Transcript The Technique of RSI

Pediatric Resuscitation
Russian Field Hospital
Nias, Indonesia
4/05
Lecture Objectives
The goal of this module:
• Perform rapid cardiopulmonary assessment
• Recognize signs of respiratory distress,
respiratory failure, and shock
Progression of Respiratory
Failure and Shock
Various Conditions
Respiratory failure
Cardiopulmonary failure
Cardiopulmonary arrest
Shock
Comparison of Survival
100%
Survival
rate
50%
0%
Respiratory
arrest
Cardiopulmonary
arrest
Rapid Cardiopulmonary
Assessment
1. Evaluation of general appearance (mental
status, tone, responsiveness)
2. Physical examination of airway, breathing,
and circulation (ABCs)
3. Classification of physiologic status
Rapid cardiopulmonary assessment should be
accomplished in less than 30 seconds!
Pediatric Assessment Triangle
General Appearance
Evaluation of
General Appearance
• General color (“looks good” vs
“looks bad”)
• Mental status, responsiveness
• Activity, movement,
muscle tone
• Age-appropriate response
Breathing Evaluation
Physical Examination: Airway
• Clear
• Maintainable
• Not maintainable
without intubation
Evaluating Respirations
• Respiratory rate
• Respiratory effort (work of breathing)
• Breath sounds/air entry/tidal volume
— STRIDOR (inspiration)
— WHEEZE (expiration)
• Skin color and pulse oximetry
Rapid Cardiopulmonary Assessment:
Classification of Status
•Respiratory distress:
Increased work of breathing
•Respiratory failure:
Inadequate oxygenation
or ventilation
Cardiovascular Assessment
Cardiovascular Variables
Affecting Systemic Perfusion
Preload
Cardiac
output
Blood pressure
Systemic
vascular
resistance
Stroke
volume
Myocardial
contractility
Heart
rate
Afterload
Response to Shock
Vascular
resistance
Percent of control
140
100
60
20
Cardiac
output
Compensated
shock
Blood
pressure
Decompensated
shock
Decompensated Shock
Compensatory mechanisms fail to
maintain adequate cardiac output
and blood pressure
Physical Examination:
Circulation
•
•
Cardiovascular function
— Heart rate
— Pulses, capillary refill
— Blood pressure
End-organ function/perfusion
— Brain
— Skin
— Kidneys
Physical Examination:
Circulation
Typical Assessment Order:
— Observe mental status
— Feel for heart rate, pulse quality, skin
temperature, capillary refill
— Measure blood pressure
— (Measure urine output later)
Physical Examination:
Circulation
Evaluation of responsiveness
• A — Awake
• V — responsive to Voice
• P — responsive to Pain
• U — Unresponsive
Heart Rates in Children
Infant
85
220
300
Normal
Compensating?
SVT
60
Child
180
Normal
Compensating?
SVT
200
Physical Examination:
Circulation
•
•
•
Evaluation of skin perfusion
Temperature of extremities
Capillary refill
Color
— Pink
— Pale
— Blue
— Mottled
Palpation of Central
and Distal Pulses
Capillary Refill
Prolonged capillary refill (10 seconds) in a
3-month-old with shock
Physical Examination:
Circulation
Estimate of Minimum Systolic Blood Pressure
Age
Minimum systolic blood
pressure (5th percentile)
0 to 1 month
60 mm Hg
>1 month to 1 year
70 mm Hg
1 to 10 years of age
70 mm Hg + (2  age in years)
>10 years of age
90 mm Hg
Minimum Systolic BP by age
(5% of the range of normal)
90
80
70
60
50
minimum BP
40
30
20
10
0
0-30 days
1mon - 1 yr
1 yr - 10 yr
> 10 yrs
Physical Examination:
Circulation
•
•
Cardiovascular function
— Heart rate
— Pulses, capillary refill
— Blood pressure
End-organ function/perfusion
— Brain (Mental Status)
— Skin (Capillary Refill Time)
— Kidneys
Physical Examination:
Circulation
Evaluation of End-Organ Perfusion
Kidneys
• Urine Output
— Normal: 1 to 2 mL/kg per hour
— Initial measurement of urine in bladder
not helpful
Classification of
Physiologic Status: Shock
Early signs (compensated)
— Increased heart rate
— Poor systemic perfusion
Late signs (decompensated)
— Weak central pulses
— Altered mental status
— Hypotension
Septic Shock Is Different
• Cardiac output may be variable
• Perfusion may be high, normal, or low
• Early signs of sepsis/septic shock include
— Fever or hypothermia
— Tachycardia and tachypnea
— Leukocytosis, leukopenia, or increased
bands
Special Situations: Trauma
•
•
•
Airway and Breathing problems are more common
than Circulatory shock
Use the ABC or assessment triangle approach plus
— Airway + cervical spine immobilization
— Breathing + pneumothorax management
— Circulation + control of bleeding
Identify and treat life-threatening injuries
Special Situations: Trauma
Spinal
Precautions?
Pneumothorax?
Bleeding control?
Special Situations: Toxicology
•
•
•
•
Airway obstruction, Breathing depression, and
Circulatory dysfunction may be present
Use the ABC and assessment triangle approach, plus
watch for
— Airway: reduced airway protective mechanisms
— Breathing: respiratory depression
— Circulation: arrhythmias, hypotension,
coronary ischemia
Identify and treat reversible complications
Administer antidotes
Special Situations: Toxicology
Is the Patient
Awake enough
to maintain
airway?
Respiratory
Effort and
Rate?
Arrythmias?
Vascular Tone?
Ischemia?
Classification of Physiologic
Status: Cardiopulmonary Failure
Cardiopulmonary failure produces signs of
respiratory failure and shock:
• Agonal respirations
• Bradycardia
• Cyanosis and poor perfusion
Classification of Cardiopulmonary
Physiologic Status
• Stable
• Respiratory distress
• Respiratory failure
• Shock
— Compensated
— Decompensated
• Cardiopulmonary failure
Many Causes
Asthma, Shock
FB, Secretions
Toxins, etc.
Respiratory Distress
Compensated
Circulatory Distress
Compensated
Respiratory Distress
DECOMPENSATED
Circulatory Distress
DECOMPENSATED
RESPIRATORY FAILURE
CIRCULATORY FAILURE
FULL ARREST
DEATH
Rapid Cardiopulmonary
Assessment: Summary
•
•
•
•
Evaluate general appearance
Assess ABCs
Classify physiologic status
— Respiratory distress
— Respiratory failure
— Compensated shock
— Decompensated shock
— Cardiopulmonary failure
Begin management: support ABCs
Checkpoint
• Rapidly perform assessment
• Use the information to prioritize your
resuscitation efforts
• Remember the Pediatric Assessment Triangle
as we practice cases
Rapid Cardiopulmonary
Assessment Application
A 3-week-old infant arrives in the ED:
•
•
CC: Severe vomiting and diarrhea
Physical exam: Gasping respirations, bradycardia,
cyanosis, and poor perfusion
What ar the results of your RAPID ASSESSMENT?
What is the PHYSIOLOGIC STATUS?
What are the emergency interventions?
What is this Child’s
Assessment?
Rapid Cardiopulmonary
Assessment Application
Case Progression
•
Response to intubation and ventilation with 100%
oxygen:
— Heart rate: 180 bpm
— Blood pressure: 50 mm Hg systolic
— Pink centrally, cyanotic peripherally
— No peripheral pulses
— No response to painful stimuli
What is happening?
What is next treatment step?
Many Causes
Asthma, Shock
FB, Secretions
Toxins, etc.
Respiratory Distress
Compensated
Circulatory Distress
Compensated
Respiratory Distress
DECOMPENSATED
Circulatory Distress
DECOMPENSATED
RESPIRATORY FAILURE
CIRCULATORY FAILURE
FULL ARREST
DEATH
Rapid Cardiopulmonary Assessment
Application: Response to Therapy
• Vital signs improved
Pediatric Intubation
Andrew Garrett, MD
Division of Transport and Emergency Medicine
Goals
• Review of some basic concepts of pediatric
airway management
• Introduce/review RSI in a stress-free
environment
• Have a chance to practice intubation skills later
today
Review and Overview of
Airway Management
• Children at higher risk for hypoxia and
respiratory failure:
• Anatomic differences
• Higher metabolic rate
• Ambiguous symptoms of hypoxia
• Head trauma is common in pediatrics
• Limited practice of management skills
Airway Anatomic Differences
(Extrathoracic)
• Relatively larger tongue
• Tongue placed superiorly (C3-4)
• Angle of epiglottis angled away from larynx
• Vocal folds can trap ET tube
• Narrowest area at cricoid vs. glottis
Anatomy
epiglottis
True VC
False VC
cartilage
trachea
esophagus
Cricoid Cartilage
Airway Anatomic Differences
(Intrathoracic)
• Compliance of conducting airways at high flow rates
• Fewer, smaller alveoli (< 8 yrs)
• Smaller FRC (functional reserve)
• Decreased diffusion
• Metabolic Rate
• 2 x adult oxygen consumption rate
• Shorter tolerance of apnea
Can your patient be managed
without intubation?
• The A of the ABC’s
• Chin lift
• Jaw thrust
• Suction
• Oropharyngeal airway
• Nasopharyngeal airway
Intubation Overview
• Positioning
• Choose the tube size
• Choose the blade size and type
• Insertion distance
• Sedation
• Paralysis
• Equipment
Positioning the Patient
• Alignment of the 3 axis
• Oropharynx, Pharynx, Trachea
P
O
T
Positioning thoughts
• Don’t rush this part…
• Be careful of cervical spine injury
• Infant
• Large occiput, gentle lift of shoulder
• Use a folded towel
• Adolescents and Adults
• Extension of head on a towel support
Proper alignment for
intubation (almost…)
Tube Size
• Cuffed vs. Uncuffed (age cutoff ~8 yrs)
• Remember pediatric airway anatomy
• ( Age + 4 ) / 4 for > 1 year old
• 3.5 for newborn
• 2.5 for preemie (< 28 weeks)
• 3 for in between
Choose your blade
• Macintosh
• Into the vallecula, lift the epiglottis from its
foundation to visualize the trachea
• Miller
• Past the epiglottis, directly lift the epiglottis
with traction to visualize
Macintosh vs. Miller
Preemie
0
Neonate
0
<2 yrs
1
2-6 yrs
1.5
2
6-12 yrs
2
3
>12 yrs
3
Insertion Distance
• Guidelines:
•< 4 kg
•>4 kg
weight (kg) + 6 *
3 x ET tube size
• Distance to mandibular ridge
• * usually a slightly high position
Confirmation of Placement
• Auscultation
• Capnography
• Radiography
• Visualization
The Technique of R.S.I.
• Keep it simple, not stressful
• In a nutshell:
• What drug has been proven to increase the
chance of successfully performing
endotracheal intubation?
The Technique of R.S.I.
• Keep it simple, not stressful
• In a nutshell:
• What drug has been proven to increase the
chance of successfully performing
endotracheal intubation?
• A paralytic agent such as succinylcholine
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
• The rest of the drugs are because we’re nice
(but that’s optional!)
– SEDATIVE
The Technique of R.S.I.
• Therefore, all RSI consists of is using a paralytic to
increase the chance of being successful
• The rest of the drugs are because we’re nice (but
that’s optional!)
– SEDATIVE
• Etomidate, benzos, propofol, etc.
• Serves to make it a more pleasant
experience
• Don’t need to duplicate efforts
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
• Or because we think they should help
prevent a side effect
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
• Or because we think they should help
prevent a side effect
– ATROPINE
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
• Or because we think they should help
prevent a side effect
– ATROPINE
• Dryer work environment
• Heart rate stabilization
The Technique of R.S.I.
• Therefore, all RSI consists of is using a
paralytic to increase the chance of being
successful
• Or because we think they should help
prevent a side effect
– LIDOCAINE *
The Technique of R.S.I.
• Therefore, all RSI consists of is using a paralytic to
increase the chance of being successful
• Or because we think they should help prevent a
side effect
– LIDOCAINE *
• A bit questionable
• May help prevent ICP increase
The Technique of R.S.I.
• Don’t forget the basics though:
• BVM skills
• Positioning
• Preparedness
• Don’t rush, RSI is not a rescue airway technique, use
BVM until you are ready
RSI: Rapid Sequence
Intubation
• “full stomach rule” in urgent intubations
• Preoxygenation 1-5 minutes with 100%
• Utilize Sellick maneuver
• Choreography of medications
• Confidence of providers to adequately ventilate
after medications are given.
• Rule out airway compression from mass effect
if paralysis is being considered.
Sedation
• Fentanyl
• Midazolam
• Diazepam
• Ketamine*
1-2 mcg/kg IV
0.1 mg/kg IV
0.1 mg/kg IV
0.5-2 mg/kg IV
•* can be tripled for IM dosing
Paralysis
•
•
Succinylcholine *
1-2 mg/kg IV
• 5 to 10 min
Rocuronium
•
1
mg/kg IV
~30-45 minutes
•
Pancuronium
•
Vecuronium
0.1 mg/kg IV
• ~1-2 hours
•
0.1 mg/kg IV
~30 minutes
• * can be doubled for IM dosing
Plans B and C?
•
After deciding to undertake RSI
• Make sure you have a backup/failed airway plan
–LMA
–Combitube
–Fiberoptic, Bougie, Digital
• The final option
–Surgical airway
• Percutaneous or Open
Equipment and Technique
Take a moment to double check
your equipment and medications
before you start
The flow of things
• Examination (esp. neuro status, etc.)
• Equipment checklist
• Preoxygenate
• Sedate, Paralyze, Intubate, Secure
• Confirm placement
• Continuous evaluation of placement
Tips from the Field:
• Know the size and depth of the tube
• Confirm placement with every move
• Tape tape tape!
• When in doubt, take it out and bag!
• Don’t forget the CXR
• Check your battery and bulb
Ready to Intubate?
Ideal
Reality!
circumstances!
Circulation
• After the RAPID ASSESSMENT is done
• After BREATHING interventions are started
• Priorities
• STOP major bleeding
• Get IV access
– IV, IO, umbilical vein
– We will review techniques
Circulation
• Priorities
• IV Fluids
– Preload, afterload
– Saline 20 mL per kg
– Give it fast
– Repeat assessments and vital signs
– Repeat if necessary
– Consider blood?
IV Fluids
Preload
Cardiac
output
Blood pressure
Systemic
vascular
resistance
Stroke
volume
Myocardial
contractility
Heart
rate
Afterload
Cardiovascular Cases
Objectives
• Differentiate shock from hypotension
• Distinguish compensated from decompensated
shock
• Outline appropriate shock management
• Identify and manage selected pediatric
dysrhythmias
Shock and Hypotension
• Shock is inadequate perfusion and oxygen
delivery.
• Hypotension is decreased systolic blood
pressure.
• Shock can occur with increased, decreased,
or normal blood pressure.
Recognition of Shock
Compensated:
Decompensated:
•
• Altered level of consciousness
(ALOC)
Normal level of
consciousness
• Tachycardia
• Profound tachycardia, or
bradycardia
• Normal or delayed
perfusion
• Delayed perfusion
• Normal or increased BP
• Hypotension
Management of Shock
Interventions:
•
•
•
•
•
•
Open airway
Provide
supplemental
oxygen
Support ventilation
Shock position
Vascular access/fluid
resuscitation
Vasopressor support
9-month-old infant
• A 9-month-old
presents with 3
days of vomiting,
diarrhea and poor
oral intake.
9-month-old infant
Appearance
Work of
Breathing
Agitated, makes
eye contact
No retractions or
abnormal airway
sounds
Circulation to Skin
Pale skin color
Initial Assessment
• Airway - Open and maintainable
• Breathing - RR 50 breaths/min, clear lungs,
•
•
•
good chest rise
Circulation - HR 180 beats/min; cool, dry, pale
skin; CRT 3 seconds
Disability - AVPU=A
Exposure - No sign of trauma, weight 8 kg
What is this child’s physiologic state?
What are your treatment priorities?
•
•
Assessment: Compensated shock, likely due to
hypovolemia with viral illness
Treatment priorities:
• Provide oxygen, as tolerated
• Obtain IV access en route
–Provide fluid resuscitation
• 20 ml/kg of crystalloid, repeat as needed
• 160 ml normal saline infused
• HR decreased to 140 beats/min
• Patient alert and interactive, receiving second
bolus on emergency department arrival
15-month-old child
• A previously healthy
15-month-old child
presents with 12
hours of fever, 1 hour
of lethargy and a
“purple” rash.
15-month-old child
Work of
Breathing
Appearance
No eye contact,
lies still with no
spontaneous
movement
No retractions or
abnormal airway
sounds
Circulation to Skin
Pale skin color
Initial Assessment
•
•
•
•
•
Airway - Open
Breathing - RR 60 breaths/min, poor chest rise
Circulation - HR 70 beats/min; faint brachial pulse;
warm skin; CRT 4 seconds; BP 50 mm Hg/palp
Disability - AVPU=P
Exposure - Purple rash, no sign of trauma, weight 10 kg
What is your assessment of this patient?
What is her problem?
• This patient is in decompensated shock.
What are your treatment and transport priorities
for this patient?
Treatment Priorities
•
•
•
Begin BVM ventilation with 100% oxygen.
Fluid resuscitation:
• IV/IO access on scene
• 20 ml/kg of crystalloid, repeat as needed en route
Vasopressor therapy
Patient received 20 ml/kg (200 ml) with no
change in level of consciousness, HR or BP.
What are your treatment priorities now?
• Consider endotracheal intubation
• Provide second 20 ml/kg fluid bolus
• Vasopressor support
3-year-old toddler
• Toddler is found cyanotic and unresponsive
• Child last seen 1 hour prior to discovery
• Open bottle of blood pressure medicine found
next to child
3-year-old toddler
Appearance
Work of Breathing
No spontaneous
activity;
unresponsive
Gurgling breath sounds
Circulation to Skin
Cyanotic, mottled
Initial Assessment
• Airway - Partial obstruction by tongue
• Breathing - RR 15 breaths/min, poor air entry
• Circulation - HR 30 beats/min; faint femoral
•
•
pulse; CRT 3 seconds; BP 50/30 mm Hg
Disability - AVPU=P
Exposure - No sign of trauma
•
The monitor shows the following rhythm.
What are your treatment priorities for this patient?
Treatment Priorities
• Open airway
• BVM ventilation/consider intubation
• Chest compressions
• IV/IO access on scene
– Medications (epinephrine, atropine)
– Possible antidote - naloxone
– Fluid resuscitation
• Check glucose
• Rapid transport
• Patient’s heart rate improved to 70 beats/min
with assisted ventilation.
• Color, CRT and pulse quality improves.
• After BVM, patient’s RR increases to 20
breaths/min, good chest rise
• Rapid glucose check 100 mg/dL
12-month-old child
• You arrive at the house of a 12-month-old
•
•
child.
Mother states the child has a history of heart
disease and has been fussy for the last 3
hours.
Mother states the child weighs 10 kg.
12-month-old child
Appearance
Alert but agitated
Work of
Breathing
Mild retractions
Circulation to Skin
Lips and nailbeds blue
• On initial assessment, you note clear breath sounds,
a RR of 60 breaths/min and a heart rate that is too
rapid to count.
What rhythm does the monitor show?
How can you distinguish SVT from sinus
tachycardia?
SVT
Sinus Tachycardia
SVT versus Sinus
Tachycardia
SVT (Supraventricular
Tachycardia)
• Vague history of irritability,
poor feeding
Sinus Tachycardia
• Cardiac monitor: QRS
complex narrow; R to R
interval regular; no visible P
waves
• HR > 200 beats/min
• Cardiac monitor: QRS complex
narrow; R to R interval varies; P
waves present and upright
• History of fever, vomiting/diarrhea,
hemorrhage
• HR < 220 beats/min
Treatment Priorities
•
•
•
Supplemental oxygen
Obtain IV access
Convert rhythm based on hemodynamic stability
– Stable: vagal maneuvers or adenosine
– Unstable:
• IV /IO access obtained - adenosine
• No IV/IO and unconscious - synchronized
cardioversion
• Blow-by oxygen administered
• IV started
• Adenosine 0.1 mg/kg (1mg), given rapid
IVP with 5 ml saline flush
• Five seconds of asystole, followed by
conversion to NSR
Conclusion
•
•
•
Cardiovascular compromise in children is often
related to respiratory failure, hypovolemia,
poisoning or sepsis.
Management priorities for shock include airway
management, oxygen and fluid resuscitation.
Treat rhythm disturbances emergently only if signs
of respiratory failure or shock are present.
Advanced Topics
Two Thumb–Encircling Hands Technique
Preferred
Effective Bag-Mask Ventilation
Is an Essential BLS Skill
• Use only the amount of force and
•
•
•
tidal volume needed to make the
chest rise
Avoid excessive volume
or pressure
Increased inspiratory time may
reduce gastric inflation
Cricoid pressure may reduce gastric
inflation
Cricoid cartilage
Occluded esophagus
Cervical vertebrae
2-Rescuer Bag-Mask Ventilation
•
•
•
One rescuer uses both
hands to open the airway
and maintain a tight
mask-to-face seal
The second rescuer
compresses the manual
resuscitator bag and
may apply cricoid pressure
if appropriate
Both rescuers verify
adequate chest expansion
Prehospital Tracheal Intubation vs
Bag-Mask Ventilation
• Bag-mask ventilation may be as
•
•
•
effective as intubation if transport
time is short
Tracheal intubation requires
training and experience
Confirmation of tracheal
tube position strongly
recommended
Monitoring of quality
improvement important
Complications of
Prehospital Tracheal Intubation
•
•
•
Successful tracheal intubation rate: 57%
Intubation attempts increased time at the scene by
2 to 3 minutes
Unrecognized tube displacement or misplacement: 8%
— Esophageal intubation: 2%
— Unrecognized extubation: 6%
— Esophageal intubation or unrecognized extubation fatal
(for 14 of 15 patients)
Gausche. JAMA. 2000;283:783.
Confirmation of Tracheal Tube Placement
in Pediatric Advanced Life Support
• Visualize tube through cords
• Assess breath sounds, chest rise bilaterally
• Secondary confirmation:
— Oxygenation (oximetry)
— Exhaled CO2 (capnography)
Tube Confirmation
• No single confirmation device or examination
•
•
•
technique is 100% reliable
Detection of exhaled CO2 is reliable in patients
weighing >2 kg with a heart rate
Exhaled CO2 can be helpful in cardiac arrest
Confirmation of tube position is particularly
important after intubation and after any patient
movement
Insertion of the Laryngeal
Mask Airway in Children
• The LMA consists of a tube with a
•
cuffed mask at the
distal end.
The LMA is blindly introduced into
the pharynx until resistance is met;
the cuff is then inflated and
ventilation assessed.
Use of Laryngeal Mask Airway in
Pediatric Advanced Life Support
• Extensive experience with pediatric and adult
patients in the operating room
• An acceptable alternative to intubation of the
unresponsive patient when the healthcare
provider is trained
• Contraindicated if gag reflex intact
• Limited data outside the operating room
(Class Indeterminate)
Intraosseous Needles Are Recommended
for Patients >6 Years of Age
• Successful use of intraosseous needles has
been documented in older children and
adolescents
• Devices for adult use are commercially
available
• “No one should die because of lack of
vascular access”
Drug Therapy for Cardiac Arrest
• Epinephrine: the drug of choice
— Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg)
— Do not routinely use high-dose (1:1,000)
—
—
epinephrine
Good at getting heart rates to return
Poor long term outcome
Resuscitation of the Newly Born
Outside the Delivery Room
•
•
•
Priority: Establish effective ventilation
Provide chest compressions if heart rate is <60 bpm despite
adequate ventilation with 100% oxygen for
30 seconds
If meconium is observed in amniotic fluid:
— Deliver head and suction pharynx (all infants)
— If infant is vigorous, no direct tracheal suctioning
— If respirations are depressed or absent, poor tone, or HR
<100 bpm, suction trachea directly
Potentially Reversible
Causes of Arrest: 4 H’s
• Hypoxemia
• Hypovolemia
• Hypothermia
• Hyper-/hypokalemia and metabolic causes
(eg, hypoglycemia)
Potentially Reversible
Causes of Arrest: 4 T’s
• Tamponade
• Tension pneumothorax
• Toxins/poisons/drugs
• Thromboembolism (pulmonary)