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Medication Management
Clinical Practice Guidelines
TITLE: IV FLUID ADMINISTRATION IN INFANTS, CHILDREN
AND ADOLESCENTS
NUMBER: 80.30
Effective Date:
Pages (1 of 14)
December 3, 2013
Applies To: Pediatric Inpatient and Ambulatory Clinic, ED (exclusions: NICU)
GUIDING PRINCIPLES & VALUES
The optimal composition of intravenous (IV) fluids for use in infants and children has
been widely discussed following a 2009 safety bulletin issued by ISMP Canada
highlighting the potential risk of fatal iatrogenic hyponatremia, with the use of hypotonic
IV fluids.
Fluid therapy restores circulation by expanding extracellular fluid (ECF). Sodium is the
major cation of the ECF and, together with the chloride anion, constitutes the major
effective osmolality of that space. Potassium and phosphate are the two major
intracellular ions, and the two compartments are separated by a semi-permeable
membrane which allows free flow of water between the intracellular fluid (ICF) and the
ECF, with no osmolar gradient. Any minor increase in osmolality is sensed by the
osmoreceptors of the hypothalamus, and causes the release of antidiuretic hormone
(ADH) by the pituitary gland, and secretion of concentrated urine. Lowering serum
osmolality normally inhibits ADH release and causes excretion of dilute urine. ADH is
also released in response to reduced plasma volume.
In hospitalized patients, salt and water homeostasis is frequently abnormal.
Hyponatremia is the most common electrolyte abnormality, indicating a low serum
osmolality and an expanded ICF compartment in most situations. An acute reduction in
sodium can result in cerebral edema and brain stem herniation, and has been observed
with the administration of hypotonic IV fluids in children, especially in the perioperative
period.
Historically, maintenance IV therapy was calculated based on normal physiological
estimates of average body requirement for water and sodium in healthy infants and
children. These requirements were best met with hypotonic solutions, such as
IV FLUID ADMINISTRATION IN HOSPITALIZED INFANTS, CHILDREN &
ADOLESCENTS - Guideline 80.30
Page 2 of 14
Dextrose 3.3% + 0.3% NaCl (“D 2/3 & 1/3”) or D5W + 0.2% NaCl. There are many
physiological stressors that can significantly alter IV fluid requirements (e.g. pain,
trauma, sepsis, and positive pressure ventilation). One response to these physiological
stressors is activation of the hypothalamo-pituitary adrenal axis leading to ADH
secretion, subsequent water retention, and thus increased risk of hyponatremia.
Isotonic fluids which contain no electrolyte-free water, will reduce, but not eliminate this
risk. Studies have shown that intra-operative volume expansion with isotonic fluids
results in the excretion of hypertonic urine and increases the risk of hyponatremia; this
process is referred to as desalination. The use of hypotonic fluid in the post operative
period increases the risk of developing acute hyponatremia.
DEFINITIONS
Acute Hyponatremia
A decrease in serum sodium (Na) to less than 132 mmol/L within 48 hours.
Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)
A disorder in which water excretion is partially impaired because of the inability to
suppress anti-diuretic hormone (ADH).
Isotonic Solution
Examples of isotonic solutions include 0.9% NaCl and Ringer’s Lactate. Isotonic
solutions do not alter the osmotic pressure of the extracellular fluid and hence cause no
net fluid shift across the cell membrane.
Hypotonic Solution
Examples of IV hypotonic solutions include 0.45% NaCl, 0.225% NaCl and D5W. The
introduction of a hypotonic solution into the body causes a net shift of fluid from the
extracellular compartment to the ICF.
Definition
Serum Sodium (mmol/L)
Normal/reference range
133-148
Moderate Hyponatremia
Age 0-4 months: 126-132
Age greater than 4 months: 130-132
Age 0- 4 months: Less than 126
Age greater than 4 months: Less than 130
Reduction in serum Na to less than 132 mmol/L in
48 hours
Severe Hyponatremia*
Acute Hyponatremia
Moderate Hypernatremia
149-154
Severe Hypernatremia*
Greater than 154
*IWK Lab reported critical values for children’s health program (excluding 6L and PICU)
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GUIDELINES
The purpose of this clinical practice guideline is to facilitate the appropriate prescribing
and management of IV fluid administration in infants, children and adolescents. The
target users are physicians, nurses, pharmacists and paramedics.
This guideline is intended to be used when prescribing IV maintenance fluids, defined
as those estimated to replace normal physiologic urine output and insensible losses, in
children not receiving enteral fluid or with reduced oral intake. Recommendations for
patients requiring a fluid bolus (e.g. dehydrated patients) are also included. Intravenous
fluid replacement for gastrointestinal (GI) losses and other ECF compartment losses
should be treated with IV fluids containing the same electrolyte composition as the fluid
that is being lost. (See Appendix I)
EXCLUSIONS
These guidelines may be superseded by subspecialty orders for specific conditions
(e.g. hematology/oncology patients, patients with cardiac, renal or hepatic failure, a
suspected metabolic disorder, diabetic ketoacidosis (DKA), acute burn patients,
neonates). These guidelines do NOT apply to patients in the Neonatal Intensive
Care Unit (NICU).
GENERAL PRINCIPLES
1. Any hospitalized child requiring IV fluids should be considered at risk of non
physiological (inappropriate) ADH secretion. Key risk groups include children
undergoing surgery and those with acute medical illnesses such as meningitis,
encephalitis, pneumonia and bronchiolitis. In patients who are not acutely
dehydrated (i.e. fluid bolus not required); IV fluids may be administered at 75% of
the calculated normal maintenance requirements (see Assessment Part 1). The use
of 0.9% NaCl or Ringer’s Lactate is recommended. The type of fluid chosen should
be based on the guidelines below.
2. Oral fluid intake must be included in the estimation of fluid requirements. Most oral
fluids are very hypotonic (i.e. low sodium concentration – for example, a 250 mL
glass of fruit juice contains less than 0.1 mmol of sodium). The volume and
concentration of sodium in both IV and oral fluids are important contributors to
development of hyponatremia.
3. TPN and most enteral fluid preparations are low in sodium (less than 40 mmol/L)
and may be a contributing source of electrolyte-free water. For example, most infant
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enteral formulas contain ~8 mmol of sodium per litre. Patients on long-term TPN
who are not acutely ill are not at increased risk of developing hyponatremia.
4. Infants and young children who have limited glycogen stores may require solutions
with dextrose to prevent hypoglycemia and ketosis.
5. Infants and children with cardiac or renal failure or hepatic failure with ascites have
chronically low plasma sodium values because of water retention and/or
abnormalities of the renin/angiotensin mechanism. These patients have chronic
hyponatremia and are not at risk for the development of cerebral edema.
ASSESSMENT (see Figure 1)
Part 1: Calculation of Maintenance IV Fluids
1.1
Before intravenous (IV) therapy is ordered:




1.2
Obtain vitals (HR, BP, RR, Temp)
Weigh patient and determine hydration status (see Part 2 if dehydration
present)
Measure serum electrolytes (Na, K+, Cl), glucose, urea, and SCr if IV therapy
for greater than 12 hours is anticipated.
Electrolyte measurements are not mandatory for routine short-term perioperative IV fluids (less than 24 hours)
Calculate Total Fluid Intake (TFI)

Traditional maintenance is calculated using the 4-2-1 Rule. See table below.
Patient’s Weight
0-10 kg
11-20 kg
Greater than 20 kg
mL/hour
4 x patient’s weight (kg)
2 x (patient’s weight – 10) + 40
1 x (patient’s weight – 20) + 60
For example: if a patient’s weight is 17.3 kg, to calculate traditional maintenance
IV fluid requirements: 2 x (17.3 kg – 10) + 40 = 54.6 mL/h. Therefore, run IV at
55 mL/hour.

In some hospitalized patients, ~75% of the calculated TFI is preferred. For
example, PICU patients receiving positive pressure ventilation are often
administered 75% maintenance. In this scenario, the IV rate above would be
calculated as 0.75 (75%) x 55 mL/hour = ~41 mL/hour.
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
If the child is also taking oral fluids, ensure that this is subtracted from the
intravenous total ordered.

Limit hypotonic oral fluids, especially if Na+ is less than 138 mmol/L or there is a
high risk of SIADH. Risk factors for SIADH include: surgery, CNS disease (e.g.
infection, trauma, hemorrhage), pulmonary disease (e.g. pneumonia, RSV
bronchiolitis), drugs that enhance ADH release or effect (e.g. carBAMazepine,
cyclophosphamide), response to fever, sepsis, pain, stress or anxiety. Orange
juice, soda pop (e.g. gingerale, cola) have less sodium than milk or sports drinks
such as Gatorade® or Powerade®.

Include TFI (IV/PO) in written orders to avoid excess free water intake.

Consider other factors that may increase or decrease a child’s fluid needs. For
example, fever, agitation, tachypnea, and high output renal failure may increase
a child’s needs for fluids, while inactivity and ventilation may decrease their
needs. Adjustments to maintenance fluid calculations may be needed in such
circumstances.
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1.3 Choose the IV fluid
Condition
Awaiting lab results
Peri-operative
IV Fluid
0.9% NaCl or Ringer’s
Lactate
0.9% NaCl or Ringer’s
Lactate
0.9% NaCl or Ringer’s
Lactate
Na (mmol/L)
154 (0.9%
130 (Ringer’s
NaCl)
Lactate)
154 (0.9%
130 (Ringer’s
NaCl)
Lactate)
154 (0.9%
130 (Ringer’s
NaCl)
Lactate)
Serum Na less than
138 mmol/L,
maintenance
Serum Na 138-144
0.9 % NaCl, 0.45% NaCl or 77 (0.45%
130 (Ringer’s
mmol/L, maintenance
Ringer’s Lactate
NaCl)
Lactate)
Serum Na 145-150
0.45% NaCl or Ringer’s
77 (0.45%
130 (Ringer’s
mmol/L, maintenance
lactate
NaCl)
Lactate)
Serum Na greater
0.2% NaCl: Consider
34 (0.2% NaCl)
than 150 mmol/L(due
Specialist consultation
to salt gain)*
Serum Na greater
0.9% NaCl: Nephrology
154 (0.9% NaCl)
than 150 mmol/L(free
Consult required
water depleted)**
 DO NOT use D5W, D10W, D5W + 0.2% NaCl or Dextrose 3.3% + 0.3% NaCl
without appropriate specialty consultation.
 Solutions with added dextrose may be required based on patient age and blood
glucose level
 Use solutions containing dextrose 5% in most children less than 1 year of age
 Add KCl 20 mmol/L if serum K+ normal and patient has voided. Pre-mixed bags
of 0.9% NaCl with 20 mmol/L K+ or 40 mmol/L K+ or Ringer’s Lactate with 20
mmol/L K+ or 40 mmol/L K+ are available from Stores.
*Patients with hypernatremia due to salt gain should receive hypotonic fluids.
**Patients with severe hypernatremia due to dehydration (free water depleted) are at
risk of cerebral edema with rapid rehydration using hypotonic saline. Nephrology
consult is required.
1.3.1 3.3% Dextrose + 0.3% NaCl has been removed from all pediatric units, with the
exception of Pediatric Nephrology. D5W, D5W + 0.2% NaCl or D10W are
considered to be extremely hypotonic solutions and should not be used as
maintenance IV fluids. Patients with free water deficit may require
administration of these types of hypotonic solutions and in such cases,
consultation with a specialist is recommended.
1.3.2 Only 0.9% NaCl or Ringer’s Lactate should be used for IV fluid boluses in
patients with impending shock or significant ECF contraction.
1.3.3 GI tract losses should be replaced with 0.9% NaCl or Ringer’s Lactate.
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1.3.8 Patients with hypernatremia have either a water loss (dehydration) or salt gain
(the use of IV solutions with a high sodium concentration). Infants and young
children with severe hypernatremia due to dehydration (free water loss) are at
risk for the development of cerebral edema with rapid rehydration when
hypotonic fluid is used. The deficit should be replaced slowly, initially with 0.9%
NaCl. A Nephrology consult is required. Patients with hypernatremia due to salt
gain may receive hypotonic fluids such as 0.2% NaCl.
1.3.9 Perioperative fluids should only be in the form of isotonic solutions (0.9% NaCl or
Ringer’s Lactate). When it is determined that IV fluid is no longer required, the IV
should be discontinued or reduced and enteral fluids encouraged.
1.3.10 Although the data on acute hyponatremia comes from case reports and case
series, the limited number of studies suggest that the use of isotonic saline is
less likely to result in hyponatremia and does not result in hypernatremia.
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Part 2: Special Considerations in the Treatment of Dehydration with IV Fluids
Note: For guidelines concerning the use of oral fluids for gastroenteritis see Canadian
Pediatric Society (CPS) recommendations:
www.cps.ca/english/statements/N/N06-01.htm
2.1
Determine the water deficit
Severity
Minimal
Age less than 1 year
% Water
Water Deficit
Deficit
(mL/kg)
Less than 5
% Water
Deficit
Less than 3
Mild
5
50 mL/kg
3
Moderate
10
100 mL/kg
6
Severe
15
150 mL/kg
9
2.2
Determine the need for IV Fluid Bolus
YES – if shock or impending shock
 20 mL/kg of 0.9% NaCl or Ringer’s
Lactate over 15-30 minutes
 May repeat if circulatory
compromise not resolved
2.3
Age 1 year and older
Water Deficit
Clinical Signs
(mL/kg)
Thirst, mild
oliguria
30 mL/kg
Dry mucous
membranes,
concentrated
urine
60 mL/kg
Loss of skin
turgor, severe
thirst, sunken
eyes &
fontanelles
90 mL/kg
Low BP, poor
circulation,
CNS
changes,
fever

NO
Unnecessary boluses may cause
increased sodium loss in the urine
Laboratory Monitoring



Measure blood gases, electrolytes (Na, K+, Cl), BUN, SCr and glucose.
If SCr is elevated, and patient has not received a diuretic within the last 24
hours, send a urine sample for urine Na and urine Cr.
If SCr is elevated, and patient has received a diuretic within the last 24 hours,
send a urine sample for urine Urea and urine Cr.
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
2.4
Consider pseudohyponatremia: an apparent decrease in serum sodium
occurring when the mass of the non-aqueous components of serum is
increased by severe hyperlipidemia or hyperproteinemia.
Determine need for specialized fluid management
2.4.1 Acute symptomatic hyponatremia




Acute symptomatic hyponatremia is a medical emergency and requires
immediate treatment to prevent seizures, apneas and brain stem herniation
from occurring. Appropriate consultation is required.
Symptoms of cerebral edema secondary to hyponatremia include lethargy,
decreased level of consciousness, vomiting and headache.
Most cases of acute symptomatic hyponatremia occur in patients that have a
decrease in serum sodium to less than 125 mmol/L within 48 hours, but it can
occur in patients with a higher serum sodium.
Any new onset seizures in a patient receiving hypotonic IV fluids should be
investigated as possible acute hyponatremia.
2.4.2 Hypernatremic states

2.5
Order IV fluids to correct deficit






2.6
Follow guidelines and consult appropriately.
Re-assess hydration status after bolus.
Re-weigh patient after bolus, after “arm board” in place, or on new unit.
Determine fluid maintenance requirements
Determine remaining deficit (if any)
Plan to correct remaining deficit over 24 to 48 hours. Order IV rate calculated
to provide maintenance plus correct estimated deficit.
Use 0.9% NaCl or Ringer’s Lactate until deficit is corrected. Add potassium
20-40 mmol/L as determined by serum potassium.
Order IV fluids to replace ongoing abnormal losses

In addition to providing maintenance and deficit replacement, measure and
replace on-going abnormal losses with a fluid that matches the composition of
losses. (see Appendix I for Composition of Common Body Fluids)
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
GI tract losses (from nausea/vomiting) should be replaced with IV isotonic
fluid (0.9% NaCl or Ringer’s Lactate).
MONITORING
Patients receiving maintenance IV fluids or IV fluids to replace ongoing losses should
have daily measurements of serum electrolytes and glucose. If results are abnormal,
consider rechecking every 4-6 hours, or sooner if serum Na is below 132 mmol/L.
Any patient receiving IV fluids greater than 50% of maintenance should have accurate
daily intake and output (ins/outs) recorded and, where possible, daily weights. Strict
ins/outs are only required under the recommendation of the attending physician.
STORAGE/LABELLING OF IV SOLUTIONS
Each care area should develop a method to ensure that the ordering, labeling, storage
and usage of intravenous fluids are monitored.
D5W and D10W should NOT be available on care areas due to their extreme
hypotonicity. Some exceptions may apply. If there is a need to stock these solutions,
the hypotonic solution should be clearly labeled as such.
D5W + 0.2% NaCl (including versions with added K+) should only be available on care
areas likely to treat and monitor demonstrable free water deficit or sodium overload (e.g.
nephrology). In those areas, these fluids should be kept separate from other IV fluids
and clearly labeled as a “high risk hypotonic solution”, to be used only after consultation
with appropriate service (e.g. PICU, Nephrology, Endocrinology).
Dextrose 3.3 + 0.3% NaCl is reserved to Nephrology and must be kept separate from
other IV fluids and clearly labeled as a “high risk hypotonic solution”, to be used only
after consultation with appropriate service (Nephrology).
D5W, D10W, D5W + 0.2% NaCl (+ any additives) and Dextrose 3.3% + 0.3% NaCl (+
any additives) have been added to the IWK’s list of High Alert Medications (refer to
Medication Management Policy 25.05) and require an independent double check and
signature prior to administration.
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EDUCATION
Each care area is be responsible for developing a method to educate all staff on
appropriate prescribing and monitoring of IV fluids in hospitalized infants, children and
adolescents and to ensure guidelines are followed.
RELATED DOCUMENTS
Medication Management Policy 25.05 High Alert Medication – Independent Double
Check
8.0 REFERENCES
Patient safety alert 22: Reducing the risk of hyponatremia when administering
intravenous infusions to children. National Patient Safety Agency (NHS) March 2007:
www.npsa.nhs.uk/health/alerts
Intravenous 0.18% saline/4% glucose solution (“hypotonic saline”) in children: reports of
fatal hyponatremia – do not use in children aged 16 years or less, except in specialist
settings under expert medical supervision. MHRA Drug Safety Update October 2012,
vol 6, issue 3: A2
Hospital-Acquired Acute Hyponatremia: Two Reports of Pediatric Deaths. ISMP
Canada Safety Bulletin. Oct 2009; 9 (7): 1-4.
Montanana, PA, et al. The use of isotonic fluid as maintenance therapy prevents
iatrogenic hyponatremia in pediatrics: A randomized, controlled open study. Pediatr Crit
Care Med. 2008; 9 (6): 589-97.
Holliday,MA et al. Fluid therapy for children: facts, fashions and questions. Arch Dis
Child. 2007; 92: 546-50.
Armon, K, et al. Hyponatraemia and hypokalaemia during intravenous fluid
administration. Arch Dis Child 2008; 93: 285-7.
Skippen, P. Fluid Management in Hospitalized Children. Preventing Iatrogenic
Hyponatremia. BC Children’s Hospital. 2008.
Fluid and Electrolyte Administration in Children, Clinical Practice Guideline, The
Hospital for Sick Children. Toronto, Ontario, Canada. 2008; 21:46.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be
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IV FLUID ADMINISTRATION IN HOSPITALIZED INFANTS, CHILDREN &
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Intravenous Fluids Clinical Practice Guideline, Royal Children’s Hospital. Melbourne,
Australia;200X.
Choong, K et al. Hypotonic versus isotonic saline in hospitalized children: A systematic
review. Arch Dis Child 2006; 91: 828-35.
Taylor, D, Durward, A. Pouring salt on troubled waters. Arch Dis Child 2004; 89: 411-4.
Neville, KA et al. Isotonic is better than hypotonic saline for intravenous rehydration of
children with gastroenteritis: a prospective randomized study. Arch Dis Child 2006; 91:
226-32.
Hoorn, EJ, et al. Acute Hyponatremia Related to Intravenous Fluid Administration in
Hospitalized Children: An Observational Study. Pediatrics 2004; 113 (5): 1279-84.
Playfor, SD. Hypotonic intravenous solutions in children. Expert Opin Drug Saf 2004; 3
(1): 67-73.
Beck, CE. Hypotonic Versus Isotonic Maintenance Intravenous Fluid Therapy in
Hospitalized Children: A Systematic Review. Clin Pediatr 2007; 46 (9): 764-770.
Choong, K et al. Hypotonic Versus Isotonic Maintenance Fluids After Surgery for
Children: A Randomized Controlled Trial. Pediatrics 2011; 128: 857-866.
Kliegman RM, Stanton BF, St Geme III JW, Schor NF. Nelson Textbook of Pediatrics
19th Ed. WB Saunders Company; 2010
Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate,
and severe hyponatremia. Am J Med. 2009 Sep;122(9):857-65.
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FIGURE I: (Clinical Practice Guidelines 80.20)





Prior to IV
Obtain vitals (HR, BP, RR, temp) &
determine hydration status
Initial investigations: Na, K+, Cl, BUN,
SCr, glucose
Calculate TFI
If elevated SCr, send urine Na/Cr or
U/Cr
Calculate TFI
Is PO/Enteral Route
Possible?
See CPS guidelines for oral
rehydration:
www.cps.ca/en/documents/position/or
al-rehydration-therapy

YES
NO
YES
Establish IV
Is pt severely dehydrated?
NO
Maintenance Fluids:
 Start maintenance IV fluids.
 0.9% NaCl or Ringer’s Lactate with or
without dextrose is appropriate for most
patients.
 Add KCl 20 mmol/L once pt voids (if serum
K+ is normal).



If pt receiving both PO/IV fluid
replacement, ensure PO intake is
included in TFI calculations
Patients with Hypovolemic Shock:
 Give 20 mL/kg bolus of IV 0.9%
NaCl or Ringer’s Lactate over 1530 minutes
 May repeat if circulatory
compromise not resolved
Fluid Deficit Replacement:
 Replace fluid deficit with
0.9% NaCl or Ringer’s
Lactate (with/without
dextrose and K+) over 2448 hours.
Ongoing Fluid Loss Replacement:
Re-assess fluid losses every 4 hours. Replacement fluid should reflect the electrolyte
composition of the lost fluid.
0.9% NaCl is the appropriate replacement fluid in most cases.
Add dextrose as required, and adjust daily thereafter based on losses.
Continuing Management
 Record fluid balance (ins/outs) every shift (q12h).
 Daily weights are recommended.
 Electrolytes and glucose should be measured q24h, and more frequently (e.g. q4-6h) if abnormal.
 If serum sodium less than 132 mmol/L, re-check lytes q4-6h until stable.
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IV FLUID ADMINISTRATION IN HOSPITALIZED INFANTS, CHILDREN &
ADOLESCENTS - Guideline 80.30
Page 14 of 14
APPENDIX I: (Clinical Practice Guidelines 80.20)
Composition of Common Body Fluids
Fluid Source
Gastric
Pancreatic
Small Bowel
Bile
Ileostomy
Diarrhea
Sweat
Burns
Na+ (mmol/L)
20-80
120-140
100-140
120-140
45-135
10-90
10-30
140
K+ (mmol/L)
5-20
5-15
5-15
5-15
3-15
10-80
3-10
5
Cl- (mmol/L)
100-150
90-120
90-130
80-120
20-115
10-110
10-35
110
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