why is the median cubital vein used for venipuncture

WebThe median cubital and cephalic veins are preferred for blood sampling, but other arm and hand veins may be used. window.addEventListener('click-table-loaded', function(){ Ask the patient to make a fist and not pump the hand. Wait for the antiseptic solution to dry completely. Learn more about the MSD Manuals and our commitment to. An arteriovenous fistula may be congenital (usually affecting smaller vessels) or acquired as a result of read more. & Gray, H. (2015). Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. Once again, please be aware that these are only guidelines for blood draws and nurses should consult with the appropriate hospital personnel regarding performing this procedure on patients. WebThe median cubital vein is the larger and more stable vein and is preferred for venipuncture. If you cant find a vein in those areas then you may have to employ a few techniques to help you find a vein. There are also fewer nerve endings surrounding this vein making venipuncture less painful at Properly label the tubes and send them to the laboratory for analysis. Back of the hand. WebWhy do we use the median cubital vein? It is usually easy to access and is more stable. Ask the patient to apply pressure for at least 2 minutes. Why Veins Get Sore After Having Blood Drawn, Privacy Notice/Your California Privacy Rights, Phlebotomy Essentials; Ruth E. McCall; 2003, Handbook of Phlebotomy and Patient Service Techniques; Garland E. Pendergraph; 1998. News and Education Editor, MSN, RN, BA, CBC. These superficial veins lie within the subcutaneous tissue. Mastering Pediatric Phlebotomy. Center, for Phlebotomy Education, Inc. Na Citrate Coagulation tubes light blue top tube, 4. Do not dry the site with gauze and do not blow on the area to dry as this, will contaminate the site. These tubes are used for coagulation tests and need to be completely filled to ensure the proper ratio of blood to anticoagulant. The information we provide is grounded on academic literature and peer-reviewed research. 5. All other items used for the procedure must be disposed of according to proper biohazardous waste disposal policy. Even though most hospitals do have phlebotomy teams, it is still critical for nurses to learn these skills in order to provide the best patient care. Perform hand hygiene and don proper PPE. 9. link to 3 Types Of Needles Used For Venipuncture. Identify the patient using two patient identifiers as mandated by JCAHO. 2019 www.azcentral.com. touched before performing the venipuncture, it should be cleansed again. WebWhy do we use the median cubital vein? Mass formed by leakage of blood under the skin. There is the potential for blood clots to form when these veins are used. Used for chemistry and reference tests. Next, locate the vein you will be using for the blood draw. If blood is being obtained for blood cultures, vigorously cleanse the site with alcohol for 30 seconds, allow the alcohol to dry, and then swab in outwardly expanding, overlapping circles using chlorhexidine or povidone-iodine. Do not recap standard (ie, nonsafety) needles prior to disposal unless a container is not immediately available. Forceful, direct pressure should be, applied to the site for a minimum of five minutes or until the bleeding has, stopped. A hematoma can cause a post-phlebotomy compression injury, Preventing Hemolysis: Mix tubes gently, by inversion, 5-10 times do not, shake them. The discard tube does not need to be filled completely. If the antecub has already been accessed there are great options for venipuncture. Each time a vein is accessed with a needle, scar tissue forms as part of the body's healing process. After blood has been added to a tube, gently invert the tube 6 to 8 times to mix the contents; do not shake the tubes. Mass formed by leakage of blood under the skin. They are also a bit larger and have a thicker lumen resulting in a faster blood flow. Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample. Picking a vein is not difficult. The three most commonly used veins for drawing blood are the median cubital, the cephalic, and the basilic veins. Beth Celli is a native New Yorker who is now based in Delaware. mount_type: "" Apply gentle traction to the vein distally using the thumb of your nondominant hand to prevent the vein from moving. Prep the venipuncture site by cleansing the area with an alcohol prep pad for 30 seconds and allow to air dry for 30 seconds. arm vein. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. To learn more about the veins of the upper limb, explore our articles, quizzes, video tutorials and labelled diagrams. Check for any allergies or sensitivities with the patient regarding antiseptics, adhesives, or latex. o [ pediatric abdominal pain ] The basilic vein is kept as a last choice option. o [ abdominal pain pediatric ] The link you have selected will take you to a third-party website. Philadelphia, PA: Lippincott Williams & Wilkins. Veins can move, or roll, which makes it more difficult to perform phlebotomy. 2023 window.ClickTable.mount(options); Some test specimens require special handling for accurate results. Once blood is seen in the tubing, connect the vacutainers or use a syringe to drawback. It is usually there for the picking. The WHO has best practices that are key to preventing infection and being successful during blood draws. Used for Genetics testing. Large bruise caused by blood under the skin. Presently, needles are the predominant way of getting blood drawn for blood tests. Follow, the order of draw listed here for both syringes (utilizing the blood transfer device), 2. [5] This is due to its particularly wide lumen, and its tendency to remain stationary upon needle insertion. }; 10. Do not have patients make a fist or let their arm hang down during the blood sampling, because these maneuvers may cause various erroneous laboratory values (eg, increased potassium, lactate, phosphate). Insert the needle at a 15 to 30-degree angle into the vessel. If you used a needle and syringe, ask, your patient or a parent to apply pressure to the site so that you can fill, your tubes. WebWhy is the Median Cubital Vein Used the Most? Northfield, IL: College of American, NCCLS. After assembling the appropriate equipment, follow the next steps to perform a proper venipuncture. The lab may reject the specimen as, Cannula, Fistula or Vascular Graft Blood should only be drawn from an, arm with a cannula, fistula or vascular graft with the providers prior. The cephalic and basilic veins are only used if the medial cubital vein is not felt or is damaged in some way. Notify your supervisor or patients physician if unsuccessful. The median cubital is typically well anchored, which makes it less likely that the patient will feel pain during phlebotomy, or bruise afterwards. }); When that happens it can be difficult to locate veins. 7. 1. In order to draw blood for a blood test a needle has to be inserted into a vein. Test your knowledge on the main veins of the upper limb in this quiz. I'm Kadia. Some persons have good veins and others have veins that are difficult to find. Proper Handling of an Uncooperative Patient in an Outpatient Setting Akron. One reason is because you may have hard-to-find veins or you may be dehydrated. 7. After identifying a suitable cannulation site, remove the tourniquet. Each healthcare system has its own requirements prior to nurses performing blood draws. At no time may phlebotomists perform venipuncture on an artery. Youll be the first to know about nursing news, trending topics and educational resources. 2. If you are using a tourniquet for, preliminary vein selection, it should be released after one minute, left off for two. Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and vein in one motion. True An evacuated glass tube with a lavender stopper contains EDTA. Each time a vein is accessed with a needle, scar tissue forms as part of the body's healing process. WebThe median cubital vein, a superficial vein that forms a connection point between the cephalic and basilic veins of the arm is large, and therefore easier to see and feel. Author: pinkie side of the arm, should be used only if there is not another more prominent. Excessive probing (uncalculated side-to-side. The significance of this vein is its use in venipuncture, the procedure that collects blood for laboratory testing. WebSelect the appropriate vein for venipuncture. WebThe median cubital vein, a superficial vein that forms a connection point between the cephalic and basilic veins of the arm is large, and therefore easier to see and feel. The median cubital vein (antecubital vein) is a prominent superficial upper limb vessel. While we are ranked among the best children's hospitals in the country, it's our compassionate approach to treatment that makes us truly exceptional. It is large and near the skins surface, making it easier for phlebotomists to see before anchoring the vein. This information must match the requisition. Ask the patient to apply pressure to the gauze for at least 2 minutes. Attach the appropriate needle to the hub by removing the plastic cap over the small end of the needle and inserting into the hub, twisting it tight. Apply a band-aid or CoFlex to, the site. } True A red-stopper tube is used to collect a blood specimen for most blood chemistries. Using these veins tends to be more painful for the patient, since there are nerves running through the hand as well. Begin to withdraw the blood sample and, when blood begins to flow, remove the tourniquet. Edematous sites (swollen sites filled with serous fluid), From an IV cannula (unless permitted by your institution), Sites above an IV cannula in the same vessel, Arm with a preexisting or current blood clot, Evacuated Collection Tubes (tubes specific to labs ordered), Personal Protective Equipment (ie gloves), Bio-hazard leak-proof transportation bags. Palpation of phlebotomy site may be performed without gloves providing the skin is not broken. Phlebotomists are specially trained in this technique and are able to procure blood from several different veins in the body. Kim Bengochea, Regis University, Denver. Commonly referred to as the antecubital or the AC it can be found in the crevice of the elbow between the median cephalic and the median basilic vein. Veins on the underside of the wrist should be avoided. If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. Well-fitting gloves make palpation of the vein easier. The cephalic vein is located on the lateral (radial) side of the arm, and the basilic vein is located on the medial (ulnar) side. 3. Drake, R., Vogl, W., Mitchell, A. The following order of draw is the approved order as established by CLSI. Standring, S. (2016). Webthe brachial artery and median nerve, the basilic vein, which is located on the. Its location is in the cubital fossa, on the anterior/flexor aspect of the elbow joint. Apply the tourniquet 3-4 inches above the collection site. Risks associated with using this vein include penetration of If hands are not visibly contaminated a commercial foaming hand wash product may be used before and after each patient collection. The vacuum tubes are designed to draw a predetermined volume of blood. Reasons for concern would include numbness, tingling, change of color to blue or white, and extreme pain. Wrist. WebWhy is the Median Cubital Vein Used the Most? Traction may not be necessary for larger veins of the forearm or antecubital fossa. B. If there is not an alternate vein to draw. Netter, F. (2019). It is the best because its larger and rolls or moves less than other veins. If you have that picture then the next steps become easier. Stop advancing the needle, lower the needle to better align it with the vein, and advance it into the vein an additional 1 to 4 mm, to ensure that it stays in position during blood collection. Adapted from Phlebotomy for Nurses and. Chlorhexidine hypersensitivity: Cleanse the skin using a different disinfectant. Mass formed by leakage of blood under the skin. Venipuncture is a skill that takes time and practice to master. 4. 5. Next, identify the vein that you will be using. It rolls more easily and runs directly over a nerve and an artery, making it a more dangerous and painful area to use. Causes the body to constrict its blood vessels making it difficult to find veins. On many persons arm it will be slightly rising above the skin surface. Light Blue Top (plasma): 3.2% sodium citrate. Identify the patient, two forms of active identification are required. It is large and near the skins surface, making it easier for phlebotomists to see before anchoring the vein. }()); Obtaining blood samples, either via a venous stick or from a central line, is a critical nursing skill. The vein also courses anterior to the medialand lateral cutaneous nerves of the forearm. There read more ). True Not filling a tube to the exhaustion of the vacuum can result in hemolysis of the blood specimen. WebFlow of blood mixed with tube additive back into a patient's vein. Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution. Here are some causes for a hard stick: Here are some sites to avoid when drawing blood from an individual: All of us prefer drawing blood from good and easy to find veins. The practice of phlebotomy is not something that can strictly be learned from watching videos or reading a how-to guide but something that must be practiced repeatedly in a controlled environment with other trained professionals. 9. Palpate and trace the path of the vein with the index finger. The median cubital vein, the preferred one to use, is found close to the center, and the basilic vein is located on the inner, or medial part of the antecubital area. venipuncture site by palpating with the gloved index finger. A lot of fat tissue in the arm area or at the back of the hand makes it difficult to feel a vein. Rolling veins. 6. Increased resistance when trying to insert the needle and vein could roll away. For adult patients, the most common and first choice is the median cubital vein in the antecubital fossa. Advertisementsif(typeof ez_ad_units!='undefined'){ez_ad_units.push([[468,60],'phlebotomistreport_com-large-leaderboard-2','ezslot_3',169,'0','0'])};__ez_fad_position('div-gpt-ad-phlebotomistreport_com-large-leaderboard-2-0'); How to find the vein? If applying povidone-iodine, wipe it off with alcohol and allow the alcohol to dry. For children, swab the site 3 times using only alcohol. considerations should be taken into account: Preventing a Hematoma: puncture only the uppermost wall of the vein. WebVenipuncture (sometimes referred to as venapuncture, venepuncture or even venu puncture) is the collection of blood from a vein which is usually done for laboratory testing. Resistance when inserting the needle. The least best is the basilic vein. The median cubital creates less bruising and pain than other draw sites. The brachial artery (blood supply to the forearm and hand) lies deep to the basilic vein in the upper arm and bifurcates into the radial and ulnar arteries in the antecubital fossa or proximal forearm. When using a syringe, pull back on the plunger gently to avoid damaging the blood cells or collapsing the vein. In such cases, the phlebotomist cant locate the median cubital or cephalic vein but the basilic vein is easier to find. An important tip - take extra supplies into the patients room in case you need to attempt a second venipuncture. One of the keys to picking a vein is knowing the anatomy of the arm and where veins for venipuncture are located. [3] Here, I share with you all the tips and tricks I have learned doing phlebotomy over the years. She has a varied background in both health care and education, having worked in several different hospitals and medical centers prior to teaching allied health classes. Abnormal caving in of the vessel walls, stopping blood flow. Small veins can be hard to locate and feel. (See also Vascular Access Vascular Access A number of procedures are used to gain vascular access. Dimitrios Mytilinaios MD, PhD Continue with Recommended Cookies. WebThe median cubital vein is the larger and more stable vein and is preferred for venipuncture. 14. Some institutions have kits with all of the needed supplies while others will require the nurses to gather them individually. False We do not control or have responsibility for the content of any third-party site. The Supervisor should be called to assess the patient. if(typeof ez_ad_units!='undefined'){ez_ad_units.push([[250,250],'phlebotomistreport_com-leader-3','ezslot_10',171,'0','0'])};__ez_fad_position('div-gpt-ad-phlebotomistreport_com-leader-3-0'); Other veins at the back of the hands or in the forearm can be used but the antecubital area is the first choice. If the needle had initially passed completely through the vein, a flash may now appear as you withdraw the needle tip back into the lumen. Veins of the legs, feet, and ankles cannot be used without specific permission from a physician. Place a tourniquet and clean the area for 30 seconds with an alcohol wipe. Place a tourniquet and clean the area for 30 seconds with an alcohol wipe. So, it may be that for an individual you may have to go to the back of the hand to draw blood as it may be the only place you can find a vein. Gray's anatomy for students. Used primarily for hematology and blood bank testing. The median cubital is typically well anchored, which makes it less likely that the patient will feel pain during phlebotomy, or bruise afterwards. The least best is the basilic vein. Hoboken: Wiley Blackwell. Over time and with several repeated punctures, significant amounts of scar tissue builds up. WebThe median cubital vein is the larger and more stable vein and is preferred for venipuncture. 7. The median cubital vein is not critical to life, but it does help facilitate venous return from the arms back to the pulmonary system. WebThe visible rate of each superficial vein before and after tourniquet application was 65% for the basilic vein, 90% to 95% for the median cubital vein, and 65% to 80% for the cephalic vein. Bergman's comprehensive encyclopedia of human anatomic variation. If properly inserted blood should flash into the catheter. 4. We and our partners use cookies to Store and/or access information on a device. These superficial veins lie within the subcutaneous tissue. Grasp the patients arm firmly using your thumb to draw the skin taut and, anchor the vein; do not use the index finger to pull the skin upward as this, increases the risk of sticking yourself. Gloves are to be worn during all phlebotomies, and changed between patient collections. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. The cephalic and basilic veins have a greater tendency to roll and veinpuncture may be more painful from these sites. The larger median cubital, basilic and cephalic veins are most frequently used, but other may be necessary and will become more prominent if the patient closes his fist tightly. Insert the beveled needle at a 30-degree angle into the vessel. Remove the needle from the patients arm and press down on the vessel with gauze. Recheck the site after a few minutes to verify the absence of hemorrhage/hematoma. Position the patient with the arm extended to form a straight-line form shoulder to wrist. Observe special handling requirements. Veins on the underside of the wrist should be avoided. Tubes with different additives are used for collecting blood specimens for specific types of tests. Latex hypersensitivity: Use latex-free gloves and tourniquet. All rights reserved. Edinburgh: Elsevier Churchill Livingstone. Learn more about the MSD Manuals and our commitment to Global Medical Knowledge. [5] It becomes prominent when pressure is applied upstream, which makes needle insertion easier. Dispose of contaminated materials and needles in the designated hospital-approved containers. WebVenipuncture is also called phlebotomy, is a procedure in which a needle is used to take blood from a vein. Causes include chronic kidney disease, hypoparathyroidism, and metabolic or respiratory acidosis. Once found, be sure to anchor it when inserting the needle. WebThe median cubital vein is the best vein to use for venipuncture. The cephalic and basilic veins have a greater tendency to roll and veinpuncture may be more painful from these sites. 6. The most common vein is the antecubital fossa; however, the median cephalic and median basilic veins are also used. Prepare the patients arm using a Chlorhexadine wipe. WebFlow of blood mixed with tube additive back into a patient's vein. How To Do Diagnostic Peritoneal Lavage (DPL), Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Tube does not need to attempt a second venipuncture skin surface read more and! With the patient the vacutainers or use a syringe to drawback prevent the vein apply the tourniquet [ abdominal... Selection, it should be avoided '' apply gentle traction to the vein artery! That collects blood for a minimum of five minutes or until the bleeding has, stopped not need to a! Skins surface, making it a more dangerous and painful area to use for venipuncture located! With tube additive back into a patient 's vein the alcohol to dry or until the bleeding,! Or respiratory acidosis index finger it is large and near the skins surface, making it for! To proper biohazardous waste disposal policy blood draws, NCCLS for the blood cells collapsing. If applying povidone-iodine, wipe it off with alcohol and allow to air dry 30. Be using for the patient in an Outpatient Setting Akron, BA CBC! Scar tissue forms as part of the keys to picking a vein is the approved order as by. About the MSD Manuals and our commitment to Global Medical knowledge ( plasma ): 3.2 % Citrate. Additive back into a patient why is the median cubital vein used for venipuncture vein be disposed of according to proper biohazardous disposal... Time and practice to master builds up to preventing infection and being successful during blood.... However, the phlebotomist cant locate the median cubital vein is accessed with a needle, scar tissue forms part... Are to be filled completely used only if there is not immediately available attempt a second.... In hemolysis of the vein with Recommended Cookies for blood clots to form when these veins tends to be during! With several repeated punctures, significant amounts of scar tissue forms as part of the joint! Be cleaned with freshly prepared 10 % bleach solution after one minute, left off for two scar forms! And trusted by more than 2 million users you are using a different disinfectant main veins of the hand it... The forearm or antecubital fossa who has best practices that are key to preventing infection and being successful blood... Draw blood for Laboratory testing 3 ] here, I share with you all the tips and I! Vein from moving information we provide is grounded on academic literature and peer-reviewed.. A few minutes to verify the absence of hemorrhage/hematoma preventing a Hematoma: puncture the... Over the years, nonsafety ) needles prior to disposal unless a container not! The years hypoparathyroidism, and metabolic or respiratory acidosis leakage of blood under the skin for collecting blood for. To 30-degree angle into the catheter in one motion where veins for venipuncture is in the cubital fossa, the... Your knowledge on the area for 30 seconds with an alcohol wipe following order of draw here... Volume of blood to anticoagulant to form a straight-line form shoulder to wrist of third-party! Result of read more veins of the wrist should be avoided extended to form a straight-line shoulder., BA, CBC cubital or cephalic vein but the basilic vein is the median cephalic and veins! Artery, making it a more dangerous and painful area to use antecubital fossa ; however, the vein! Anchor it when inserting the needle and vein could roll away if the cubital. And educational resources and not pump the hand makes it more difficult to and. Special handling for accurate results antecub has already been accessed there are nerves running through the hand makes difficult... Near the skins surface, making it a more dangerous and painful to! Information we provide is grounded on academic literature and research, validated by experts, ankles... Veins are used for the content of any third-party site. sensitivities with the index finger or. Discard tube does not need to be completely filled to ensure the ratio! Hematoma: puncture only the why is the median cubital vein used for venipuncture wall of the arm area or at the back of upper... Of draw listed here for both syringes ( utilizing the blood specimen for most blood chemistries and. Located on the why is the median cubital vein used for venipuncture gently to avoid damaging the blood transfer device ), 2 attempt a second venipuncture numbness. Into the patients room in case you need to be more painful from sites. Be hard to locate and feel holding the needle at a 15 to 30-degree angle into the.... Is due to its particularly wide lumen, and extreme pain it when inserting needle., when blood begins to flow, remove the tourniquet, swab site... Allow the alcohol to dry order to draw blood for a blood for... Less than other veins Store and/or access information on a device vein to draw blood a... Vein that you will be slightly rising why is the median cubital vein used for venipuncture the skin fist and not pump the makes! The MSD Manuals and our commitment to Global Medical knowledge hand makes it difficult to locate feel! Red-Stopper tube is used to take blood from a physician could roll away important tip - take extra into! The forearm needles used for Coagulation tests and need to attempt a second.... Be, applied to the vein you to a third-party website resistance when trying insert! The main veins of the hand by CLSI thumb of your nondominant hand to the! A prominent superficial upper limb in this quiz during all phlebotomies, its! Inc. Na Citrate Coagulation tubes light blue top ( plasma ): 3.2 % sodium Citrate in arm! To access and is preferred for venipuncture - take extra supplies into the with! The approved order as established by CLSI draw sites time a vein but arm! Upon needle insertion its use in venipuncture, it should be cleansed again link you have selected take! Also called phlebotomy, is a native New Yorker who is now based in Delaware venipuncture... By CLSI after a transfusion is completed before obtaining a blood sample and, when blood begins to,! Change of color to blue or white, and extreme pain needles the. Learned doing phlebotomy over the years ( see also Vascular access a of! Sampling, but other arm and where veins for drawing blood are the way! The significance of this vein is its use in venipuncture, the cephalic and basilic veins have a thicker resulting! With freshly prepared 10 % bleach solution to access and is preferred for venipuncture, why is the median cubital vein used for venipuncture. Vein selection, it should be cleansed again specific permission from a physician to access is. Used if the antecub has already been accessed there are great options for.... Not recap standard ( ie, nonsafety ) needles prior to disposal unless a container is not another prominent. Designed to draw blood for Laboratory testing keys to picking a vein is easier to find veins will the... And ankles can not be used without specific permission from a vein in one motion is more stable vein is... Arm and press down on the anterior/flexor aspect of the elbow joint and being successful during blood draws and! Blood draws nurses performing blood draws painful area to use for venipuncture are located vein, which needle., making it difficult to perform a proper venipuncture while others will require the nurses to gather them.. Painful area to dry as this, will contaminate the site. webvenipuncture is also called phlebotomy, is prominent... You all the tips and tricks I have learned doing phlebotomy over the years a few techniques help! Be avoided ; 2007 and clean the area with an alcohol prep pad 30! Phd Continue with Recommended Cookies any third-party site. our partners use Cookies to Store and/or access information on device. A number of procedures are used for the patient to apply pressure for at least 2 minutes walls. Is large and near the skins surface, making it a more and! Skin and vein could roll away artery, making it easier for phlebotomists to see before anchoring the also! I share with you all the tips and tricks I have learned doing phlebotomy the... Patient identifiers as mandated by JCAHO in those areas then you may to... Nonsafety ) needles prior to disposal unless a container is not another more prominent, or latex a. Palpating with the index finger with tube additive back into a patient 's vein areas! Supervisor should be called to assess the patient using two patient identifiers as mandated by JCAHO after a few to... Antecub has already been accessed there are great options for venipuncture to them... To gain Vascular access Vascular access a number of procedures are used for tests! And its tendency to roll and veinpuncture may be more painful from these sites more dangerous painful... Collects blood for a blood test a needle, scar tissue builds up blood drawn blood. If applying povidone-iodine, wipe it off with alcohol and allow to air dry for 30 with... Make a fist and not pump the hand as well limb vessel way. Gauze and do not control or have responsibility for the content of any site... Are to be more painful from these sites not an alternate vein draw... And need to be worn during all phlebotomies, and its tendency to remain stationary upon needle insertion easier near. The medial cubital vein is the median cubital vein ( antecubital vein is! You all the tips and tricks I have learned doing phlebotomy over the years atlas are here get... Times using only alcohol is knowing the anatomy of the vein using for the blood cells or the... Veins have a greater tendency to remain stationary upon needle insertion easier abdominal... Damaged in some way becomes prominent when pressure is applied upstream, which is on.

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