����JFIFXX�����    $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222����"��4�� ���,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu���#ډb���_�N�?��wQ���5-�~�I���8����TK<5o�Iv-�����k�_U_�����~b�M��d����Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F�?_�'ϔ��_�Ջt��=||I ��6�έ"�����D���/[�k�9���Y�8ds|\���Ҿp6�Ҵ���]��.����6�z<�v��@]�i%��$j��~�g��J>��no����pM[me�i$[����s�o�ᘨ�˸ nɜG-�ĨU�ycP�3.DB�li�;��hj���x7Z^�N�h������N3u{�:j�x�힞��#M&��jL P@_���� P��&��o8������9�����@Sz6�t7#O�ߋ �s}Yf�T���lmr����Z)'N��k�۞p����w\�Tȯ?�8`�O��i{wﭹW�[�r�� ��Q4F�׊���3m&L�=��h3����z~��#�\�l :�F,j@�� ʱ�wQT����8�"kJO���6�֚l����}���R�>ډK���]��y����&����p�}b��;N�1�m�r$�|��7�>e�@B�TM*-iH��g�D�)� E�m�|�ؘbҗ�a��Ҿ����t4���o���G��*oCN�rP���Q��@z,|?W[0�����:�n,jWiE��W��$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S����VN;�}�s?.����� w�9��˟<���Mq4�Wv'��{)0�1mB��V����W[�����8�/<� �%���wT^�5���b��)iM� pg�N�&ݝ��VO~�q���u���9� ����!��J27����$O-���! �:�%H��� ـ����y�ΠM=t{!S�� oK8������t<����è:a������[�����ա�H���~��w��Qz`�po�^ ����Q��n� �,uu�C�$ ^���,������8�#��:�6��e�|~���!�3�3.�\0��q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�<���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y�|�y��� ~�6�@c��1vOp�Ig����4��l�OD���L����� R���c���j�_�uX6��3?nk��Wy�f;^*B� ��@�~a�`��Eu������+���6�L��.ü>��}y���}_�O�6�͐�:�YrG�X��kG�����l^w���~㒶sy��Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2��#I/�׍qz��^t�̔���b�Yz4x���t�){ OH��+(E��A&�N�������XT��o��"�XC��'���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�|Lp�d�H��}�(�.|����k��c4^�"�����Z?ȕ ��a<�L�!039C� �Eu�C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf���M}7����]����s2tcS{�\icTx;�\��7K���P���ʇ Z O-��~��c>"��?�������P��E��O�8��@�8��G��Q�g�a�Վ���󁶠�䧘��_%#r�>�1�z�a��eb��qcPѵ��n���#L��� =��׀t� L�7�`��V���A{�C:�g���e@�w1 Xp3�c3�ġ����p��M"'-�@n4���fG��B3�DJ�8[Jo�ߐ���gK)ƛ��$���� ���8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`���?��K����QK�d����B`�s}�>���`��*�>��,*@J�d�oF*����弝��O}�k��s��]��y�ߘ��c1G�V���<=�7��7����6�q�PT��tXԀ�!9*4�4Tހ3XΛex�46���Y��D ����� �BdemDa����\�_l,��G�/���֌7���Y�](�xTt^%�GE�����4�}bT���ڹ�����;Y)���B�Q��u��>J/J �⮶.�XԄ��j�ݳ�+E��d ��r�5�_D�1 ��o�� �B�x�΢�#���<��W�����8���R6�@g�M�.��� dr�D��>(otU��@x=��~v���2� ӣ�d�oBd��3�eO�6�㣷�����ݜ6��6Y��Qz`��S��{���\P�~z m5{J/L��1������<�e�ͅPu�b�]�ϔ���'������f�b� Zpw��c`"��i���BD@:)ִ�:�]��hv�E�w���T�l��P���"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u�)]կ�����7x���s�M�-<ɯ�c��r�v�����@��$�ޮ}lk���a���'����>x��O\�ZFu>�����ck#��&:��`�$�ai�>2Δ����l���oF[h��lE�ܺ�Πk:)���`�� $[6�����9�����kOw�\|���8}������ބ:��񶐕��I�A1/�=�2[�,�!��.}gN#�u����b��� ~��݊��}34q����d�E��Lc��$��"�[q�U�硬g^��%B �z���r�pJ�ru%v\h1Y�ne`ǥ:g���pQM~�^�Xi� ��`S�:V29.�P���V�?B�k�� AEvw%�_�9C�Q����wKekPؠ�\�;Io d�{ ߞo�c1eP����\� `����E=���@K<�Y���eڼ�J���w����{av�F�'�M�@/J��+9p���|]�����Iw &`��8���&M�hg��[�{��Xj��%��Ӓ�$��(����ʹN���<>�I���RY���K2�NPlL�ɀ)��&e����B+ь����( � �JTx���_?EZ� }@ 6�U���뙢ط�z��dWI�n` D����噥�[��uV��"�G&Ú����2g�}&m��?ċ�"����Om#��������� ��{�ON��"S�X��Ne��ysQ���@Fn��Vg���dX�~nj�]J�<�K]:��FW��b�������62�=��5f����JKw��bf�X�55��~J �%^����:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v���g�8�1��f24;�V���ǔ�)����9���1\��c��v�/'Ƞ�w�������$�4�R-��t���� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃������A��20�c#��@ 0!1@AP"#2Q`$3V�%45a6�FRUq��� ����^7ׅ,$n�������+��F�`��2X'��0vM��p�L=������5��8������u�p~���.�`r�����\���O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;������S�T���1���i[U�ɵz�]��U)V�S6���3$K{�ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u�!��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� ���D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v�����멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$�JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4�[�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ�dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il��d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J��oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.���3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R=X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N�����#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%���JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$���L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����)�H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>�dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\�y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~������Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7��ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz��)�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!)'��8Ϣ�ٔ��ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'�L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���(}��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3�������QT��a����x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3�,#c�co��q�a)*Pt����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O���������m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l�O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m���PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q������~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~�|,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)`7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ����}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i����>J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q��nxҍ!U�f�!eh�i�2�m���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{/ �?�͟��|1�:�#g��W�>$����d��J��d�B��=��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H����O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l����l�cGs�ځ�������y�Ac�����\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6����N6�q������N ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td�� ?���N����a��3��m���C���w��������xA�m�q�m���m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4���r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0������u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ����V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�����Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q�(v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9��3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M����A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#yw��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa����Q�#� WeF��ŮNj�p�J* mQ�N����*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]��陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv:��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WPw���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp�BGv[]�u�Ov���0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R��� ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`(�>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG��{+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�>e]�����Q�r�:����g�,i"�����ԩA�*M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f�����֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ���˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)��h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~������ G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W�I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��BS�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c���]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪�\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W�����6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}�����6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@�P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6�����m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw�k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ����mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e��R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1[y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN��ĕ��0 !01@Q"2AaPq3BR������?���@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j�ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^���ԯ̾9Z��F��������n��1��� ��]�[��)�'������:�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0��;_��3 !01"@AQa2Pq#3BR������?��ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6����������4B>��o��](��$B���m�����a�!=��?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)����I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a�84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b��$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7��k�� 403WebShell
403Webshell
Server IP : 104.21.45.146  /  Your IP : 172.69.130.120
Web Server : Apache/2.4.52 (Ubuntu)
System : Linux ip-172-31-19-221 6.8.0-1029-aws #31~22.04.1-Ubuntu SMP Thu Apr 24 21:16:18 UTC 2025 x86_64
User : www-data ( 33)
PHP Version : 8.1.28
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : OFF  |  Sudo : ON  |  Pkexec : ON
Directory :  /efsdata/scitechnol.com/httpdocs/submission/uploads/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :


[ Back ]     

Current File : /efsdata/scitechnol.com/httpdocs/submission/uploads/0-1-Manuscript-2014-07-10.doc
��ࡱ�;��	}����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������|	

���� !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{��������~��������Root Entry����������������������������������������������������������������������������	����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
����	�FMicrosoft Word-Dokument
MSWordDocWord.Document.8�9�q����Oh��+'��0
X`���	�
���
�2At our institution, a tertiary referral- center, mechNormal.dotmech3@���@@F�wA]�@
�~���9
[b�bStandard1$*$A$3B*OJQJCJsH	sH	KHPJnH^JaJ_H9tH9^ar^
�berschrift 1@&
&F
&FOJQJCJ05PJ^JaJ0\"���"	WW8Num1z0"��"	WW8Num1z1"��"	WW8Num1z2"��!"	WW8Num1z3"��1"	WW8Num1z4"��A"	WW8Num1z5"��Q"	WW8Num1z6"��a"	WW8Num1z7"��q"	WW8Num1z8B��BAbsatz-StandardschriftartD��DAbsatz-Standardschriftart5D��DAbsatz-Standardschriftart4D��DAbsatz-Standardschriftart3D��DAbsatz-Standardschriftart2D���DAbsatz-Standardschriftart14U��4InternetlinkB*ph�>*���jrnl �� ppvtitle$��$
ppvauthors&��!&ppvcitation"X�1"Betont6]"��A"	highlight.W�Q.Stark betont5\N�rN�berschrift
&���x$OJQJCJPJ	^JaJ0Br0
Textk�rper
'��x"/q�"Liste(^JJ��JBeschriftung
)�x�x$CJ6^J
aJ]2��2Verzeichnis*$^JL��L
Beschriftung6
+�x�x$CJ6^JaJ]L��L
Beschriftung5
,�x�x$CJ6^JaJ]L��L
Beschriftung4
-�x�x$CJ6^JaJ]L��L
Beschriftung3
.�x�x$CJ6^JaJ]L��L
Beschriftung2
/�x�x$CJ6^JaJ]L�L
Beschriftung1
0�x�x$CJ6^JaJ]H�Htitle11$*$�d�dsHsHKHPJ^J_HtHF�"Fdesc21$*$�d�dsHsHKHPJ^J_HtHL�2Ldetails31$*$�d�dsHsHKHPJ^J_HtH(�B(Normal4sH	sH	6�R6Tabellen Inhalt5$L�QbLTabellen �berschrift6$a$$5\2 r2Fu�zeile7
���%$4�4	Kopfzeile8
���%$�Q[�����6������,�u����`abc�:f?�kԒ���>���defghijkl	!��!������������^��`�P���^�@`�����^��`�0���^�``�����^��`����^��`�����^�`����^��`�`���^�0`����������@Q[Q[PG�Times New Roman5�Symbol3&�ArialG��Garamond-NormalS�TimesTimes New Roman3$�ArialG��Times New Roman;��SimSun�[SO5�MangalG�Microsoft YaHei5��MangalB��h��/PGN
�Z
s��sN
�Z
ss' 0 0���1At our institution, a tertiary referral- center, mechmech�M 	�0��Caolan80	l�6[��`��d	���


$(
Px
$�
L
��
(��b/������Repeat percutaneous Tracheostomy is safe- a retrospective Analysis of 15 Cases



Authors

Knuth, Jurgen			jurgen.knuth@gmx.net
Department of Abdominal, Vascular & Transplant Surgery, Witten/Herdecke University, Medical Center Cologne-Merheim, Ostmerheimer Str. 200, 51109 K�ln,Germany
A further affiliation exists for Dr. Knuth:
Departement of General, Visceral, Vascular and Thoracic Surgery, Hospital of Kempten, Kempten, Germany

Bulian, Dirk Rolf		buliand@kliniken-koeln.de 
Department of Abdominal, Vascular & Transplant Surgery, Witten/Herdecke University, Medical Center Cologne-Merheim, Ostmerheimer Str. 200, 51109 K�ln,Germany

Wappler, Frank		wapplerf@kliniken-koeln.de 
Department of Anesthesiology and Intensive Care Medicine, Witten/ Herdecke University, Medical Center Cologne Merheim, Ostmerheimer Str. 200, 51109 K�ln,Germany

Heiss, Markus Maria		heissm@kliniken-koeln.de
Department of Abdominal, Vascular & Transplant Surgery, Witten/Herdecke University, Medical Center Cologne-Merheim, Ostmerheimer Str. 200, 51109 K�ln,Germany

Sakka, Samir G.		sakkas@kliniken-koeln.de 
Department of Anesthesiology and Intensive Care Medicine, Witten/ Herdecke University, Medical Center Cologne Merheim, Ostmerheimer Str. 200, 51109 K�ln,Germany


Corresponding Author

Knuth, Jurgen
Department of General, Visceral, Vascular and Thoracic Surgery, Hospital of Kempten, KemptenRobert-Weixler- Stra�e 50
87439 Kempten, Germany
Tel.: +49 (0)831 530-1618Fax: +49 (0)831 530-3458
jurgen.knuth@gmx.net


Conflict of interest

Jurgen Knuth, Dirk Rolf Bulian, Markus Maria Heiss, Frank Wappler and Samir G. Sakka have no conflicts of interest to disclose. There was no sponsor for any part of this study.Abstract
Purpose
We consider redo- percutaneous dilatational tracheostomy an option, despite previous percutaneous dilatational tracheostomy sometimes being considered a contraindication for a redo-procedure. Since data on this issue is limited, we analyzed our respective procedures.
Methods
All patients who had undergone a redo- percutaneous dilatational tracheostomy at our institution were retrospectively analyzed.
Results
15 cases of redo- percutaneous dilatational tracheostomy were found in 14 out of 1015 Patients (1.4%).  Patients' mean age at the time of the redo- procedure was 66 years. Mean time from decannulation until the redo- procedure was 412 days with a median of 68 days. 6 of 15 cases (40.0%) were conducted during the same hospital stay. One patient had external skin- bleeding after the redo- procedure. No other complications occurred. 9 of 14 (64.3%) patients were discharged from hospital alive. Time to percutaneous dilatational tracheostomy after onset of mechanical ventilation was not shorter (p=0.21) before a redo- procedure as compared to the first procedure. Neither was there a significant correlation of  redo- procedure during same hospital stay  and  discharge from hospital alive after redo-procedure  (p=0.33).
Conclusions
Redo- percutaneous dilatational tracheostomy is a safe procedure. Contraindications should be the same as for a first time procedure.

Keywords
Tracheostomy; Percutaneous Dilatational Tracheostomy; Redo- Procedure; Complications; Weaning
Introduction
Tracheostomy is frequently performed in critically ill patients [1]. It offers an improved weaning process by facilitating spontaneous respiratory mechanics with less dead space ventilation resulting in the following proven benefits: lower sedative requirements, accelerated weaning from mechanical ventilation and ultimately a shorter intensive care unit (ICU) or hospital stay [2, 3]. Percutaneous dilatational tracheostomy (PDT), first described in 1957 [4], evolved as described by Ciaglia [5] and can be performed using different techniques. The single-step dilation is most widely used [1] and has been reported to be the most reliable technique [6]. PDT has been shown to be cost-effective [6,7] and safe [2,3,7,8]. Recently, PDT has even been used for establishing an emergency airway [9,10]. It can easily be performed by ICU staff as an elective bedside procedure. Several procedure- ready- kits are commercially available. PDT is an adequate, often preferred alternative to surgical tracheostomy (ST) [2,3,8] with shorter procedural times [1]. However, some contraindications exist [11,12,13,14]. Specifically, previous PDT is sometimes considered a contraindication for a new PDT and ST is suggested instead [11,12,13]. Although limited data exists on the subject, redo- PDT is considered a viable option at our institution. We conducted a retrospective analysis of our respective patient collective to analyze the safety of redo- PDT.

Materials and Methods
Patient integrity
The institutional review board of our institution found that an anonymous retrospective analysis derived from patient files would not need approval by an ethics committee. For not to jeopardize patients' anonymity, gender is not listed for each individual patient.

Definition of redo- PDT and contraindications
The minimum time from decannulation until the redo- procedure was considered 14 days, which did not result in exclusion of any patient. Overlying skin was closed in all cases. Contraindications for a PDT as considered in our institution are listed in table 1.

Procedural setting
In our institution the single-step-dilation modification of the Ciaglia- technique [5] is favored for PDT. All procedures were performed using the Portex� ULTRAperc� Single Dilator Technique Kit (Smiths Medical, Ashford, UK). Continuous monitoring included ECG, pulse oximetry, capnometry and blood pressure. In addition to sedation, a non depolarizing muscle relaxant was used and FiO2 was increased to 1.0 as a safety measure. Patients were placed in a supine position and a towel roll was placed between the scapulae for neck extension.
The procedural field was disinfected and draped in a sterile fashion. Anatomic landmarks (sternal notch, thyroid cartilage and cricoid cartilage) were identified. Bronchoscopic tracheal view of the whole procedure through the translaryngeal tube was mandatory in all cases. After palpation of the intended puncture site, a horizontal skin incision and blunt dissection were followed by needle- puncture of the trachea between the first and second or between the second and third tracheal ring, depending on the individual anatomic situation. After guidewire insertion and single step dilation, the handle- mounted tracheostomy tube (8.0mm inner diameter for women and 9.0mm inner diameter for men) was inserted, blocked and secured with the provided strap and sutures, the latter staying in place for 10 days to avoid accidental dislocation. Mechanical ventilation was then changed to the tracheostomy tube, the translaryngeal tube was removed under fiberoptic guidance.
Redo- PDT followed the same principle with the same materials used. The previous puncture site was regularly used for establishing the new access. Simple recanullation of a still existing cutaneotracheal opening after successful decanullation was not considered a redo- PDT.

Anticoagulation
All patients received standard thrombosis prophylaxis with low molecular weight heparin or unfractioned heparin. In cases where a therapeutic anticoagulation therapy with the same substances was necessary, timely disruption of the therapy before the procedure was initiated. Other anticoagulants like acetylsalicylic acid (ASA) or clopidogrel were not discontinued.

Patient collective
We identified all patients from the below mentioned departments that underwent a PDT in our institution between February 2005 and August 2013. Out of these, all patients that had undergone a PDT more than once were retrospectively analyzed. PDT following previous ST did not enter the analysis. Patient data are listed in table 2. As for not to jeopardize patients' anonymity, gender is not listed for each individual patient. Patient 1, 4 and 12 had their first PDT in another institution with the Ciaglia- technique, too. Respective reports had been obtained to ensure safety and feasibility prior to the redo- procedure. However, the commercial sets and material that were used are unknown. 
At our institution, PDT is only performed for patients in need of prolonged, already established mechanical ventilation that is potentially reversible. Thus, all PDTs were elective bedside procedures in the ICU, performed by an experienced anesthesiology intensivist and a trainee.
A wide spectrum of critically ill patients was analyzed, namely from a burns- ICU, neurological ICU, and surgical ICU (neurosurgery, trauma/ orthopedic surgery, abdominal surgery, vascular surgery and thoracic surgery). The latter ICU contributed the majority of patients, no redo- PDTs were found for burns patients. Informed consent by the legal guardian was obtained in all cases prior to PDT. All patients were adults.

Statistical analysis
IBM SPSS Statistics 22 was used for data processing and statistics. The parameters  duration of mechanical ventilation before PDT 1  vs.  duration of mechanical ventilation before PDT 2  were analyzed using t test. Fisher's exact test was used for analysis of correlation between  redo- PDT during same hospital stay  and  discharge from hospital alive after redo- PDT . P<0.05 was considered statistically significant. All variables are depicted using descriptive statistics. Namely, the normally distributed parameters  age ,  BMI ,  time from decannulation until re-PDT  and also  mechanical ventilation before PDT  were analyzed for median and mean values. Dichotomous variables ( gender ,  anticoagulation ,  complications ,  redo- PDT during new hospital stay  and  discharge from hospital alive after redo- PDT ) are depicted as percentage. Procedure dependent variables were related to the amount of procedures, while patient related variables were related to the amount of patients. Admitting diagnoses are stated in free text.

Results
An overall of 1015 Patients patients who had received a PDT were identified for the mentioned time frame. Out of these, 14 patients (1.4%) received a redo- PDT. One of these patients underwent a re-redo- PDT. The re- redo- procedure of the first redo- PDT was considered a separate case resulting in an overall number of 15 cases from 14 patients. No anatomical difficulties were encountered in any of the redo- procedures according to the reports. There was a wide variety of underlying diagnoses. These, as well as details of descriptive statistics, are listed in table 2. Median and mean are given to emphasize distribution. For dichotomous variables, percentages are depicted.
One patient received ASA during his first and second PDT, one patient received ASA plus clopidogrel at the time of redo- PDT. In both cases, there was no procedure associated bleeding. Patient 11 had external bleeding from the skin at the puncture site after the redo- procedure, which was successfully managed by a skin suture. Platelet inhibition was not associated with a procedure related bleeding. In patient one, tracheal stenosis was seen during bronchoscopy at re- PDT. Duration of mechanical ventilation before the respective PDTs was compared. Time to PDT after onset of mechanical ventilation was not found to be shorter (p=0.21) before a redo- PDT. No correlation between  redo- PDT during same hospital stay  and  discharge from hospital alive after redo- PDT  was found (p=0.33).

Discussion
So far, only few reports about redo- PDT are available. Some of them apply to patients whose first procedure was only PDT [15], or a mixed collective with PDT and ST as the first procedure [16] including 12 and 14 cases, respectively. A mixed collective in terms of the primary procedure is also true for some of the existing case reports and small series. Additionally, these describe different types of PDT- techniques for the redo- procedure [17,18,19,20,21]. They all agree on redo- PDT being a safe option in the hands of an experienced operator under different circumstances. Negative experiences with redo- PDT might exist, but were not found in our literature search, possibly due to a publication bias for negative events, or possibly for a lack of actual negative experiences. With PDT having replaced ST as the standard tracheostomy procedure in many ICUs for some years now [1,3], most patients in need of a redo- tracheostomy will have had a PDT in the past. Therefore, we concentrated on this patient collective, only. Neither of the larger redo- reports [15,16] mentioned above reveal the rate of redo- procedures as compared to the overall number of PDTs. We find our rate of 1.4% to be of relevance for the clinician, at least in institution that frequently perform PDTs. The rate of potential candidates should be even higher.
One case (6.7%) of procedure related bleeding at redo- PDT was the only complication, an incidence comparable to that of complication rates for primary PDT in the literature [1,22]. Interestingly, the bleeding did not occur in a patient receiving ASA or other platelet inhibitors.
During bronchoscopy for re- PDT, we found one case (6.7%) of tracheal stenosis (patient 1). A rate of around 4% has been described following primary PDT [23,24]. However, not all patients in our collective even had the time to develop a stenosis before the redo- procedure. Furthermore, long term follow up is difficult in the critically ill, and there are high mortality rates. Thus,  tracheal stenosis  was not analyzed following the redo- procedures. We do not know the rate of this parameter after redo- PDT and consider it hardly clinically relevant, especially when compared to subglottic stenosis after long term translaryngeal intubation [25].
The two obese patients with a body mass index of 47 and 49 kg/m2, respectively, did not suffer from any complications. Obese patients were among the extended PDT- indications as described by Ben Nun et al. [20]. We find that a successful first time PDT in the obese should not result in exclusion for a redo- PDT.
We did not find redo- PDT to result in a shorter time to PDT following onset of mechanical ventilation as compared to the first PDT. The literature suggests a reduced duration of ICU and hospital stay [22,26] for PDT as compared to translaryngeal intubation. One could argue that the known history of the patient with a previous PDT for a severe underlying disease should allow for better clinical judgment of a need for long term mechanical ventilation and therefore lowers clinicians' threshold for performing the new procedure early. However, the timing also greatly depends on the clinical status of the patient, also in accordance with the contraindications mentioned in table 1. The TracMan trial [1] revealed no significant difference of early vs. late tracheostomy in terms of overall survival for a follow up of two years. Additionally, in that trial the reduced use of sedatives after PDT did not significantly reduce the average duration of mechanical ventilation.
Analysis of  time from decannulation until redo- PDT in days  shows a wide uneven distribution (mean 68 days vs. median 411.7 days). Roughly, two groups of patients can be distinguished. One group consists of patients who had the redo- PDT during the same hospital stay, and thus quite early. They had a new complication following the first decannulation or a new onset of the underlying disease, like patient 13 who received 3 PDTs. Exaggeratedly speaking, too early a decannulation with seemingly unsolved therapeutic problems would in a discussion stand against a firmly considered and indicated decannulation followed by an unexpected relapse of the clinical problem. In a recent cohort study of more than 2000 ICU patients, 19% of translaryngeally intubated patients required reintubation within the first 24 hours [27]. Patients will certainly be in a more stable respiratory state before considering decannulation after PDT as compared to translaryngeal extubation, but one gets the idea of the unexpected to be quite common. The other group of patients consists of those, who have been discharged from hospital up to several years (e.g. patient 14) and then required log term ventilatory support for a new, acquired problem. Interestingly,  redo- PDT during same hospital stay  vs.  discharge from hospital alive after redo- PDT  is not associated with a significant correlation. Most likely, the decisive factor for mortality is the underlying disease or its severity, while the need for redo- PDT during the same hospital stay seems not to be an influence.

Limitations
Naturally, the inherent limitations of a retrospective analysis apply. Patients with previous PDT might have been ruled out for a redo- PDT to receive ST instead. They would not have been registered for this analysis. Furthermore, no comparison group was available. Also, a heterogeneous patient collective, reflecting the wide range of intensive care medicine, entered the data collection.

Conclusion
Previous percutaneous dilatational tracheostomy as a contraindication for a pending new percutaneous dilatational tracheostomy should be reconsidered, contraindications should be the same as for a first time procedure. The bronchoscopic view during the procedure will reveal possible anatomic pathologies prior to puncture. We believe redo- percutaneous dilatational tracheostomy to be a safe procedure even for a heterogeneous patient collective in the hands of an experienced operator. It offers the same advantages as a first time procedure.
List of abbreviations
ICU	intensive care unit
PDT	percutaneous dilatational tracheostomy
ST	surgical tracheostomy
ASA	acetylsalicylic acid
References

[1] Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators.
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013 May 22;309(20):2121-9.

[2] Durbin CG Jr. Tracheostomy: why, when, and how? Respir Care. 2010 Aug;55(8):1056-68.

[3] Mallick A, Bodenham AR. Tracheostomy in critically ill patients. Eur J Anaesthesiol. 2010 Aug;27(8):676-82.

[4] Shelden CH, Pudenz RH, Tichy FY. Percutaneous Tracheotomy. JAMA. 1957;165(16):2068-2070.

[5] Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985 Jun;87(6):715-9.

[6] Cabrini L, Monti G, Landoni G, Biondi-Zoccai G, Boroli F, et al. Percutaneous tracheostomy, a systematic review. Acta Anaesthesiol Scand. 2012 Mar;56(3):270-81.

[7] Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007 Mar;117(3):447-54.

[8] Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55.

[9] Davidson SB, Blostein PA, Walsh J, Maltz SB, VandenBerg SL. Percutaneous tracheostomy: a new approach to the emergency airway. J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S83-8.

[10] Ault MJ, Ault B, Ng PK. Percutaneous dilatational tracheostomy for emergent airway access. J Intensive Care Med. 2003 Jul-Aug;18(4):222-6.

[11] Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, et al. Comparison of percutaneous and surgical tracheostomies. Chest. 1996 Aug;110(2):480-5.

[12] Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov;118(5):1412-8.

[13] Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, et al. Percutaneous versus surgical tracheostomy: a double-blind randomized trial. Ann Surg. 1999 Nov;230(5):708-14.

[14] Susarla SM, Peacock ZS, Alam HB. Percutaneous dilatational tracheostomy: review of technique and evidence for its use. J Oral Maxillofac Surg. 2012 Jan;70(1):74-82.

[15] Yilmaz M, Dosemeci L, Cengiz M, Sanli S, Gajic O, et al. Repeat percutaneous tracheostomy in the neurocritically ill patient. Neurocrit Care. 2006;5(2):120-3.

[16] Meyer M, Critchlow J, Mansharamani N, Angel LF, Garland R, et al. Repeat bedside percutaneous dilational tracheostomy is a safe procedure. Crit Care Med. 2002 May;30(5):986-8.

[17] Bass SP, Field LM. Repeat percutaneous tracheostomy. Anaesthesia. 1994 Jul;49(7):649.

[18] Mazzon D, Zanardo G, Dei Tos AP. Repeat percutaneous tracheostomy with the Ciaglia technique after translaryngeal tracheostomy. Intensive Care Med. 1999 Jun;25(6):639.

[19] Kinnear J, Lee M, Higgins D. Second redo percutaneous tracheostomy following complicated revision surgical tracheostomy. Anaesthesia. 2008 Aug;63(8):891-2.

[20] Ben Nun A, Altman E, Best LA. Extended indications for percutaneous tracheostomy. Ann Thorac Surg. 2005 Oct;80(4):1276-9.

[21] Rashid A, Raj B, Stoddart A. Repeat percutaneous dilatational tracheostomy in an awake and unintubated patient. Acta Anaesthesiol Scand. 2007 Mar;51(3):378-9.

[22] Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Berardino M, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303(15):1483- 1489.

[23] Melloni G, Muttini S, Gallioli G, Carretta A, Cozzi S, et al. Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up. J Cardiovasc Surg (Torino). 2002 Feb;43(1):113-21.

[24] Antonelli M, Michetti V, Di Palma A, Conti G, Pennisi MA, et al. Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up. Crit Care Med. 2005 May;33(5):1015-20.

[25] Pe�a J, Cicero R, Mar�n J, Ram�rez M, Cruz S, et al. Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present. Otolaryngol Head Neck Surg. 2001, Oct;125(4):397-400.

[26] Koch T, Hecker B, Hecker A, Brenck F, Preuss M, et al. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Arch Surg. 2012;397(6):1001-1008.

[27] Miu T, Joffe AM, Yanez ND, Khandelwal N, Dagal AH, et al. Predictors of Re-intubation in Critically Ill Patients. Respir Care. 2013 Jul 23. [Epub ahead of print; doi: 10.4187/ respcare.02527]

Table legends:
Table 1
Contraindications for primary- and redo- percutaneous dilatational tracheostomy in our institution

[table 1]

Previous radiotherapy of the neck, morbid obesity and ongoing monitoring of intracranial pressure as well as previous percutaneous dilatational tracheostomy or surgical tracheostomy are not considered a contraindication.

Table 2
Descriptive data and statistics for 14 patients with 15 redo- percutaneous dilatational tracheostomy procedures

[table 2]

($)  For not to jeopardize patients' anonymity, gender is not listed for each individual patient
(�) Other than standard thrombosis prophylaxis with (low molecular weight) heparin
(#) Including more than one attempt for puncture, bleeding, loss of airway, via falsa, tracheal or esophageal injury, puncture site infection
(*) One patient received a re- redo- PDT. It was considered a separate case: a second redo- PDT of the first redo- PDT
ASA = acetylsalicylic acid; PDT = percutaneous dilatational tracheostomy; m= male

 PAGE 1

 PAGE 13



��������:
���T
���04��������$2�����Tfv����D 8D H X !.!~,�,�,�,���������������������������ӵ�ӨӨӡ�ӵ�������&sH	sH	5nH^J_HtH\OJQJsH	sH	nH0J%sH	sH	^JOJQJsH	sH	5^JOJQJ5\sH	sH	5sH	sH	5\sH	sH	%B*phsH	sH	PJnH^J_HtH(B*phsH	sH	5PJnH^J_HtH4�,@.�.�.@/81F1H1L1p1H2d4�5>=d?h?�?bBfB�B�DEE�GvH,JzM~M�MhN�NBO�P�QS^S�U�U�U�V�V�VWxW
Y@ZNZ$[�[�^V`Xa\apa�k$n<s�s�s�u���������������������������Ѷ��Ѡ��������������������ј�H*sH	sH	^JB*phsH	sH	^JsH	sH	nH_HtH%B*phsH	sH	PJnH^J_HtHsH	sH	5^JsH	sH	^JB*phsH	sH	5sH	sH	sH	sH	5sH	sH	5^J\sH	sH	5\;�u�z
{P}l������������Ό��V��<�l�‘�&�<�@�Ғ$�(�ؔܔ����v�z�ȗ̗��"�&�����(�,�J�N�v�z����^�b��������j�n�"�&�~���©Ʃªƪ����֯گ����$�(�������������������������������������������������������������������������������sH	sH	^JsH	sH	5\sH	sH	nH_HtH0J$sH	sH	sH	sH	5sH	sH	L������v�z�����H�L�Z�:�>�P�T����ּĽh�l�n�z�|�~����������������������Ų�����В����Ѝ�����	jU>8S*7CJsH	sH	69>*5PJ^JaJ]\4*OJQJ%B*phsH	sH	PJnH^J_HtHB*phsH	sH	nHsH	sH	+B*phsH	sH	5PJnH^J_HtH\(B*phsH	sH	5PJnH^J_HtH������	<
�
bd���V
���24��������������������������1$*$1$*$1$*$����4������Vhx����":���������������������d�d�d�d�d�d�d�d�$:F H Z !0!�,�,�,�,�.�.B/J1L1r1�5@=f?������������������d�d�d�d�d�d�d�d�d�d�d�d�d�d�$d�d�d�d�f?h?�?dBfB�B�G.J|M~M�M�U�U�U&[Za\ara�k������������������d�d�d�d�d�d�	d�1$*$7$d�d�d�d�d�d�d�d�d�d�d��k&n>s�uR}����������Ќ�>�n�đ��(�>�@�Ԓ�������������������$d�d�d�d�d�d�d�d�d�d�d�d�d�d�d�d�Ԓ&�(�ڔܔ����x�z�ʗ̗��$�&�����*�,�L�N�x�z�����������������������������`�b�������l�n�$�&�����ĩƩĪƪ����دگ������������������������������&�(�������������x�z�����J�L�\�<�>������������������d�1$*$d�d�d�1$*$d�1$*$d�1$*$d�1$*$d�1$*$d�1$*$d�1$*$	d�1$*$$d�1$*$>�R�T����ؼƽj�l���������������������������7$a$7$a$
d�$a$7$A$
d�$a$7$A$
d�$a$7$A$
d�$a$7$A$
d�$a$7$A$d�d�1$*$4��. ��A!�n"�n#�n�n$��2P1�X0p�3P(204��. ��A!�n"�n#�n�n$��2P1�X0p�3P(20����՜.��+,��D��՜.��+,��\��Root Entry��������	�F�CompObj����jOle
��������1Table�������������SummaryInformation(����<WordDocument������������l�DocumentSummaryInformation8������������t����������������

Youez - 2016 - github.com/yon3zu
LinuXploit