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Salice V, Castellari A, Lucchelli M, Fiameni R, Orsenigo F, Gomarasca M, Mondin F, Moro-Salihovic B, Mietto C, Credico GD, Mistraletti G. ROTEM-GUIDED TRANSFUSION MANAGEMENT FOR ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE. J Cardiothorac Vasc Anesth 2022. [DOI: 10.1053/j.jvca.2022.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Mietto C, Salice V, Ferraris M, Zuccon G, Valdambrini F, Piazzalunga G, Socrate AM, Radrizzani D. Acute Lower Limb Ischemia as Clinical Presentation of COVID-19 Infection. Ann Vasc Surg 2020; 69:80-84. [PMID: 32791191 PMCID: PMC7417264 DOI: 10.1016/j.avsg.2020.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/05/2020] [Indexed: 01/14/2023]
Abstract
Novel 2019 coronavirus (COVID-19) infection usually causes a respiratory disease that may vary in severity from mild symptoms to severe pneumonia with multiple organ failure. Coagulation abnormalities are frequent, and reports suggest that COVID-19 may predispose to venous and arterial thrombotic complications. We report a case of acute lower limb ischemia and resistance to heparin as the onset of COVID-19 disease, preceding the development of respiratory failure. This case highlights that the shift of coagulation profile toward hypercoagulability was associated with the acute ischemic event and influenced the therapy.
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Affiliation(s)
- Cristina Mietto
- Department of Anesthesia and Critical Care, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy.
| | - Valentina Salice
- Department of Anesthesia and Critical Care, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Matteo Ferraris
- Vascular Surgery Unit, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Gianmarco Zuccon
- Vascular Surgery Unit, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Federico Valdambrini
- Department of Anesthesia and Critical Care, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Giorgio Piazzalunga
- Vascular Surgery Unit, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Anna Maria Socrate
- Vascular Surgery Unit, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - Danilo Radrizzani
- Department of Anesthesia and Critical Care, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
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Florio G, Ferrari M, Bittner EA, De Santis Santiago R, Pirrone M, Fumagalli J, Teggia Droghi M, Mietto C, Pinciroli R, Berg S, Bagchi A, Shelton K, Kuo A, Lai Y, Sonny A, Lai P, Hibbert K, Kwo J, Pino RM, Wiener-Kronish J, Amato MBP, Arora P, Kacmarek RM, Berra L. A lung rescue team improves survival in obesity with acute respiratory distress syndrome. Crit Care 2020; 24:4. [PMID: 31937345 PMCID: PMC6961369 DOI: 10.1186/s13054-019-2709-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS. METHODS In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring. RESULTS The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74). CONCLUSION Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.
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Affiliation(s)
- Gaetano Florio
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Matteo Ferrari
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Roberta De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Massimiliano Pirrone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Maddalena Teggia Droghi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Cristina Mietto
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Sheri Berg
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Aranya Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Yvonne Lai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Peggy Lai
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn Hibbert
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jean Kwo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Richard M Pino
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Jeanine Wiener-Kronish
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Marcelo B P Amato
- Pulmonary Division, Cardio-Pulmonary Department, Heart Institute (Incor), Hospital Das Clinicas da FMUSP, University of Sao Paulo, Sao Paulo, Brazil
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
- Department of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA.
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Pinciroli R, Mietto C, Piriyapatsom A, Chenelle CT, Thomas JG, Pirrone M, Bry L, Wojtkiewicz GR, Nahrendorf MP, Kacmarek RM, Berra L. Endotracheal Tubes Cleaned With a Novel Mechanism for Secretion Removal: A Randomized Controlled Clinical Study. Respir Care 2016; 61:1431-1439. [PMID: 27460104 DOI: 10.4187/respcare.04363] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Intubation compromises mucus clearance, allowing secretions to accumulate inside the endotracheal tube (ETT). The purpose of this trial was to evaluate a novel device for ETT cleaning. We hypothesized that its routine use would reduce tube occlusion due to mucus accumulation, while decreasing airway bacterial colonization. METHODS Subjects were randomized to either the use of the device every 8 h, or the institutional standard of care (blind tracheal suction) only. ETTs were collected at extubation and analyzed with high-resolution computed tomography (HRCT) for quantification of mucus volume. Microbiological testing was performed on biofilm samples. Vital signs and ventilatory settings were collected at the bedside. In-hospital follow-up was conducted, and a final evaluation survey was completed by respiratory therapists. RESULTS Seventy-four subjects expected to remain intubated for longer than 48 h were enrolled (77 ETTs, 37 treatment vs 40 controls). Treated tubes showed reduced mucus accumulation (0.56 ± 0.12 vs 0.71 ± 0.28 mL; P = .004) and reduced occlusion (6.3 ± 1.7 vs 8.9 ± 7.6%; P = .039). The HRCT slice showing the narrowest lumen within each ETT exhibited less occlusion in cleaned tubes (10.6 ± 8.0 vs 17.7 ± 13.4%, 95% CI: 2-12.1; P = .007). Data on microbial colonization showed a trend in the treatment group toward a reduced ETT-based biomass of bacteria known to cause ventilator-associated pneumonia. No adverse events were reported. The staff was satisfied by the overall safety and feasibility of the device. CONCLUSION The endOclear is a safe and effective device. It prevents luminal occlusion, thereby better preserving ETT nominal function.
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Affiliation(s)
- Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina Mietto
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Annop Piriyapatsom
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - John G Thomas
- School of Dentistry, West Virginia University, Morgantown, West Virginia
| | - Massimiliano Pirrone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lynn Bry
- Center for Clinical and Translational Metagenomics, Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts
| | | | | | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Chiumello D, Colombo A, Algieri I, Mietto C, Carlesso E, Crimella F, Cressoni M, Quintel M, Gattinoni L. Effect of body mass index in acute respiratory distress syndrome. Br J Anaesth 2016; 116:113-21. [PMID: 26675954 DOI: 10.1093/bja/aev378] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Obesity is associated in healthy subjects with a great reduction in functional residual capacity and with a stiffening of lung and chest wall elastance, which promote alveolar collapse and hypoxaemia. Likewise, obese patients with acute respiratory distress syndrome (ARDS) could present greater derangements of respiratory mechanics than patients of normal weight. METHODS One hundred and one ARDS patients were enrolled. Partitioned respiratory mechanics and gas exchange were measured at 5 and 15 cm H2O of PEEP with a tidal volume of 6-8 ml kg(-1) of predicted body weight. At 5 and 45 cm H2O of PEEP, two lung computed tomography scans were performed. RESULTS Patients were divided as follows according to BMI: normal weight (BMI≤25 kg m(-2)), overweight (BMI between 25 and 30 kg m(-2)), and obese (BMI>30 kg m(-2)). Obese, overweight, and normal-weight groups presented a similar lung elastance (median [interquartile range], respectively: 17.7 [14.2-24.8], 20.9 [16.1-30.2], and 20.5 [15.2-23.6] cm H2O litre(-1) at 5 cm H2O of PEEP and 19.3 [15.5-26.3], 21.1 [17.4-29.2], and 17.1 [13.4-20.4] cm H2O litre(-1) at 15 cm H2O of PEEP) and chest elastance (respectively: 4.9 [3.1-8.8], 5.9 [3.8-8.7], and 7.8 [3.9-9.8] cm H2O litre(-1) at 5 cm H2O of PEEP and 6.5 [4.5-9.6], 6.6 [4.2-9.2], and 4.9 [2.4-7.6] cm H2O litre(-1) at 15 cm H2O of PEEP). Lung recruitability was not affected by the body weight (15.6 [6.3-23.4], 15.7 [9.8-22.2], and 11.3 [6.2-15.6]% for normal-weight, overweight, and obese groups, respectively). Lung gas volume was significantly lower whereas total superimposed pressure was significantly higher in the obese compared with the normal-weight group (1148 [680-1815] vs 827 [686-1213] ml and 17.4 [15.8-19.3] vs 19.3 [18.6-21.7] cm H2O, respectively). CONCLUSIONS Obese ARDS patients do not present higher chest wall elastance and lung recruitability.
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Affiliation(s)
- D Chiumello
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, Italy Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - A Colombo
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - I Algieri
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - C Mietto
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - E Carlesso
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - F Crimella
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - M Cressoni
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - M Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August University of Göttingen, Göttingen, Germany
| | - L Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, Italy Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
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Panigada M, Artoni A, Passamonti SM, Maino A, Mietto C, L'Acqua C, Cressoni M, Boscolo M, Tripodi A, Bucciarelli P, Gattinoni L, Martinelli I. Hemostasis changes during veno-venous extracorporeal membrane oxygenation for respiratory support in adults. Minerva Anestesiol 2016; 82:170-179. [PMID: 25990432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND We investigated the coagulation system in patients during extracorporeal membrane oxygenation (ECMO) initiated for respiratory failure and the influence of the ECMO circuit on coagulation tests; we compared different coagulation tests for monitoring unfractionated heparin (UH) therapy; we investigated whether or not coagulation parameters were predictive of bleeding during ECMO. METHODS Pilot study on twelve consecutive adult patients admitted at our general ICU for acute respiratory failure and placed on ECMO from November 2011 to October 2012. Coagulation tests were performed before ECMO start and daily, including day of circuit change and day of circuit removal. UH was monitored with activated partial thromboplastin time (APTT) ratio, at a therapeutic range of 1.5-2.0. RESULTS We observed no effect of ECMO circuit on coagulation parameters measured pre- and postlung, but platelet count decreased significantly over time (-82x10(3)/mmc, 95%CI 40-123). APTT showed a correlation with antifactor Xa activity, whereas other global coagulation tests such as activated clotting time, thromboelastography and endogenous thrombin potential did not. Major bleeding occurred in three patients but no difference in any coagulation parameter was observed between them and those who did not bleed. CONCLUSIONS This pilot study shows that ECMO initiated for respiratory support in adults does not change coagulation parameters. Over time a statistically significant reduction of platelet count was observed, possibly due to consumption within the circuit, consumption microangiopathy or the underlying patients' diseases. Although APTT was appropriate to monitor UH, major bleedings occurred and a lower therapeutic range may be advisable.
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Affiliation(s)
- Mauro Panigada
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Ospedale Maggiore Policlinico, Milan, Italy -
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Mietto C, Malbrain MLNG, Chiumello D. Transpulmonary pressure monitoring during mechanical ventilation: a bench-to-bedside review. Anaesthesiol Intensive Ther 2015; 47 Spec No:s27-37. [PMID: 26575165 DOI: 10.5603/ait.a2015.0065] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/12/2015] [Indexed: 11/25/2022] Open
Abstract
Different ventilation strategies have been suggested in the past in patients with acute respiratory distress syndrome (ARDS). Airway pressure monitoring alone is inadequate to assure optimal ventilatory support in ARDS patients. The assessment of transpulmonary pressure (PTP) can help clinicians to tailor mechanical ventilation to the individual patient needs. Transpulmonary pressure monitoring, defined as airway pressure (Paw) minus intrathoracic pressure (ITP), provides essential information about chest wall mechanics and its effects on the respiratory system and lung mechanics. The positioning of an esophageal catheter is required to measure the esophageal pressure (Peso), which is clinically used as a surrogate for ITP or pleural pressure (Ppl), and calculates the transpulmonary pressure. The benefits of such a ventilation approach are avoiding excessive lung stress and individualizing the positive end-expiratory pressure (PEEP) setting. The aim is to prevent over-distention of alveoli and the cyclic recruitment/derecruitment or shear stress of lung parenchyma, mechanisms associated with ventilator-induced lung injury (VILI). Knowledge of the real lung distending pressure, i.e. the transpulmonary pressure, has shown to be useful in both controlled and assisted mechanical ventilation. In the latter ventilator modes, Peso measurement allows one to assess a patient's respiratory effort, patient-ventilator asynchrony, intrinsic PEEP and the calculation of work of breathing. Conditions that have an impact on Peso, such as abdominal hypertension, will also be discussed briefly.
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Affiliation(s)
- Cristina Mietto
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
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Panigada M, L’Acqua C, Passamonti SM, Mietto C, Protti A, Riva R, Gattinoni L. Comparison between clinical indicators of transmembrane oxygenator thrombosis and multidetector computed tomographic analysis. J Crit Care 2015; 30:441.e7-13. [DOI: 10.1016/j.jcrc.2014.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/26/2014] [Accepted: 12/05/2014] [Indexed: 11/30/2022]
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Berra L, Pinciroli R, Stowell CP, Wang L, Yu B, Fernandez BO, Feelisch M, Mietto C, Hod EA, Chipman D, Scherrer-Crosbie M, Bloch KD, Zapol WM. Autologous transfusion of stored red blood cells increases pulmonary artery pressure. Am J Respir Crit Care Med 2015; 190:800-7. [PMID: 25162920 DOI: 10.1164/rccm.201405-0850oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Transfusion of erythrocytes stored for prolonged periods is associated with increased mortality. Erythrocytes undergo hemolysis during storage and after transfusion. Plasma hemoglobin scavenges endogenous nitric oxide leading to systemic and pulmonary vasoconstriction. OBJECTIVES We hypothesized that transfusion of autologous blood stored for 40 days would increase the pulmonary artery pressure in volunteers with endothelial dysfunction (impaired endothelial production of nitric oxide). We also tested whether breathing nitric oxide before and during transfusion could prevent the increase of pulmonary artery pressure. METHODS Fourteen obese adults with endothelial dysfunction were enrolled in a randomized crossover study of transfusing autologous, leukoreduced blood stored for either 3 or 40 days. Volunteers were transfused with 3-day blood, 40-day blood, and 40-day blood while breathing 80 ppm nitric oxide. MEASUREMENTS AND MAIN RESULTS The age of volunteers was 41 ± 4 years (mean ± SEM), and their body mass index was 33.4 ± 1.3 kg/m(2). Plasma hemoglobin concentrations increased after transfusion with 40-day and 40-day plus nitric oxide blood but not after transfusing 3-day blood. Mean pulmonary artery pressure, estimated by transthoracic echocardiography, increased after transfusing 40-day blood (18 ± 2 to 23 ± 2 mm Hg; P < 0.05) but did not change after transfusing 3-day blood (17 ± 2 to 18 ± 2 mm Hg; P = 0.5). Breathing nitric oxide decreased pulmonary artery pressure in volunteers transfused with 40-day blood (17 ± 2 to 12 ± 1 mm Hg; P < 0.05). CONCLUSIONS Transfusion of autologous leukoreduced blood stored for 40 days was associated with increased plasma hemoglobin levels and increased pulmonary artery pressure. Breathing nitric oxide prevents the increase of pulmonary artery pressure produced by transfusing stored blood. Clinical trial registered with www.clinicaltrials.gov (NCT 01529502).
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Affiliation(s)
- Lorenzo Berra
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine
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Algieri I, Chiumello D, Mietto C, Carlesso E, Colombo A, Babini G, Cressoni M. Influence of body weight on lung mechanics and respiratory function in ARDS patients. Crit Care 2015. [PMCID: PMC4472817 DOI: 10.1186/cc14319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. Clinical diagnosis has been criticized to have poor accuracy and reliability. Thus, the Centers for Disease Control and Prevention has introduced a new definition based upon objective and recordable data. Institutions are nowadays reporting a VAP zero rate in surveillance programs, which is in discrepancy with clinical data. This reduction has been highlighted in epidemiological studies, but it can only be attributed to a difference in patient selection, since no additional intervention has been taken to modify pathogenic mechanisms in these studies. The principal determinant of VAP development is the presence of the endotracheal tube (ETT). Contaminated oropharyngeal secretions pool over the ETT cuff and subsequently leak down to the lungs through a hydrostatic gradient. Impairment of mucociliary motility and cough reflex cannot counterbalance with a proper clearance of secretions. Lastly, biofilm develops on the inner ETT surface and acts as a reservoir for microorganism inoculum to the lungs. New preventive strategies are focused on the improvement of secretions drainage and prevention of bacterial colonization. The influence of gravity on mucus flow and body positioning can facilitate the clearance of distal airways, with decreased colonization of the respiratory tract. A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the antimicrobial properties over time. Here, after reviewing the most noteworthy issues in VAP definition and pathophysiology, we will present the more interesting proposals for VAP prevention.
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Affiliation(s)
- Cristina Mietto
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Mietto C, Foley K, Salerno L, Oleksak J, Pinciroli R, Goverman J, Berra L. Removal of endotracheal tube obstruction with a secretion clearance device. Respir Care 2013; 59:e122-6. [PMID: 24368863 DOI: 10.4187/respcare.02995] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accumulation of secretions may suddenly occlude an endotracheal tube (ETT), requiring immediate medical attention. The endOclear catheter (Endoclear LLC, Petoskey, Michigan) is a novel device designed to clear mucus and debris from an ETT and restore luminal patency. We present 3 subsequent cases of life-threatening partial ETT occlusions recorded over a period of 6 months at Massachusetts General Hospital. After conventional methods (standard tracheal suctioning and bronchoscopy) failed, the endOclear was used, with successful restoration of the airways in all 3 cases. The respiratory conditions rapidly improved, and all 3 patients tolerated the ETT-cleaning maneuver. These results show that such a device is safe and easy to use during an emergency airway situation for efficient and rapid removal of secretions from obstructed ETTs by respiratory therapists.
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Affiliation(s)
| | | | | | | | | | - Jeremy Goverman
- Department of Surgery, Burn Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine
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Panigada M, Mietto C, Pagan F, Bogno L, Berto V, Gattinoni L. Monitoring anticoagulation during extracorporeal membrane oxygenation in patients with acute respiratory failure. Crit Care 2013. [PMCID: PMC3642433 DOI: 10.1186/cc12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Protti A, Cressoni M, Santini A, Langer T, Mietto C, Febres D, Chierichetti M, Coppola S, Conte G, Gatti S, Leopardi O, Masson S, Lombardi L, Lazzerini M, Rampoldi E, Cadringher P, Gattinoni L. Lung Stress and Strain during Mechanical Ventilation. Am J Respir Crit Care Med 2011; 183:1354-62. [DOI: 10.1164/rccm.201010-1757oc] [Citation(s) in RCA: 222] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Chiumello D, Cressoni M, Marino A, Gallazzi E, Mietto C, Berto V, Chierichetti M. Continuous central venous saturation monitoring in critically ill patients. Crit Care 2011. [PMCID: PMC3061669 DOI: 10.1186/cc9459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chiumello D, Mietto C, Berto V, Marino A, Gallazzi E, Tubiolo D. Lung recruitment and PEEP response in ARDS-related H1N1 virus patients. Crit Care 2010. [PMCID: PMC2934115 DOI: 10.1186/cc8417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Febres D, Langer T, Cressoni M, Protti A, Coppola S, Mietto C, Santini A, Lombardi L, Lazzerini M, Cadringher P, Bertoli P, Gattinoni L. Continuous urinary electrolyte measurement in a swine model of mechanical ventilation. Crit Care 2010. [PMCID: PMC2934088 DOI: 10.1186/cc8755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, Mancebo J, Guérin C, Ayzac L, Blanch L, Fumagalli R, Tognoni G, Gattinoni L. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 2009; 302:1977-84. [PMID: 19903918 DOI: 10.1001/jama.2009.1614] [Citation(s) in RCA: 331] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Post hoc analysis of a previous trial has suggested that prone positioning may improve survival in patients with severe hypoxemia and with acute respiratory distress syndrome (ARDS). OBJECTIVE To assess possible outcome benefits of prone positioning in patients with moderate and severe hypoxemia who are affected by ARDS. DESIGN, SETTING, AND PATIENTS The Prone-Supine II Study, a multicenter, unblinded, randomized controlled trial conducted in 23 centers in Italy and 2 in Spain. Patients were 342 adults with ARDS receiving mechanical ventilation, enrolled from February 2004 through June 2008 and prospectively stratified into subgroups with moderate (n = 192) and severe (n = 150) hypoxemia. INTERVENTIONS Patients were randomized to undergo supine (n = 174) or prone (20 hours per day; n = 168) positioning during ventilation. MAIN OUTCOME MEASURES The primary outcome was 28-day all-cause mortality. Secondary outcomes were 6-month mortality and mortality at intensive care unit discharge, organ dysfunctions, and the complication rate related to prone positioning. RESULTS Prone and supine patients from the entire study population had similar 28-day (31.0% vs 32.8%; relative risk [RR], 0.97; 95% confidence interval [CI], 0.84-1.13; P = .72) and 6-month (47.0% vs 52.3%; RR, 0.90; 95% CI, 0.73-1.11; P = .33) mortality rates, despite significantly higher complication rates in the prone group. Outcomes were also similar for patients with moderate hypoxemia in the prone and supine groups at 28 days (25.5% vs 22.5%; RR, 1.04; 95% CI, 0.89-1.22; P = .62) and at 6 months (42.6% vs 43.9%; RR, 0.98; 95% CI, 0.76-1.25; P = .85). The 28-day mortality of patients with severe hypoxemia was 37.8% in the prone and 46.1% in the supine group (RR, 0.87; 95% CI, 0.66-1.14; P = .31), while their 6-month mortality was 52.7% and 63.2%, respectively (RR, 0.78; 95% CI, 0.53-1.14; P = .19). CONCLUSION Data from this study indicate that prone positioning does not provide significant survival benefit in patients with ARDS or in subgroups of patients with moderate and severe hypoxemia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00159939.
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Affiliation(s)
- Paolo Taccone
- Dipartimento di Anestesia e Rianimazione, Fondazione IRCCS-Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena di Milano, 20122 Milan, Italy
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Protti A, Chiumello D, Cressoni M, Carlesso E, Mietto C, Berto V, Lazzerini M, Quintel M, Gattinoni L. Relationship between gas exchange response to prone position and lung recruitability during acute respiratory failure. Intensive Care Med 2009; 35:1011-7. [PMID: 19189081 DOI: 10.1007/s00134-009-1411-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 12/24/2008] [Indexed: 12/15/2022]
Abstract
PURPOSE To clarify whether the gas exchange response to prone position is associated with lung recruitability in mechanically ventilated patients with acute respiratory failure. METHODS In 32 patients, gas exchange response to prone position was investigated as a function of lung recruitability, measured by computed tomography in supine position. RESULTS No relationship was found between increased oxygenation in prone position and lung recruitability. In contrast, the decrease of PaCO(2) was related with lung recruitability (R(2) 0.19; P = 0.01). Patients who decreased their PaCO(2) more than the median value (-0.9 mmHg) had a greater lung recruitability (19 +/- 16 vs. 8 +/- 6%; P = 0.02), higher baseline PaCO(2) (48 +/- 8 vs. 41 +/- 11 mmHg; P = 0.07), heavier lungs (1,968 +/- 829 vs. 1,521 +/- 342 g; P = 0.06) and more non-aerated tissue (1,009 +/- 704 vs. 536 +/- 188 g; P = 0.02) than those who did not. CONCLUSIONS During prone position, changes in PaCO(2), but not in oxygenation, are associated with lung recruitability which, in turn, is associated with the severity of lung injury.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena di Milano, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
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Chiumello D, Berto V, Mietto C, Botticelli M, Chierichetti M, Tallarini F. Accuracy of central venous oxygen saturation with a fiberoptic catheter. Crit Care 2009. [PMCID: PMC4084120 DOI: 10.1186/cc7398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Chiumello D, Cressoni M, Chierichetti M, Tallarini F, Botticelli M, Berto V, Mietto C, Gattinoni L. Correction: Nitrogen washout/washin, helium dilution and computed tomography in the assessment of end expiratory lung volume. Crit Care 2009. [PMCID: PMC2689468 DOI: 10.1186/cc7743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Chiumello D, Mietto C, Berto V, Cressoni M, Lazzerini M, Gattinoni L. Effect of pleural effusion on gas exchange and response to positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome patients. Crit Care 2009. [PMCID: PMC4083925 DOI: 10.1186/cc7203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chiumello D, Cressoni M, Chierichetti M, Tallarini F, Botticelli M, Berto V, Mietto C, Gattinoni L. Nitrogen washout/washin, helium dilution and computed tomography in the assessment of end expiratory lung volume. Crit Care 2008; 12:R150. [PMID: 19046447 PMCID: PMC2646315 DOI: 10.1186/cc7139] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 10/07/2008] [Accepted: 12/01/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION End expiratory lung volume (EELV) measurement in the clinical setting is routinely performed using the helium dilution technique. A ventilator that implements a simplified version of the nitrogen washout/washin technique is now available. We compared the EELV measured by spiral computed tomography (CT) taken as gold standard with the lung volume measured with the modified nitrogen washout/washin and with the helium dilution technique. METHODS Patients admitted to the general intensive care unit of Ospedale Maggiore Policlinico Mangiagalli Regina Elena requiring ventilatory support and, for clinical reasons, thoracic CT scanning were enrolled in this study. We performed two EELV measurements with the modified nitrogen washout/washin technique (increasing and decreasing inspired oxygen fraction (FiO2) by 10%), one EELV measurement with the helium dilution technique and a CT scan. All measurements were taken at 5 cmH2O airway pressure. Each CT scan slice was manually delineated and gas volume was computed with custom-made software. RESULTS Thirty patients were enrolled (age = 66 +/- 10 years, body mass index = 26 +/- 18 Kg/m2, male/female ratio = 21/9, partial arterial pressure of carbon dioxide (PaO2)/FiO2 = 190 +/- 71). The EELV measured with the modified nitrogen washout/washin technique showed a very good correlation (r2 = 0.89) with the data computed from the CT with a bias of 94 +/- 143 ml (15 +/- 18%, p = 0.001), within the limits of accuracy declared by the manufacturer (20%). The bias was shown to be highly reproducible, either decreasing or increasing the FiO2 being 117+/-170 and 70+/-160 ml (p = 0.27), respectively. The EELV measured with the helium dilution method showed a good correlation with the CT scan data (r2 = 0.91) with a negative bias of 136 +/- 133 ml, and appeared to be more correct at low lung volumes. CONCLUSIONS The EELV measurement with the helium dilution technique (at low volumes) and modified nitrogen washout/washin technique (at all lung volumes) correlates well with CT scanning and may be easily used in clinical practice. TRIAL REGISTRATION Current Controlled Trials NCT00405002.
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Affiliation(s)
- Davide Chiumello
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena", via Francesco Sforza 35, 20122, Milano, Italy
| | - Massimo Cressoni
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Monica Chierichetti
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Federica Tallarini
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Marco Botticelli
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Virna Berto
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Cristina Mietto
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena", via Francesco Sforza 35, 20122, Milano, Italy
- Istituto di Anestesiologia e Rianimazione, Fondazione IRCCS – "Ospedale Maggiore Policlinico Mangiagalli Regina Elena" di Milano, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122, Milano, Italy
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