accidents occur during the maintenance phase of
anaesthesia—rather than during induction or emergence—implies a
failure of vigilance. Inspection, auscultation, and palpation of the
patient provide important information.
• Instruments should supplement but never replace the practitioner’s
own senses.
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28. STUDENT ACTIVITY
Break into your existing groups for 15 minutes and
collaboratively work out three (3) strategies to prevent
anaesthetic complications.
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29. Prevention
•To minimize errors in drug administration, drug
syringes and ampules in the work area should be
restricted to only those needed for the current,
specific case.
•They should be consistently diluted to the same
concentration for each use and clearly labelled.
•Computer systems for scanning bar-coded drug
labels are being developed to help reduce
medication errors.
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30. Prevention
•Continuous improvement in anaesthesia training.
•Education must continue beyond the basic training as new
drugs, techniques, and equipment are continually being
developed.
•Part of this continuing education requirement includes
awareness of the most current monitoring standards,
familiarity with new equipment, and utilization techniques that
have been shown to improve anaesthetic outcomes.
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31. Prevention
• Continuous quality improvement programmes at the departmental
level may reduce anesthetic morbidity and mortality rates by
addressing monitoring standards, equipment, practice guidelines,
continuing education, and staffing issues.
• Specific responsibilities of peer-review committees include identifying
and preventing potential problems, formulating and periodically
revising departmental policies, ensuring the availability of properly
functioning anesthetic equipment, enforcing standards required for
clinical privileges, and evaluating the appropriateness of patient care.
• A quality improvement system impartially reviews complications,
ensures clinician’s compliance, and continuously monitors quality
indicators.
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32. Prevention
•The most effective steps in preventing harm from
complications are implemented before the complication
occurs.
•Thorough preparation should prevent the majority of
complications.
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33. Prevention
Preparation include:
preoperative assessment,
investigation and counselling of the patient,
preoperative checking of equipment,
the assurance of backup equipment,
the availability of an appropriately trained assistant,
preoperative consultation with more experienced personnel,
where necessary, regarding the most appropriate anaesthetic
technique and
the use of appropriate monitoring techniques.
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34. Prevention
Experience
•Complications occur more commonly in inexperienced hands.
•It is the individual anaesthetist’s responsibility to ensure that
he or she has adequate training for the task presented.
•If the anesthetist does not have the necessary experience, then
senior assistance must be sought.
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35. Prevention
Record-Keeping
• The maintenance of accurate records of a patient’s treatment and vital
signs is of paramount importance in preventing complications.
• It allows the observation of trends in vital signs, often providing
valuable clues to a gradual deviation from a stable physiological state
and allowing early intervention before a harmful condition arises.
• Accurate record-keeping also allows safer sharing of care between
anaesthetists, facilitating handover of care during long operations and
allowing better teamwork in complex cases in which two anaesthetists
are required.
• It also allows after-the-event investigation and learning – an important
system-level mechanism for reducing the impact and incidence of
complications.
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36. Prevention
Redundant Systems
• The use of redundant systems helps prevent complications.
• The availability of at least two working laryngoscopes illustrates this.
Should one system fail, another may be put in its place.
• Other examples include the insertion of two or more intravenous
cannulae if significant blood loss is expected.
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37. Prevention
Monitoring
•Monitoring systems have been designed to detect and prevent
complications during anaesthesia.
•Aspects of the patient that are likely to deviate from the norm,
or that are dangerous if they deviate from the norm should be
keenly monitored.
•Modern monitoring systems have automatically activated
alarms, and the anaesthetist chooses the values at which these
alarms sound.
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38. Prevention
Monitoring
The default values are not always the optimal choices.
Thought should be applied to the values at which the anesthetist gains useful
insight into the patient’s deviation from the healthy status quo, without generating
unnecessary visual and auditory pollution.
In general, alarms should sound before the value in question reaches a potentially
damaging level, but should not sound at values that would be considered within
the patient’s expected range.
Clearly, this is different for each patient, whose coexisting disease, age, anaesthesia
and surgical procedure vary greatly.
The repeated sounding of an alarm should not trigger reflex silencing of the alarm
but should cause the anaesthetist to consider if treatment of the patient is
required or if the alarm limit should be altered
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39. Generic Management of Complications
•The majority of complications that result in serious harm
to the patient compromise the delivery of oxygen to
tissues.
•Organs which are damaged most rapidly by a deficiency
in oxygen supply include the brain and heart.
•The liver and the kidneys are less fragile, but potentially
at risk from even short interruptions of oxygen supply.
•Cessation of perfusion results in more rapid damage to
organs than low levels of oxygenation while perfusion is
maintained.
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40. Generic Management of Complications
• Treatment must be provided rapidly when organ perfusion is
threatened or when arterial oxygenation is impaired.
• The management of virtually any significant complication should
include the provision of a high inspired oxygen fraction and the
assurance of an adequate cardiac output.
• In general, complications should be dealt with through a sequence of:
1. Continual vigilance and monitoring
2. Recognition of the evolution of a problem
3. Creation of a list of differential diagnoses
4. Choice of a working diagnosis, which is either the most likely or the
most dangerous possibility.
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41. Generic Management of Complications
5. Treatment of the working diagnosis.
6. Assessment of the response of the problem to the treatment
administered.
7. Refinement of the list of differential diagnoses, especially if
the response has not been as expected.
8. Confirmation or elimination of the choice of working
diagnosis; if the response to treatment has been unexpected
then replacement with a more likely working diagnosis is
indicated.
9. Go to step 5 and repeat until the problem is resolved.
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42. The Evolving Problem
•The early recognition of an evolving problem allows the
anaesthetist time to manage a complication before it damages
the patient.
•Appropriate selection of monitoring alarm limits and the
anesthetist’s vigilance should allow more time for pre-emptive
treatment can be provided to reduce the impact of the
complication.
•The first response to an emerging complication should be to
minimize the potential harm to the patient.
•Such harm may be produced by the anaesthetist’s treatment
or by a pathological source.
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43. The Evolving Problem
• It is important to ensure that an abnormal reading from a monitor is
not an artefact; inaccurate information may be displayed if, for
example, a pulse oximeter probe is poorly positioned or if an ECG
electrode becomes displaced and the anesthetist should ensure,
through rapid clinical assessment of the patient, that the values shown
on the monitor screen are consistent with the patient’s clinical
appearance and the context.
• For example, a sudden reading of arterial oxygen saturation of 70%
when the values have been greater than 96% throughout the
procedure should prompt a rapid examination of the patient; if the
patient is not cyanosed and ventilation appears to continue
uninterrupted, then the position of the pulse oximeter probe should be
checked, particularly if the plethysmograph trace is poor.
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44. Record-Keeping
•Record-keeping, while useful in preventing complications, is
also important during complications.
•Trends in a patient’s physiological data may become apparent
only when charted, and new differential diagnoses may be
generated through examination of the recorded data.
•Review of critical incidents and complications is vitally
important in preventing future repetitions of the incident and
in providing continuing education to individual practitioners
and to Departments of Anaesthesia.
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45. Record-Keeping
•Thorough record-keeping is vital in allowing informed review of
these cases.
•Finally, some complications result in harm to the patient and it
is very important for the practitioner and the patient that
detailed records are available for later review.
•In a minority of such cases, legal action may result and
detailed, legible records are vital in defending the actions of
the staff and in providing an adequate explanation to the
patient (and possibly to the court) of what happened in the
operating theatre.
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46. MEDICOLEGAL ASPECTS OF COMPLICATIONS
• A minority of complications result in a formal complaint, but litigation
by patients who feel that they have been wronged by the healthcare
system is becoming increasingly common.
• Defensive practice is consequently becoming widespread. Such
practice aims to reduce the potential culpability of the anesthetist
should complications arise.
• In some situations, this may lead to over investigation of patients and
even to the provision of care which is not necessarily optimal for the
patient.
• The ‘culture of blame’ in which we now practice dictates that
anaesthetists must protect themselves as well as their patients.
• Meticulous record-keeping, preoperative information and consent,
and frank discussion of risks with the patient are vital.
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47. Management of the Medicolegal Aspects of Complications
•Complications must be recognized promptly and treated
efficiently, with the patient’s best outcome the aim of
treatment.
•Record-keeping must continue to be meticulous, even during
the occurrence of problems during an anaesthetic.
•Help should be sought early if there is any doubt about the
anaesthetist’s ability or experience.
•Complaints by patients should be dealt with promptly and
professionally.
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48. Management of the Medicolegal Aspects of Complications
• The complaint and the anesthetist’s response must be recorded clearly
in the patient’s records.
• The anesthetist should express regret and sympathy that the
complication has occurred, and explain why.
• A frank discussion of the difficulties that occurred during an
anaesthetic may provide the patient with sufficient information.
• If human error has occurred, then the anaesthetist should apologize,
and assure the patient that further information will be provided when
it becomes available.
• If the anaesthetist is a trainee, then it is prudent to enlist the
assistance of a consultant to attend discussions with the patient.
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49. Management of the Medicolegal Aspects of Complications
• The clinical director should be informed of all discussions with the patient.
• It may be prudent that the clinical director accompanies the anesthetist during
their dealings with the patient.
• The results and content of all such discussions must be recorded in the patient’s
medical records.
• Any complaint that goes further than an informal conversation should be referred
to the hospital’s complaints department and the anesthetist’s defense
organization should be informed.
• The defense organization will provide advice on subsequent action.
• It must be emphasized that throughout this often distressing process, meticulous
and professional record-keeping may make the difference between exoneration
and condemnation, irrespective of the true source of fault.
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50. Specific Complications
•Complications are classified, where possible, according to the
body system involved.
•Some complications (such as hypothermia) do not fit easily into
this classification and are described separately.
•This list of complications is not exhaustive and the reader is
encouraged to consult the texts listed at the end of the lesson.
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51. Summary
• Key concepts of anaesthetic complications
• Causes of anaesthetic complications
• Strategies to prevent anaesthetic complications
• General management of anaesthetic complications
• Legal aspects of anaesthetic complications
• Anaesthetic complications are bodily system specific.
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52. REFERENCES
• Brouillette, M. A., Aidoo, A. J., Hondras, M. A., Boateng, N. A., Antwi-kusi, A.,
Addison, W., & Hermanson, A. R. (2017). Anaesthesia Capacity in Ghana: A
Teaching Hospital’s Resources, and the National Workforce and Education.
XXX(Xxx), 1–9. https://doi.org/10.1213/ANE.0000000000002487
• Paul G. Barash, Michael K. Cahalan, Bruce F. Cullen, M. Christine Stock, Robert
K. Stoelting, Rafael Ortega, Sam R. Sharar, and Natalie Holt, 2017 Clinical
Anaesthesia, Eighth Edition Pp 825-830
• Peavy, R. D., & Metcalfe, D. D. (2008). Understanding the Mechanisms of
Anaphylaxis. Current Opinion in Allergy and Clinical Immunology, 8 (1528), 310–
315.
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