|Year : 2017 | Volume
| Issue : 4 | Page : 147-153
Cardiopulmonary resuscitation: What is new in 2017
ST Yavagal DM
Department of Cardiology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||27-Oct-2017|
S T Yavagal
1782, 34th Cross, 14th Main, BSK 2nd Stage, Bengaluru - 560 070, Karnataka
Source of Support: None, Conflict of Interest: None
A timely and effective cardiopulmonary resuscitation (CPR) is crucial for saving lives of the individuals who suffer sudden cardiac arrest. Different relevant authorities have published guidelines for educating the caregivers in delivering effective CPR. The present report summarizes the recent changes in the CPR guidelines.
Keywords: Cardiac arrest, defibrillation, sudden cardiac death
|How to cite this article:|
Yavagal S T. Cardiopulmonary resuscitation: What is new in 2017. J Clin Prev Cardiol 2017;6:147-53
| Introduction|| |
Today, medical profession and media have educated the public regarding coronary artery disease and hypertension. However, the most neglected field is sudden cardiac death (SCD). Thousands of people are dying outside the hospital due to SCD. In India, survival rate following SCD is <1%. Thus, there is a need for updating ourselves with the recent changes in the concept of cardiopulmonary resuscitation (CPR) and to create awareness about performing high-quality CPR.
| Sudden Cardiac Death|| |
SCD is the leading cause of death globally, and the incidence of SCD is increasing in India also. The global incidence of out-of-hospital cardiac arrest (OHCA) is 62/10,000. Estimated survival to hospital discharge is 8% and not much has changed for many years. In the USA alone, 275,000 sudden deaths per year occur as OHCA. Unfortunately, often the first sign of cardiovascular disease (CVD) is the last sign in SCD. Nearly 50% of all deaths in ST-elevation myocardial infarction and 50% of all CVD deaths are due to SCD. Nearly 80% of all SCDs are due to ventricular arrhythmias. Obviously, OHCA is a major public health problem that has not been addressed adequately. The survival rate can be improved if high-quality CPR is attempted. In-hospital cardiac arrests (IHCAs) occur in 3–6/1000 hospital admissions. These are often secondary to hypotension and shock which is the end result of physiological deterioration from the underlying medical conditions such as infections, renal failure, anemia, toxins, electrolyte imbalance, hypoxia, drugs, and trauma. In these cases, the best approach is treating the underlying disease to prevent cardiac arrest. These patients tend to have a better survival to discharge (37%).
| Part 1: Executive Summary|| |
In 2010 guidelines, the new approach to primary cardiac arrest (PCA) was cardio-cerebral resuscitation (CCR). Classic CPR should be reserved for secondary cardiac arrest (SCA). Recently, the American Heart Association (AHA) has updated the guidelines for CPR and Emergency Cardiac Care (ECC). There are several suggested changes including the system care, continuous quality improvement, education and continuous updating of guidelines. The AHA ECC committee has set an impact goal of doubling bystander CPR rate and doubling the cardiac arrest survival by 2020. In total, there are 315 recommendations which are discussed in 15 sections.
Evolution of cardiopulmonary resuscitation
In 1960, Kouwenhoven (retired, engineer), Jude (surgical resident), and Kriscker Bocker (engineer) published an article titled - “survival of a patient with closed chest cardiac massage” from John Hopkins Hospital. This was based on their experience in animal studies. In 1960, a combination of closed chest compression with rescue breathing was introduced. In 1962, DC defibrillator was introduced. In 1966, the CPR guidelines were developed by the AHA and periodically these guidelines are updated. During the past 50 years, early recognition and activation of emergency medical system, early CPR, and early defibrillation has saved many lives around the world. In 1970, trained ambulance personnel started treating OHCA. Today, trained lay persons have started initiating the treatment for OHCA.
| Part 2: Evidence Review and Guideline Development|| |
In 2015 guidelines – Scientific Evidence Evaluation and Review System – a web-based resource which will be continuously updated has been introduced instead of periodical review. The International Liaison Committee on Resuscitation and International Consensus on CPR and ECC science with treatment recommendations were used in 2015 AHA update. They categorized the recommendations as Class I, II, III and level of evidence as a, b, c.
Class (strength of recommendation)
- I – Strong
- IIa – Moderate
- IIb – Weak
- IIIa – No benefit
- IIIb – Harmful.
Level (quality) of evidence
- High-quality evidence from randomized clinical trials and meta-analysis
- R – moderate-quality evidence from randomized trials
NR - moderate-quality evidence from nonrandomized trials
- Poor - expert opinion based on clinical experience.
Thus, 2015 guidelines are evidence-based recommendations. OHCA and IHCA care must function differently. The education of both lay rescuers and health-care providers must be targeted.
There are two types of cardiac arrest – primary and secondary.
Primary cardiac arrest
It is an unexpected, witnessed (seen or heard) collapse in a person who is not responsive. Gasping occurs in majority (55%) of patients in OHCA and is often interpreted as breathing. Here, heart suddenly stops pumping blood and the arterial blood is oxygenated at the time of the arrest. About 70%–80% of patients with OHCA have PCA.
Secondary cardiac arrest
SCA is secondary to severe hypoxia often from drowning, respiratory failure, drug overdose, or hypotension due to shock or hemorrhage. Classic CPR should be reserved for SCA.
| Part 3: Ethical Issues|| |
Ethical issues related to CPR are discussed. However, no clear-cut recommendations are made.
| Part 4: System Care and Quality Improvement|| |
The AHA 2015 guidelines suggest that OHCA and IHCA care must function differently. For OHCA, a cardiac resuscitation center (CRC) such as a hospital with all facilities should be recognized. The contact number of CRC should be known to all people in that area. When a cardiac arrest occurs, the bystander needs to inform the CRC. It is expected that the person at the CRC – (1) will ask the bystander to start chest compressions at a rate of 100–120/min, (2) will arrange to send the ambulance with all facilities, and (3) using the available technologies, will summon the nearest CPR-trained person to the rescue spot (Class IIb). With this approach, bystander initiation of CPR has been shown to increase to 62% versus 48% in control group. Use of defibrillator by lay person continues to improve survival. Dispatcher should provide compression-only-CPR (CO-CPR) instruction to caller (Class I).
For IHCA, the medical emergency team or rapid response team should be formed at institution level which can include trained experts in advance life support. In the event of a cardiac arrest in the indoor patient ward, the available staff can initiate the treatment and simultaneously send the call to the rapid response team. Implementation of these systems and methods can improve the survival rate in both OHCA and IHCA.
| Part 5: Adult Basic Life Support|| |
In 2015, the AHA published CPR guidelines that included major changes as compared to the earlier guidelines.,
In the earlier guidelines, the recommendations included the initial sequence of steps known as, A B C; where A = airway, B = breathing, and C = chest compression. The current guidelines now recommend the sequence as, C A B, except in newborns. “Look, listen, and feel” is no longer recommended, instead here is an increased focus on methods to ensure high-quality CPR. Rapid identification of potential cardiac arrest is important. An unconscious person with an abnormal or absent breathing or agonal gasp is a sign of cardiac arrest (Class IIa). Rescuer should activate emergency response system without leaving the victim. CPR should be started before the rhythm is identified and should be continued.
- Chest compressions of adequate rate (100–120/min) (Class IIa)
- Chest compression of adequate depth. In adults, at least 2 inches (5 cm); in children, about 2 inches (5 cm); and in infants, depth of 1/3rd of the anteroposterior (AP) diameter of the chest are recommended
- Allowing complete chest recoil after each compression
- Minimizing interruptions in compression
- Avoiding excessive ventilation
- Emergency cardiac treatment such as routine atropine, cricoid pressure, and airway suctioning is no longer recommended
- If multiple rescuers are available, they should rotate the task of compressions every 2 min.
Indications of cardiopulmonary resuscitation
CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as malignant arrhythmias. The most common being ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electrical activity, asystole, and pulseless bradycardia.
Contraindications of cardiopulmonary resuscitation
The only absolute contraindication to CPR is a “do not resuscitate” order. A relative contraindication is if a clinician justifiably feels that the intervention would be medically futile.
Standard cardiopulmonary resuscitation procedure
CPR should be started before the rhythm is identified and should be continued. In its full standard form, CPR comprises three steps:
- Chest compression
It is not cardiac massage but a compression and decompression maneuver. Each compression is in accordance with the patient's heart beat. If the chest compressions are interrupted for any reason, blood flow to the heart and brain essentially stops, decreasing the chance for neurologically intact survival. Idris et al. observed in their study that the highest rate of return to spontaneous circulation is at a chest compression rate of about 125/min. Other studies further showed that the compression depth becomes shallow if it is done at a rate more than 120/min. Thus, on the basis of the available evidence, the optimum compression rate as recommended should be 100–120/min. Depth of at least 2 inches or 5 cm for an average adult is needed while avoiding excessive chest compression depth (>2.4 inches or 6 cm) (Class I). However, this is challenging without a feedback device. The key thing to keep in mind while doing CPR is “push hard and push fast.” Matlock  demonstrated that singing, humming, or listening to songs during CPR improved the compliance, predictable return of spontaneous circulation (ROSC), and imparted neurologically intact survival; however, this is not recommended in the guidelines.
Compression-only-cardiopulmonary resuscitation versus standard cardiopulmonary resuscitation
In CO-CPR, the provider delivers only chest compressions at a rate of 100–120/min with a depth of 2 inches without pause until the arrival of the medical team. Chest compressions should be continued through defibrillation or resumed immediately without any postshock pulse check since ROSC is not instantaneous even after successful defibrillation.
The initiation of bystander resuscitation, especially when begun within 1 min of arrest, markedly improves the survival. In the study by Becker et al., survival was more than four times greater in patients who received early bystander resuscitation. Further, a meta-analysis of several observational studies showed higher survival rate in CO-CPR compared to standard CPR. CO-CPR is clearly better than no CPR and this should be the primary message to be conveyed to all health-care professionals and general population.
| Part 6: Alternative Techniques|| |
Automated cardiopulmonary resuscitation
Three types of automated compressors are available:
- Pneumatically driven piston compressors
- Active compression-decompression device (LUCAS)
- Load-distributing band compression (AutoPulse)
These devices improve coronary perfusion pressure during IHCA compared to manual compression. ASPIRE study showed that survival to discharge was better with AutoPulse than manual CPR. LINC  and PARAMEDIC  trials are large ongoing randomized trials evaluating the prehospital use of mechanical compression-decompression devices. Routine use of these mechanical devices is not recommended at present. They can be used in hospital settings where standard CPR is difficult, for example, during transport or when access to patient is limited such as CPR during percutaneous coronary intervention (PCI). If these devices are used, it is important to provide training to minimize interruptions in chest compression during the use of the device. Most of the studies did not demonstrate the superiority of mechanical chest compressions over conventional CPR. Thus, manual chest compression remains the standard of care.
Present guidelines have repositioned airway and breathing below circulation in SCA from a cardiac cause. SCA from pulmonary cause, for example, drowning, choking, and respiratory failure in whom oxygen reserve is likely to be depleted, the airway and breathing should be restarted as quickly as possible. If patient is not breathing, two ventilations are given through providers' mouth or bag-valve mask. This can be challenging to perform correctly and is best done by two trained rescuers. It is recommended that tidal volume of 500 ml should be delivered in 1 s. In effective mouth-to-mouth ventilation, chest should rise with each ventilation. If not, it indicates inadequate mouth seal or airway occlusion. Two ventilations should be given in sequence after 30 compressions (30:2). When breaths are completed, compressions are restarted. If available, a barrier device (pocket mask or face shield) should be used. Ventilations should be provided every 6–8 s (8–10 breaths/min). Ambu bag is sufficient. Higher ventilation rate can increase intrathoracic pressure resulting in diminished venous return and reduced cardiac output. It can also cause gastric inflation which increases the risk of aspiration and can impede ventilation further by elevating the diaphragm and restricting the lung expansion. Endotracheal tube placement should be done when possible. If possible, it should be confirmed by continuous wave capnography and should be connected to the ventilator (Class I). Ultrasound is an additional method. “Death by Hyperventilation,” an editorial by Aufderheide and Lurie, stresses that frequent forcible ventilation decreases survival. 100% oxygen can be used. The use of maximal feasible inspired oxygen during CPR is strengthened. This recommendation applies only while CPR is ongoing and does not apply to care after ROSC.
Gasping is a sign of cardiac arrest with an adequate perfusion to the brain. Untreated gasping lasts for 4–5 min. If compressions are initiated while patient is gasping or soon after gasping stops, the patient is likely to continue or resume gasping. Gasping results in ventilation with a negative intrathoracic pressure and is associated with increased survival. In Arizona study, survival of patients with OHCA was 9% when CPR was applied and patient was not gasping, but 39% if patient was gasping during CPR. Gasping is more physiological than any form of positive ventilation. Positive ventilation increases intrathoracic pressure, intracerebral pressure and decreases venous return to the thorax and subsequent cardiac output.
Early defibrillation is critical to survival after SCA. The most frequent initial rhythm in OHCA is VF. The chance of successful defibrillation diminishes over time. Two high-quality, population-based cohort studies showed that the use of these devices by bystanders doubles the survival after OHCA. It is an effective treatment for VF or pulseless VT associated with cardiac arrest. No specific training is required. The rescuer simply follows the audiovisual instructions when the device is switched on. It is very important to reduce the pauses in chest compression during defibrillation. One cycle of chest compression is to be resumed immediately after shock without waiting to look for pulse or rhythm. Even the interruptions in the compression while preparing for defibrillation result in a drop in coronary perfusion pressure. Hence, every effort should be made to minimize the interruption in compression (Class I). Several studies  have shown that it is completely safe for a rescuer wearing standard examination gloves to continue chest compressions during the use of a biphasic defibrillator and self-adhesive pads. Automated external cardioverter defibrillator (AECD) is used in more intensively monitored areas. They provide continuous monitoring with two pads placed over the patient's chest and automatically defibrillate a shockable rhythm. Ali et al. in a prospective study of 55 patients at risk of pulseless VT/VF reported that the average interval between onset of arrhythmia and first defibrillation was 33 s and resulted in 94% of ROSC. AECD is safe and likely results in early defibrillation than standard telemetry monitoring. However, its routine use is not recommended.
| Part 7: Adult Advanced Cardiovascular Life Support|| |
Role of drugs in cardiopulmonary resuscitation
Current guidelines recommend that adrenaline should be given intravenously (IV) every 3–5 min during cardiac arrest (adult 1 mg, children 10 mcg/kg) (Class I). It increases the aortic relaxation (diastolic) pressure and the rate of ROSC. However, no difference in survival/hospital discharge was observed. Large randomized trials are needed to resolve this uncertainty. Regarding timing of administration, for nonshockable rhythm, adrenaline gets priority. For shockable rhythm, defibrillation gets the priority.
Vasopressin, steroid, and epinephrine combo
Treatment with vasopressin, steroid, and epinephrine (VSE) during CPR is found to be beneficial (Class IIb). Spyros et al. (2013) in their randomized trial in patients with IHCA observed that treatment with VSE followed by treatment of survivors with daily steroids increased the frequency of being discharged with a neurologically favorable outcome compared to the patients receiving standard care with epinephrine alone. VSE patients also had improved hemodynamic and central venous oxygen saturation as well as less organ dysfunction.,
Vasopressin is removed from the advanced cardiovascular life support (ACLS) cardiac arrest algorithm. It simplified the approach. IV atropine, fibrinolysis, routine fluid loading, and artificial pacing have no effect on outcome. Sodium bicarbonate is only to be used in prolonged resuscitation. Delivery of drugs through a tracheal tube is no longer recommended. Precordial thump recommendation is neither for for nor against. Not recommended for OHCA.
Prognostication during cardiopulmonary resuscitation
Low partial pressure of end-tidal carbon dioxide in intubated patients after 20 min of CPR is associated with failure of CPR. This should not be used in isolation and in nonintubated patients.
Return of spontaneous circulation not rapidly achieved - other options
Other options include mechanical CPR device, endovascular assist device, intra-aortic balloon counter pulsation, and extracorporeal CPR. Role of these options either alone or in combination is not well understood.
| Part 8: Postresuscitation Care|| |
The principles of postarrest care are:
- To identify and treat the underlying etiology
- To mitigate ischemia–reperfusion injury and prevent secondary organ injury
- To make accurate estimates of prognosis to guide the clinical team and to inform the family when selecting goals of continued care.
Apart from timely and effective CPR, optimal postresuscitation care is also crucial for good outcomes. The two important pillars of postresuscitation care are coronary angiogram (CAG) and therapeutic hypothermia. Specific management includes avoiding and immediately correcting hypotension and hypoxemia.
Coronary angiogram/percutaneous coronary intervention
A number of studies have documented the high prevalence of acute coronary occlusion in patients resuscitated from OHCA. Hence, CAG and coronary intervention should be performed as an emergency (rather than late in the hospital or not at all) for all OHCA even in comatose patients. In a retrospective study  in survivors of IHCA caused by VF, 27% underwent CAG, 17 patients had PCI, and 13 showed ST segment elevation myocardial infarction (STEMI) or new left bundle branch block. Patients who underwent CAG or PCI were more likely to survive than those who did not. Survivors of OHCA were treated with therapeutic hypothermia and CAG was done. At least one significant lesion in 58% of patients without ST elevation was observed. Thus, there is a need for liberal use of CAG and stent or surgery PCI following cardiac arrest.
All comatose (i.e., lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should have targeted temperature management to select and maintain a constant temperature between 32°C and 36°C for at least 24 h. One should try to prevent fever. Routine cooling of patients after ROSC using rapid infusion of cold saline is not recommended.
The use of mild (32°C–36°C) therapeutic hypothermia for comatose postresuscitated cardiac arrest victims is accepted by many resuscitation scientists. Two large randomized prospective trials  showed improved survival and improved neurologic function of survivors when therapeutic hypothermia was used for comatose victims of OHCA. The AHA and European Society of Cardiology recommend that induced hypothermia may be considered for comatose adult patients with ROSC after IHCA of any initial rhythm.
The different methods available for therapeutic hypothermia include:
- IV infusion of cold saline
- External cooling methods such as:
- Cooling blankets
- Icepacks to groin, axilla, and neck
- Wet towels and fanning
- Cooling helmet
- Intravascular heat exchange device.
Hypothermia improves neurological outcome after ROSC. It reduces metabolic rate. It suppresses many chemical reactions associated with reperfusion injury and reduces mitochondrial damage and apoptosis (programmed cell death). Possible adverse effects of hypothermia are arrhythmias, infection, and coagulopathy. Contraindications for hypothermia include severe cardiogenic shock, life-threatening arrhythmias, pregnancy, and patients with primary coagulopathy.
Postresuscitation care includes the use of amiodarone, beta-blockers, and full cardiac evaluation which includes electrocardiogram (ECG), echocardiogram, CAG, and implantable cardioverter defibrillator in selected cases.
All cardiac arrest persons who progress to death or brain death should be evaluated as potential organ donators in settings where program exists.
| Part 9: Acute Coronary Syndrome|| |
It addresses prehospital and emergency department phase only. Prehospital ECG recording (Class I) and computer-assisted interpretation (Class 2b) or transmission of ECG to emergency department physician (Class 2a) by trained staff in ambulance is recommended. This will help in prearrival notification to the hospital and/or prehospital activation of cath lab. If there are no signs of STEMI on ECG, measurement of hs-cTnI or hs-TnT can be done. Heparin and aspirin can be started at prehospital level (Class 2b). Supplementary oxygen can be given. Aim should be for primary PCI (Class I). If delay is anticipated, thrombolysis should be given and the patient should be shifted to PCI center (Class 2b).
| Part 10: Special Circumstances|| |
- Opioid overdose: Naloxone administration by nonhealth-care provider in opioid overdose is a new recommendation
- Drug toxicity: IV lipid emulsion in cardiac arrest due to drug toxicity when CPR is failing is recommended
- Cardiac arrest in later half of pregnancy: Left uterine displacement to be done during CPR to avoid aortocaval compression
- Perimortem cesarean delivery (PMCD): PMCD should be considered after 4 min after maternal cardiac arrest when there is no ROSC (Class 2a).
| Part 11: Pediatric Basic Life Support|| |
Algorithm for one and two health-care providers has been separated. CAB (Class 2b) not compression-CPR (Class 1) is recommended. Rate of chest compression should be 100–120/min. Depth should be 1/3rd of AP diameter (Class 2a) or 1.5 inches (4 cm) for infants and 2 inches (5 cm) for children. Rescue breathing is required because of asphyxial nature of the cardiac arrest. If unwilling or unable to deliver breath, CO-CPR (Class 1) is recommended.
| Part 12: Pediatric Advanced Life Support|| |
Aggressive volume replacement/increase is not recommended. Titrated fluid therapy is indicated. There is limited survival benefit for routine use of atropine. Titration of CPR should be done to achieve the BP target. Amiodarone/lignocaine is acceptable for shock refractory VT/VF. Fever in comatose children should be avoided. Hypothermia or normothermia is equally beneficial in comatose children. If hemodynamic instability is present after cardiac arrest, patients should be treated actively with fluids/inotropes/vasopressin to maintain systemic blood pressure.
| Part 13: Neonatal Resuscitation|| |
This is primarily for newborn infants. Guidelines remain unchanged from 2010. There is increased focus on umbilical cord management, maintaining normal temperature, accurate determination of heart rate, and optimizing oxygen use. There is de-emphasis on routine suctioning of meconium. Etiology is always asphyxia. Hence, effective ventilation is critical.
| Part 14: Education|| |
Even today, there is low survival rate both in OHCA and IHCA. High-quality training is needed for both lay public and health-care professionals. Use of high-fidelity manikins are recommended for advanced life support training. It is beneficial to use audiovisual feedback devices during CPR training (Class IIb). More frequent training instead of 2-year retraining cycle is useful. To reduce the time taken for defibrillation is needed. Communities may consider training of bystanders in CO-CPR.
| Part 15: First Aid|| |
First aid means helping behavior and initial care provided for acute illness or injury. Training should include early recognition of stroke, hypoglycemia, how to manage chest wound without no occlusive dressing, and dental avulsion. Trained persons should be able to recognize symptoms of anaphylaxis.
A new approach for patients with PCA has shown significantly increased survival. After introducing CCR program, which stressed upon CO-CPR, lay rescuer CPR increased from 28% to 40% and resulted in 300% improvement (3.7%–17.6%) in survival to hospital discharge [Figure 1].
PCA is an unexpected witnessed (seen or heard) collapse in a person who is not responsive.
- Calling: 108
- Place the person on hard surface
- Compression for 100–120/min of 2” depth, with complete release after each compression.
PCA prohibits early intubation, advocates passive ventilation, minimal interruption of chest compression, and encourages early administration of epinephrine [Figure 2].
In the past, comatose patients following OHCA were often “medically abandoned.” Today, improved survival rate is reported with the aggressive postresuscitation care which includes:
- Therapeutic mild hypothermia
- Early CAG to open occluded coronary artery
- With aggressive management of blood glucose, ventilation to avoid hyperoxemia and hemodynamic control, survival rate improves from 34% to 59% and favorable neurological outcome from 39% to 55%.
No new recommendations are added to the existing guidelines. But there are few things that have been observed. Andersen et al. have reported that there is no benefit with early intubation within 15 minutes in IHCA. Survival benefits with intubation was 16% as against 19% in persons without intubation. Reynolds et al. have reported that shorter the duration of resuscitation to get ROSC more favourable will be the outcome. Rajan et al. have reported that shorter the ambulance response time better will be the prognosis.
| Conclusion|| |
Currently recommended initial sequence of steps in CPR is no longer ABC. It is CAB. High-quality CPR with minimum interruption should be our goal. Role of routine use of drugs is unclear. However, epinephrine has got some benefits. After successful resuscitation, the focus should shift to postresuscitation care which includes maintenance of cardio-cerebral perfusion pressure, achieving therapeutic hypothermia and early CAG. The four Cs of CPR (compression, cardioversion, cooling, and cardiac catheterization) are the only interventions which improve survival rate in both OHCA and IHCA.
| Summary|| |
Guidelines now have changed from periodical review to continuous update. Recommendations have AHA class and level of evidence. There is tremendous potential for increasing the survival in CA. Success in CPR depends on prompt rescuer action, high-quality CPR, optimized ACLS, and post-CA care. Thus, there is a need for high-quality training for everyone.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]