Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%

La anestesia regional subaracnoidea (ARS) es una técnica ampliamente utilizada en cirugías de abdomen inferior, pelvis y extremidades inferiores. El medicamento más empleado es la bupivacaína hiperbárica al 0,5%. A pesar de ser un anestésico local de uso común, ha mostrado comportamientos clínicos v...

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Autores:
Hernández Villarraga, Andrés Felipe
Tipo de recurso:
Fecha de publicación:
2025
Institución:
Universidad Autónoma de Bucaramanga - UNAB
Repositorio:
Repositorio UNAB
Idioma:
spa
OAI Identifier:
oai:repository.unab.edu.co:20.500.12749/30068
Acceso en línea:
http://hdl.handle.net/20.500.12749/30068
Palabra clave:
Anesthesiology
Medical sciences
Risk Factors
Bupivacaine
Spinal Anesthesia
Medicine
Local anesthesia
Comorbidity
Anesthesia in obstetrics
Anesthetics (Side effects)
Anestesiología
Ciencias médicas
Medicina
Anestesia local
Comorbilidad
Anestesia en obstetricia
Anestésicos (Efectos secundarios)
Ciencias de la salud
Anestesia raquídea
Bupivacaína
Factores de riesgo
Rights
License
http://creativecommons.org/licenses/by-nc-nd/2.5/co/
id UNAB2_98aac73780b1fd1ce1bb8fa8a1cb576f
oai_identifier_str oai:repository.unab.edu.co:20.500.12749/30068
network_acronym_str UNAB2
network_name_str Repositorio UNAB
repository_id_str
dc.title.spa.fl_str_mv Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
dc.title.translated.spa.fl_str_mv Factors associated with regional subarachnoid blockade failed o incomplete with hyperbaric bupivacaine 0.5%
title Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
spellingShingle Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
Anesthesiology
Medical sciences
Risk Factors
Bupivacaine
Spinal Anesthesia
Medicine
Local anesthesia
Comorbidity
Anesthesia in obstetrics
Anesthetics (Side effects)
Anestesiología
Ciencias médicas
Medicina
Anestesia local
Comorbilidad
Anestesia en obstetricia
Anestésicos (Efectos secundarios)
Ciencias de la salud
Anestesia raquídea
Bupivacaína
Factores de riesgo
title_short Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
title_full Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
title_fullStr Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
title_full_unstemmed Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
title_sort Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%
dc.creator.fl_str_mv Hernández Villarraga, Andrés Felipe
dc.contributor.advisor.none.fl_str_mv Leotau Rodríguez, Mario Andrés
Meléndez Flórez, Héctor Julio
dc.contributor.author.none.fl_str_mv Hernández Villarraga, Andrés Felipe
dc.contributor.cvlac.spa.fl_str_mv Hernández Villarraga, Andrés Felipe [0001707159]
Meléndez Flórez, Héctor Julio [0000320609]
dc.contributor.orcid.spa.fl_str_mv Hernández Villarraga, Andrés Felipe [0000-0002-3442-8748]
Leotau Rodríguez, Mario Andrés [0000-0003-4374-2840]
Meléndez Flórez, Héctor Julio [0000-0003-1791-8099]
dc.contributor.apolounab.spa.fl_str_mv Leotau Rodríguez, Mario Andrés [mario-andrés-leotau-rodríguez]
dc.subject.keywords.spa.fl_str_mv Anesthesiology
Medical sciences
Risk Factors
Bupivacaine
Spinal Anesthesia
Medicine
Local anesthesia
Comorbidity
Anesthesia in obstetrics
Anesthetics (Side effects)
topic Anesthesiology
Medical sciences
Risk Factors
Bupivacaine
Spinal Anesthesia
Medicine
Local anesthesia
Comorbidity
Anesthesia in obstetrics
Anesthetics (Side effects)
Anestesiología
Ciencias médicas
Medicina
Anestesia local
Comorbilidad
Anestesia en obstetricia
Anestésicos (Efectos secundarios)
Ciencias de la salud
Anestesia raquídea
Bupivacaína
Factores de riesgo
dc.subject.lemb.spa.fl_str_mv Anestesiología
Ciencias médicas
Medicina
Anestesia local
Comorbilidad
Anestesia en obstetricia
Anestésicos (Efectos secundarios)
dc.subject.proposal.spa.fl_str_mv Ciencias de la salud
Anestesia raquídea
Bupivacaína
Factores de riesgo
description La anestesia regional subaracnoidea (ARS) es una técnica ampliamente utilizada en cirugías de abdomen inferior, pelvis y extremidades inferiores. El medicamento más empleado es la bupivacaína hiperbárica al 0,5%. A pesar de ser un anestésico local de uso común, ha mostrado comportamientos clínicos variables en nuestra población, presentando bloqueos subaracnoideos incompletos o fallidos. Este estudio tuvo como objetivo identificar los factores asociados bloqueo fallido o incompleto con bupivacaína hiperbárica, evaluando variables relacionadas con la técnica, el operador, el paciente y el medicamento así como la relación entre dosis, calidad y duración del bloqueo, mediante un estudio de tipo analítico prospectivo. La incidencia de bloqueo subaracnoideo fallido o incompleto fue del 11,46% (IC 95%), y el 5,71% de los casos requirió conversión a anestesia general. Dentro de los factores de riesgo que aumentaron la probabilidad de ARS fallida o incompleta se identificaron las punciones realizadas en niveles bajos (L4-L5 a L5-S1) (OR: 4,84; p=0,004), y la ejecución del procedimiento por parte de residentes de primer año (OR: 4,7; p=0,041). Además, los niveles sensoriales bajos alcanzados (T7 a T10) se asociaron a una mayor tasa de fallos (OR: 29,28; p=0,001). No se encontró asociación significativa con otras variables sociodemográficas, farmacológicas, de la técnica anestésica, ni del subgrupo obstétrico. Finalmente, el análisis del medicamento y su lote respectivo no mostró significancia estadística en relación con el bloqueo fallido o incompleto. Adicionalmente, el comportamiento del medicamento fue aceptable en relación a lo descrito en la literatura, con una disminución significativa en su perfil de inicio de acción.
publishDate 2025
dc.date.accessioned.none.fl_str_mv 2025-06-25T18:53:48Z
dc.date.available.none.fl_str_mv 2025-06-25T18:53:48Z
dc.date.issued.none.fl_str_mv 2025-06-18
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.local.spa.fl_str_mv Tesis
dc.type.hasversion.none.fl_str_mv info:eu-repo/semantics/acceptedVersion
dc.type.redcol.none.fl_str_mv http://purl.org/redcol/resource_type/TM
status_str acceptedVersion
dc.identifier.uri.none.fl_str_mv http://hdl.handle.net/20.500.12749/30068
dc.identifier.instname.spa.fl_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional UNAB
dc.identifier.repourl.spa.fl_str_mv repourl:https://repository.unab.edu.co
url http://hdl.handle.net/20.500.12749/30068
identifier_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
reponame:Repositorio Institucional UNAB
repourl:https://repository.unab.edu.co
dc.language.iso.spa.fl_str_mv spa
language spa
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66. Colish J, Milne AD, Brousseau P, Uppal V. Factors Associated With Failure of Spinal Anesthetic: An 8-Year Retrospective Analysis of Patients Undergoing Elective Hip and Knee Joint Arthroplasty. Anesth Analg [Internet]. 2020 Jan 1 [cited 2025 May 31];130(1):E19–22. Available from: https://pubmed.ncbi.nlm.nih.gov/31306240/
67. Frawley G. Second infant spinal anesthetic: Incidence, dose modification, and adverse events after initial failure. Paediatr Anaesth [Internet]. 2024 Apr 1 [cited 2025 May 31];34(4):324–31. Available from: https://pubmed.ncbi.nlm.nih.gov/38146636/
68. Patel J, Karimi H, Olmos M, Wiepert L, Kanter M, Hernandez NS, et al. The Relationship of Spinal Anesthesia Dosing Based on Thecal Sac Area to Anesthetic Failure in Lumbar Surgery. Neurosurgery [Internet]. 2024 Jul 1 [cited 2025 May 31];95(1):103–9. Available from: https://pubmed.ncbi.nlm.nih.gov/38299846/
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spelling Leotau Rodríguez, Mario Andrésed2346f0-1be0-4530-9aae-29c3f6d35ef5Meléndez Flórez, Héctor Julio20cc143a-86c7-44c4-bcab-57fb40719b36Hernández Villarraga, Andrés Felipe391a7de6-b983-4d5f-ab62-e9944510ceedHernández Villarraga, Andrés Felipe [0001707159]Meléndez Flórez, Héctor Julio [0000320609]Hernández Villarraga, Andrés Felipe [0000-0002-3442-8748]Leotau Rodríguez, Mario Andrés [0000-0003-4374-2840]Meléndez Flórez, Héctor Julio [0000-0003-1791-8099]Leotau Rodríguez, Mario Andrés [mario-andrés-leotau-rodríguez]Floridablanca (Santander, Colombia)Septiembre 2024 a Febrero 2025UNAB Campus Bucaramanga2025-06-25T18:53:48Z2025-06-25T18:53:48Z2025-06-18http://hdl.handle.net/20.500.12749/30068instname:Universidad Autónoma de Bucaramanga - UNABreponame:Repositorio Institucional UNABrepourl:https://repository.unab.edu.coLa anestesia regional subaracnoidea (ARS) es una técnica ampliamente utilizada en cirugías de abdomen inferior, pelvis y extremidades inferiores. El medicamento más empleado es la bupivacaína hiperbárica al 0,5%. A pesar de ser un anestésico local de uso común, ha mostrado comportamientos clínicos variables en nuestra población, presentando bloqueos subaracnoideos incompletos o fallidos. Este estudio tuvo como objetivo identificar los factores asociados bloqueo fallido o incompleto con bupivacaína hiperbárica, evaluando variables relacionadas con la técnica, el operador, el paciente y el medicamento así como la relación entre dosis, calidad y duración del bloqueo, mediante un estudio de tipo analítico prospectivo. La incidencia de bloqueo subaracnoideo fallido o incompleto fue del 11,46% (IC 95%), y el 5,71% de los casos requirió conversión a anestesia general. Dentro de los factores de riesgo que aumentaron la probabilidad de ARS fallida o incompleta se identificaron las punciones realizadas en niveles bajos (L4-L5 a L5-S1) (OR: 4,84; p=0,004), y la ejecución del procedimiento por parte de residentes de primer año (OR: 4,7; p=0,041). Además, los niveles sensoriales bajos alcanzados (T7 a T10) se asociaron a una mayor tasa de fallos (OR: 29,28; p=0,001). No se encontró asociación significativa con otras variables sociodemográficas, farmacológicas, de la técnica anestésica, ni del subgrupo obstétrico. Finalmente, el análisis del medicamento y su lote respectivo no mostró significancia estadística en relación con el bloqueo fallido o incompleto. Adicionalmente, el comportamiento del medicamento fue aceptable en relación a lo descrito en la literatura, con una disminución significativa en su perfil de inicio de acción.1. Resumen ejecutivo …………………………………………………………………. 5 2. Lista de abreviaturas ……………………………………………………………….. 6 3. Introducción..……………………………………………………………………….. 7 4. Planteamiento del problema ..………………………………………………………. 8 5. Pregunta de investigación ………………………………………………………… 10 6. Hipótesis de trabajo ..……………………………………………………………… 11 7. Justificación .……………………………………………………………………… 12 8. Marco teórico .…………………………………………………………………….. 13 9. Objetivos .…………………………………………………………………………. 26 a. General ……………………………………………………………………………. 26 b. Específicos ..………………………………………………………………………. 26 10. Materiales y métodos .…………………………………………………………….. 27 a. Tipo de estudio ..…………………………………………………………………... 27 b. Población blanco ..………………………………………………………………... 27 c. Población elegible .……………………………………………………………….. 27 d. Criterios de inclusión ..……………………………………………………………. 27 e. Criterios de exclusión ..………………………………………………..…….……. 27 f. Tamaño de muestra .………………………………………………………………. 27 g. Sitio de ejecución ..…………………………………………………………..……. 28 h. Variables ..….………………………………………………………………..……. 28 i. Flujograma ..…………………….………………………………………………… 30 11. Aspectos éticos y legales .…………………………………………………………. 32 12. Resultados .……………………...…….……………………………………..……. 34 a. Manejo de datos y análisis estadísticos ..…….………………………………..…… 34 b. Resultados .………………………………………………………………………... 34 c. Discusión ..………………………………………………………………………... 48 d. Conclusiones .……………………………………………………………………... 52 13. Impacto y resultados esperados ..………………………………………….………. 54 14. Presupuesto ………………………………………………………………………. 55 15. Referencias bibliográficas …...…….………………………………………………56 16. Anexos …...……..………………………………………………………………… 64 a. Cronograma ……………….……………………………………………………… 64 b. Operacionalización de variables ………………..………………………………… 65 c. Instrumento de recolección ……………………………………………………..….68 d. Consentimiento informado ………………………………………………………... 70 17. Índice de tablas y gráficas …………………………………………………..…..… 76EspecializaciónSubarachnoid regional anesthesia (SRA) is a widely used technique for surgeries involving the lower abdomen, pelvis, and lower extremities. The most commonly employed drug is 0.5% hyperbaric bupivacaine. Although it is a local anesthetic frequently used in clinical practice, it has shown variable clinical behavior in our population, including cases of incomplete or failed subarachnoid blocks. This study aimed to identify the factors associated with failed or incomplete blocks using hyperbaric bupivacaine by evaluating variables related to the technique, the operator, the patient, and the drug, as well as the relationship between dose, block quality, and duration, through a prospective analytical study. The incidence of failed or incomplete subarachnoid block was 11.46% (95% CI), with 5.71% of cases requiring conversion to general anesthesia. Risk factors that significantly increased the probability of failed or incomplete SRA included punctures performed at lower spinal levels (L4-L5 to L5-S1) (OR: 4.84; p=0.004), and procedures carried out by first-year residents (OR: 4.7; p=0.041). Additionally, lower achieved sensory levels (T7 to T10) were associated with a higher failure rate (OR: 29.28; p=0.001). No significant associations were found with other sociodemographic, pharmacological, or anesthetic technique-related variables, nor with the obstetric subgroup. Finally, the analysis of the drug and its respective batch showed no statistically significant association with failed or incomplete blocks. Furthermore, the pharmacological behavior of the drug was deemed acceptable when compared with descriptions in the literature, although a significant reduction in its onset of action profile was observed.Modalidad Presencialapplication/pdfspahttp://creativecommons.org/licenses/by-nc-nd/2.5/co/Abierto (Texto Completo)Atribución-NoComercial-SinDerivadas 2.5 Colombiahttp://purl.org/coar/access_right/c_abf2Factores asociados al bloqueo regional subaracnoideo fallido o incompleto con bupivacaína hiperbárica 0,5%Factors associated with regional subarachnoid blockade failed o incomplete with hyperbaric bupivacaine 0.5%Especialista en AnestesiologíaUniversidad Autónoma de Bucaramanga UNABFacultad Ciencias de la SaludEspecialización en AnestesiologíaEANE-1049info:eu-repo/semantics/masterThesisTesisinfo:eu-repo/semantics/acceptedVersionhttp://purl.org/redcol/resource_type/TMAnesthesiologyMedical sciencesRisk FactorsBupivacaineSpinal AnesthesiaMedicineLocal anesthesiaComorbidityAnesthesia in obstetricsAnesthetics (Side effects)AnestesiologíaCiencias médicasMedicinaAnestesia localComorbilidadAnestesia en obstetriciaAnestésicos (Efectos secundarios)Ciencias de la saludAnestesia raquídeaBupivacaínaFactores de riesgo1. Flodd P, Rollins M. Miller Anesthesia. Editorial: Elsevier, 2016. Capítulo 56: Anestesia intradural, epidural y caudal.2. Goyal A, Shankaranarayan P, Ganapathi P. A randomized clinical study comparing spinal anesthesia with isobaric levobupivacaine with fentanyl and hyperbaric bupivacaine with fentanyl in elective cesarean sections. Anesth Essays Res. 2015 Jan-Apr;9(1):57-62. doi: 10.4103/0259-1162.150169.3. Olawin AM, M Das J. Spinal Anesthesia. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537299/4. Lirk P, Kleber N, Mitterschiffthaler G, Keller C, Benzer A, Putz G. Pulmonary effects of bupivacaine, ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: a randomised controlled study. Int J Obstet Anesth. 2010 Jul;19(3):287-92. doi: 10.1016/j.ijoa.2009.03.0155. Hashemi M, Taheri M, Aminnejad R. 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Bremerich DH, Fetsch N, Zwissler BC, Meininger D, Gogarten W, Byhahn C. Comparison of intrathecal bupivacaine and levobupivacaine combined with opioids for Caesarean section. Curr Med Res Opin. 2007 Dec;23(12):3047-54. doi: 10.1185/030079907X24276410. Singh A, Gupta A, Datta PK, Pandey M. Intrathecal levobupivacaine versus bupivacaine for inguinal hernia surgery: a randomized controlled trial. Korean J Anesthesiol. 2018 Jun;71(3):220-225. doi: 10.4097/kja.d.18.2719111. del-Rio-Vellosillo M, Garcia-Medina JJ, Pinazo-Duran MD, Abengochea-Cotaina A. Doses and effects of levobupivacaine and bupivacaine for spinal anaesthesia. Br J Anaesth. 2014 Sep;113(3):521-2. doi: 10.1093/bja/aeu27612. Bouchacourt V. Causas de fallas del bloqueo subaracnoideo; formas de evitarlas. Anest Analg Reanim [Internet]. 2005 Ago [citado 2022 Dic 21] ; 20( 1 ): 31-37. Recuperado de: http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-12732005000100005&lng=es.13. 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Comparison of Isobaric Levobupivacaine with Hyperbaric Bupivacaine in spinal anesthesia in patients undergoing Lower Abdominal Surgeries. JMSCR. 2019 Dec 7(12): 731-37. doi: 10.18535/jmscr/v7i12.12818. Local anaesthesia. In: Joint Formulary Committee, ed. British Na- tional Formulary, Vol. 65. (March–September 2013). London: BMJ Group and Pharmaceutical Press, 2013; 834–4019. Alvarez-Ferrer JA, Jimenez-Orjuela GA, Evaluación de señales en farmacovigilancia: bupivacaina y fallo terapéutico [Tesis de pregrado]. Bogotá: Universidad de ciencias aplicadas y ambientales; 2016. Recuperado de: https://repository.udca.edu.co/bitstream/handle/11158/563/trabajo%20grado%20bupivacaina%20y%20fallo.pdf?sequence=1&isAllowed=y20. Wasan EK, Sacevich C, El-Aneed A, Mohammed M, Syeda J, Neville E, Orlowski T, Campbell D, Gamble J. Investigation into spinal anesthetic failure with hyperbaric bupivacaine: the role of cold exposure on bupivacaine degradation. Can J Anaesth. 2019 Jul;66(7):803-812. 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Estudio comparativo de dos anestésicos locales en cirugía bucal: bupivacaína y articaína [tesis de pregrado). Madrid: Universiad complutense; 2019. Recuperado de: https://eprints.ucm.es/id/eprint/21488/28. Casati A, Vinciguerra F. Intrathecal anesthesia. Curr Opin Anaesthesiol. 2002 Oct;15(5):543-51. doi: 10.1097/00001503-200210000-0001229. Ben-David B, Levin H, Solomon E, Admoni H, Vaida S. Spinal bupivacaine in ambulatory surgery: the effect of saline dilution. Anesth Analg. 1996 Oct;83(4):716-20. doi: 10.1097/00000539-199610000-0000930. Velasco-Jiménez MT, Torres-Fonseca A. Introducción. Revista de Especialidades Médico-Quirúrgicas [Internet]. 2012;17(1):S1. Recuperado de: https://www.redalyc.org/articulo.oa?id=4732695900131. Whizar-Lugo VM., Flores-Carrillo JC., Preciado-Ramírez S, Campos-León Jaime, Silva Víctor. Anestesia espinal para cirugía de corta estancia en cirugía plástica. Anest. Méx. [revista en la Internet]. 2017 [citado 2022 Dic 21] ; 29( Suppl 1 ): 41-63. 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Available from: https://pubmed.ncbi.nlm.nih.gov/38299846/https://apolo.unab.edu.co/en/persons/mario-andr%C3%A9s-leotau-rodr%C3%ADguezORIGINALTesis.pdfTesis.pdfTesisapplication/pdf1324272https://repository.unab.edu.co/bitstream/20.500.12749/30068/8/Tesis.pdf9b2cd675fe41805ffd8fcd9828ad7ba6MD58open accessTesis.pdfTesis.pdfArticulo principalapplication/pdf1601686https://repository.unab.edu.co/bitstream/20.500.12749/30068/1/Tesis.pdf343047db762c8ab469a821e99d286d37MD51open accessLicencia.pdfLicencia.pdfLicenciaapplication/pdf280908https://repository.unab.edu.co/bitstream/20.500.12749/30068/7/Licencia.pdf089518b392cc819de0aa314c7aa22be4MD57metadata only accessLICENSElicense.txtlicense.txttext/plain; charset=utf-8829https://repository.unab.edu.co/bitstream/20.500.12749/30068/6/license.txt3755c0cfdb77e29f2b9125d7a45dd316MD56open accessTHUMBNAILTesis.pdf.jpgTesis.pdf.jpgIM Thumbnailimage/jpeg4516https://repository.unab.edu.co/bitstream/20.500.12749/30068/9/Tesis.pdf.jpga159a20e9cbebedf7fe5aef1b75cc938MD59open accessLicencia.pdf.jpgLicencia.pdf.jpgIM Thumbnailimage/jpeg13182https://repository.unab.edu.co/bitstream/20.500.12749/30068/10/Licencia.pdf.jpga2979082a465257890c3f74c16db4fb6MD510metadata only access20.500.12749/30068oai:repository.unab.edu.co:20.500.12749/300682025-06-25 22:01:03.704open accessRepositorio Institucional | Universidad Autónoma de Bucaramanga - UNABrepositorio@unab.edu.coRUwoTE9TKSBBVVRPUihFUyksIG1hbmlmaWVzdGEobWFuaWZlc3RhbW9zKSBxdWUgbGEgb2JyYSBvYmpldG8gZGUgbGEgcHJlc2VudGUgYXV0b3JpemFjacOzbiBlcyBvcmlnaW5hbCB5IGxhIHJlYWxpesOzIHNpbiB2aW9sYXIgbyB1c3VycGFyIGRlcmVjaG9zIGRlIGF1dG9yIGRlIHRlcmNlcm9zLCBwb3IgbG8gdGFudG8sIGxhIG9icmEgZXMgZGUgZXhjbHVzaXZhIGF1dG9yw61hIHkgdGllbmUgbGEgdGl0dWxhcmlkYWQgc29icmUgbGEgbWlzbWEuCgpFbiBjYXNvIGRlIHByZXNlbnRhcnNlIGN1YWxxdWllciByZWNsYW1hY2nDs24gbyBhY2Npw7NuIHBvciBwYXJ0ZSBkZSB1biB0ZXJjZXJvIGVuIGN1YW50byBhIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBzb2JyZSBsYSBvYnJhIGVuIGN1ZXN0acOzbi4gRWwgQVVUT1IgYXN1bWlyw6EgdG9kYSBsYSByZXNwb25zYWJpbGlkYWQsIHkgc2FsZHLDoSBlbiBkZWZlbnNhIGRlIGxvcyBkZXJlY2hvcyBhcXXDrSBhdXRvcml6YWRvcywgcGFyYSB0b2RvcyBsb3MgZWZlY3RvcyBsYSBVTkFCIGFjdMO6YSBjb21vIHVuIHRlcmNlcm8gZGUgYnVlbmEgZmUuCgpFbCBBVVRPUiBhdXRvcml6YSBhIGxhIFVuaXZlcnNpZGFkIEF1dMOzbm9tYSBkZSBCdWNhcmFtYW5nYSBwYXJhIHF1ZSBlbiBsb3MgdMOpcm1pbm9zIGVzdGFibGVjaWRvcyBlbiBsYSBMZXkgMjMgZGUgMTk4MiwgTGV5IDQ0IGRlIDE5OTMsIERlY2lzacOzbiBBbmRpbmEgMzUxIGRlIDE5OTMgeSBkZW3DoXMgbm9ybWFzIGdlbmVyYWxlcyBzb2JyZSBsYSBtYXRlcmlhLCB1dGlsaWNlIGxhIG9icmEgb2JqZXRvIGRlIGxhIHByZXNlbnRlIGF1dG9yaXphY2nDs24uCg==

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