LOW-RISK SPINAL FUSION

Transcription

1 LOW-RISK SPINAL FUSION PRE-HOSPITAL MANAGEMENT Assessment Evaluate learning needs, psychscial assessment, nutritin assessment, and sleep assessment Educatin Patients 11 years and lder attend pre-p spine class, patients yunger than 11 years receive 1:1 teaching Pre-perative skin care (at hme) the night befre surgery Shwer, dry ff, use 1 packet f 2% chlrhexidine glucnate clths t wipe entire back, air dry, clean pajamas PRE-OPERATIVE MANAGEMENT Assessment Radigraphs PA and lateral standing radigraphs in EOS prir t surgery with spine-bending films as clinically indicated Assessment Labratry MRSA nasal culture, Urine Analysis (UA) as clinically indicated, Urine pregnancy test (females age 12 and lder), type and screen, type and crssmatch Antibitics and Pain Medicatins See Table 2. Suggested Pre-perative Medicatins See Algrithm fr Standard Surgical Prphylaxis Surgery Patients POST-OPERATIVE MANAGEMENT Assessment Mnitring Vital signs and neurvascular assessment every 4 hurs fr the first 24 hurs, then every 8 hurs until discharge. Cntinuus pulse ximetry if patient requires xygen r is n patient-cntrlled analgesia Recrd utput frm indwelling catheter every 4 hurs fr the first 24 hurs, then every 8 hurs until discntinued Medicatins Activity See Table 3. Suggested Pst-perative Medicatin See Algrithm fr Standard Surgical Prphylaxis Surgery Patients Day f surgery: lgrll every 2 hurs, elevate head f the bed, dangle edge f bed as tlerated Pst-p Day 1: lgrll, up t chair, begin ambulatin, parent f child assistance in activities Pst-p Day 2 t Discharge: Dress, get ut f bed, ambulate in rm and hallway, walk up and dwn stairs Treatments Incentive spirmetry, cld therapy, and SCD stckings DISCHARGE CRITERIA The fllwing criteria must be met: Off xygen as clinically indicated, tlerate ral intake, viding, pain well cntrlled with rals meds, cleared by PT, uter dressing remved, receive and understand discharge instructins Page 1 f 17

2 TABLE OF CONTENTS Algrithm- N/A Pathway Summary Target Ppulatin Backgrund Definitins-N/A Initial Evaluatin- See Clinical Management Clinical Management Pre-Hspital Management Pre-Operative Management Pst-Operative Management Labratry Studies Imaging- See Clinical Management Therapeutics- See Clinical Management Discharge Criteria Fllw-Up Algrithm- Standard Surgical Prphylaxis Table 1. Develpmentally Nrmal Spine Fusin Care Path Table 2. Suggested Medicatins fr the Pre-Operative Perid Table 3. Suggested Medicatins fr the Pst-Operative Perid Parent Caregiver Educatin References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Patients 8 t 21 years f age with idipathic r cngenital sclisis, kyphsis, r spndyllysis withut cmplex chrnic cnditins Exclusin Criteria Patients less than 8 years f age High-risk spinal fusin patients PRE-HOSPITAL MANAGEMENT Assessment Evaluate the learning needs f the patient and caregivers prir t admissin Nte: Evidence indicates a large prtin f parents have limited literacy [Yin, 2009]. Parent health literacy may be linked t child health utcmes [Yin, 2009; DeWalt, 2009] Page 2 f 17

3 Cmplete a psychscial assessment prir t admissin Educatin Nte: The psychscial assessment shuld include evaluatin f the family supprt system, plan fr family pst-surgery, schl issues/cncerns, guardianship, and resurces Nutritin assessment by registered dietician fr patients with a bdy mass index (BMI) less than 10% fr age r greater than 85% fr age Cmplete sleep assessment prir t surgery by asking the fllwing fur questins: Des yur child pause in their breathing at night? Des yur child struggle t take a breath at night? Des yur child feel sleepy during the day? Des yur child snre mre than half f the night? Patients ver 11 years: shuld attend a pre-perative spine class Patients less than 11 years f age: shuld receive 1:1 pre-perative teaching Patients unable t attend a spine class: shuld receive 1:1 pre-perative teaching Nte: caregivers shuld receive educatin alng with the patient It is suggested that patients and caregivers receive a tur f the hspital prir t surgery Nutritin Encurage a well-balanced diet during the pre-perative perid Nte: Adequate pre-perative nutritin has been assciated with imprved healing and decreased infectin [Hatlen, 2010] Nil per s (NPO) guidelines accrding t anesthesia guidelines Treatments Nte: The American Sciety f Anesthesilgists recmmends a minimum fasting perid f six hurs fr slids and nnhuman milk/frmula and a minimum f tw hurs fasting frm clear liquids [Practice guidelines fr pre-perative fasting, 2011] Preadmissin pre-perative skin care Parents instructed nt t shave r use depilatry n the patient s back fr at least a week prir t surgery N new tatts r piercings in the 3 mnths prir t surgery date Preadmissin pre-perative skin care the night befre surgery Patient t shwer the night befre surgery After drying ff frm the shwer, patient t use ne packet (= 2 clths) f 2% chlrhexidine glucnate clths t wipe their entire back; d nt rinse with water; allw t air dry Put n clean pajamas Pre-perative cleanse by pre-p nurse with 2% chlrhexidine glucnate (CHG) antiseptic clth the mrning f the surgery Use ne packet (= 2 clths) t wipe the entire back frm tp f shulders t upper buttcks, including sides, cmpletely wetting the skin; discard clths Allw skin t cmpletely air dry d nt rinse Page 3 f 17

4 Nte: The use f a 2% chlrhexidine glucnate-cated clth r 4% CHG sap with a standardized, timed prcess befre hspital admissin is an effective infectin preventin strategy fr reducing the risk f pstperative surgical site infectins (SSIs) [Edmistn, 2010] PRE-OPERATIVE MANAGEMENT Assessment Radigraphs Psterir/Anterir (PA) and lateral standing radigraphs in standard EOS prir t surgery Sclisis patients: AP supine bending radigraphs, Kyphsis patients: AP lateral blster radigraphs f the thracic spine Other radigraphs as clinically indicated MRI as clinically indicated Assessment Labratry Nasal culture fr methicillin-resistant Staphylcccus aureus (MRSA) within 30 days prir t surgery Nte: Pre-perative testing and treatment f patients psitive fr MRSA has been shwn t decrease the incidence f pst-perative infectins [Epstein, 2011] Urine analysis (UA) with micrscpy btained if clinically indicated Questins fr verbal assessment fr UA D yu have a histry f urinary tract infectins (UTIs)? If yes, when was the mst recent UTI? Answer: NO N UA is needed Answer: YES Clean catch UA and hld fr culture if psitive UTI in the past 3 mnths r has histry f frequent (definitin f frequent based n clinical judgment) UTIs D yu currently have any frequency, burning r ful-smelling urine? Answer: NO N UA is needed Answer: YES Clean catch UA and culture Nte: If UA is suggestive f UTI, a urine culture shuld be btained and apprpriate antibitic cverage shuld be initiated A psitive UA wuld include any f the fllwing and shuld be sent fr culture (per Dr. Nyquist) Psitive fr white cells, greater than 0-5/hpf Psitive fr red cells, greater than 0-3/hpf Psitive fr nitrates Psitive fr leukcytes Nte: Pre-perative bacteriuria may increase pst-perative cmplicatins [Hatlen, 2010] Urine pregnancy test fr all females 12 years and lder and/r pstmenarchal Day f pre-p visit: HCT and Type and screen t determine if antigens are present Type and crssmatch n day f surgery Assessment Other Tests Pulmnary functin tests (PFTs) fr patients with a thracic sclisis curve greater than 70, kyphsis greater than 70, any planned chest wall vilatin during surgery, r histry f uncntrlled asthma Page 4 f 17

5 Medicatins Obtain infectius disease recmmendatins fr apprpriate antibitic cverage fr patients that have received antibitic treatment within the previus 90 days Antibitics See Table 2. Pre-perative Medicatins See Algrithm fr Standard Surgical Prphylaxis Surgery Patients Cefazlin 30 mg/kg IV cmpletin f antibitic within 60 minutes f surgical incisin OR Vancmycin 15 mg/kg IV cmpletin f antibitic within 60 minutes f incisin fr patients with a beta-lactam allergy, patients in an institutin with a high prevalence f MRSA r MRSE surgical site infectins, patients clnized r at high-risk fr clnizatin with MRSA, patients ver the age f 13, r pst menarchal, r with acne, r with signs f maturity such as pubic hair r breast buds If vancmycin, pre-medicate with PO r IV ranitidine and diphenhydramine Pain Medicatins Fr patients wh can swallw pills, give gabapentin capsule r acetaminphen tablet n arrival t the pre-p area Fr patients wh can t swallw pills, give gabapentin ral slutin r acetaminphen ral slutin, chewable tablets, r IV acetaminphen will be given in the OR POST-OPERATIVE MANAGEMENT Assessment Mnitring Vital signs and neurvascular assessment every 4 hurs fr 24 hurs, then every 8 hurs until discharge Cntinuus pulse ximetry if patient requires supplemental xygen r is n patient-cntrlled analgesia Recrd utput frm indwelling catheter every 4 hurs fr the first 24 hurs and then every 8 hurs until discntinued Discntinue urinary catheter as sn as the patient can ambulate t the bathrm (pst-p day 1 r 2) Labratry Hematcrit (HCT) every mrning fr the first three pst-perative days unless: If HCT greater than (>)30 n pst-perative day 1, discntinue If HCT greater than (>)27 n pst-perative day 2, discntinue Decisin t transfuse shuld be based n clinical symptms and hematcrit Medicatins Persistent tachycardia nt due t pain Oxygen requirement despite aggressive pulmnary tilet Symptms f hyptensin n standing See Table 3. Pst-perative Medicatins See Algrithm fr Standard Surgical Prphylaxis Surgery Patients Page 5 f 17

6 Antibitics Cntinue antibitic prphylaxis (cefazlin r vancmycin) fr 3 dses pst-peratively and discntinued by 24 hurs pst surgery See Algrithm fr Standard Surgical Prphylaxis Surgery Patients Pain Medicatin cnfirm with Anesthesia Patient-Cntrlled Analgesia (PCA) (Mrphine r Dilaudid) N basal rate shuld be rdered due t intrathecal mrphine given in OR. Only demand thse rdered. Discntinue PCA after patient has tlerated 2 dses f ral pain medicatins n pst-p day 1 See Patient-cntrlled Analgesia (PCA) Set-up, Administratin, and Dcumentatin Acetaminphen Oral every 4 hurs fr 48 hurs, then every 4 hurs per PRN Oxycdne Every 4 hurs scheduled fr 48 hurs, then every 4 hurs PRN First pst-p dse t begin first pst-p day at 0900 ( Start PRN dse 4 hurs after scheduled dse. ) Gabapentin Same dse as pre-p dse TID (three times a day) starting n the evening f the surgery day (2100) and cntinuing thrugh until the evening f the secnd pst-p day, fr a ttal f 7 dses Ketrlac Arund the clck fr 48 hurs beginning 0900 n the first pst-perative day, then ibuprfen PRN until discharge Diazepam Every 6 hurs as needed fr spasms Bwel Regimen Senna/Dcusate twice a day Plyethylene glycl nce a day Fleets enema PRN Other Medicatins Nalbuphine Ondansetrn Scplamine, fr patients 12 years f age and lder Ranitidine Multivitamin Activity Day f surgery If mrning surgery, dangle patient n side f the bed and/r stand and/r sit in the chair if the patient is able (standing and chair are ptinal based n clinical assessment) Lgrll patient every 2 hurs and as needed Elevate head f bed up t 90 (ptinal) Page 6 f 17

7 Pst-perative Day 1 Lgrll patient every 2 hurs and as needed Physical therapy (PT) twice daily Encurage and assist patient t sit n the edge f the bed, stand and t chair Begin ambulatin Parent f child (POC) shuld be encuraged t participate in assisting with turning, ambulatin, and activities f daily living, as well as with guided imagery, distractin and ther frms f pain management Once cleared by PT, nursing r parent f child shuld assist patient with standing, sitting in chair, and ambulatin at least 4 times per day until discharge Pst-perative Day 2 t Discharge Patient shuld dress in wn clthing nce the urinary catheter has been discntinued Assist patient up t chair and t ambulate in patent rm and hallway at least 3-4 times per day Patient shuld be able t get ut f bed with minimal family assistance Walk up and dwn stairs Patient must be able t climb stairs t pass PT After patient has been discharged frm PT, patient and caregiver shuld be cmpetent with independent transfers prir t discharge frm hspital Nutritin Idipathic r therwise healthy patients shuld nly have clear liquids n the day f surgery Prvide a light diet fr breakfast n pstperative day 1 and then advance t regular diet as tlerated A well-balanced, high fiber diet with small frequent meals and increased calric intake shuld be prvided t encurage healing Treatments VTE preventin Patients at risk fr Venus Thrmbemblism (VTE) receive prphylaxis in accrdance with the VTE guideline Cld therapy As needed t decrease pain Cld therapy is prvided t patients fr cmfrt and nt necessarily t manage swelling r drainage If the patient des nt tlerate cld therapy, it des nt need t be used Family t take cld therapy unit hme upn discharge Fley catheter Discntinue when the patient is able t ambulate t the bathrm (pst-p day 1 r day 2) Incentive spirmetry (14cc/kg) 10 times per hur while awake If nt able t cnsistently achieve 14cc/kg n incentive spirmeter, EZ pap treatments shuld be implemented per lung expansin prtcl Page 7 f 17

8 Dressing care Reinfrce dressings if saturated until first dressing change Dressing ptins (3) MediHney and Mepilex First dressing change is day prir t r day f discharge (r sner if siled with feces r urine) Keep the dressing clean and dry Parents remve dressing 3 days after discharge Prine w/mepilex and Tegaderm Remve mepilex and tegaderm befre discharge D nt replace mepilex prir t discharge Leave prine intact upn discharge Parents t remve Prine 3 weeks after day f surgery Zipline Remve medihney and mepilex befre discharge D nt replace mepilex prir t discharge. Caregiver may remve zipline 3 weeks after discharge by applying baby il alng the whle length f the zipline, which will allw fr gentle separatin frm the skin. The zipline is allwed t get wet in the shwer (n bathing) and can take up t 2-3 days t remve. Assess fr clinical signs and symptms f surgical site infectin and, if present, reprt t surgical team Discharge teaching includes hand hygiene and dressing/wund care DISCHARGE CRITERIA Patient shuld nt be discharged until the fllwing criteria have been met: Off xygen as clinically indicated Tlerating ral intake Viding Bwel mvement (BM) nt required prir t discharge if NOT symptmatic (nausea, vmiting, distentin) Pain well cntrlled with ral medicatins Cleared by PT Patient r caregiver can verbalize understanding f discharge teaching instructin FOLLOW-UP Fllw-up visits shuld ccur at 4 t 8 weeks pst-peratively and annually frm the surgical date until discharged frm care by the prvider. Additinal visit may be advised per prvider discretin Page 8 f 17

9 ALGORITHM: STANDARD SURGICAL PROPHYLAXIS FOR SURGERY PATIENTS Page 9 f 17

10 Table 1. Develpmentally Nrmal Spine Fusin Care Path Time frame Within 1-2 mnths f scheduled spine fusin Assessment/ Mnitring Fluids/ Medicatins Assess learning needs. Screen fr sleep apnea. Screen med/surg and scial histry. Nutritinal assessment. NA Pre-p/ Day f Surgery H&P and cncents. Pre-p x-rays including benders and blsters as rdered by prvider. MRSA, type and screen (day f prep). urine pregnancy test, type and crssmatch (day f surgery) PFTs if indicated. Prep medicatin fr anxiety per anesthesia. Antibitics per surgical prphylaxis algrithm. If vancmycin indicated give diphenhydramine and ranitidine. Gabapentin and acetaminphen as rdered fr pain management. Pst-p/ Day f Surgery Vitals, neurvascular checks, lgrll q 4hrs. Fley. EMR every 4hrs x24. Pulse x /CR mnitr while n PCA r xygen needed. Sedatin scre every 2hrs x24 hrs. MIVF, PCA as rdered. Ranitidine until tlerating ral medicatins. Diazepam as needed. Ondansetrn and ketrlac as scheduled. Cefazlin r vancmycin 3 dses pst-p. Gabepentin and acetaminphen as rdered. Activity Ad lib Ad lib Lgrll every 2 hrs (even thrugh the night). If am surgery dangle/ stand/ sit in chair as tlerated in the afternn/ evening Nutritin Encurage well balanced diet NPO per anesthesia guidelines Clear liquids day f surgery Pst-p: Day 1 Vitals, neurvascular checks, lgrll q 4hrs. Fley. EMR every 8hrs until discharge. Discntinue fley if able t ambulate t bathrm. Hematcrit every am x3 days. Reinfrce dressing as needed. PCA: transitin t ral pain medicatins. Give ral pain med every 4hrs ATC as rdered. Discntinue PCA after patient has tlerated 2 dses f ral pain medicatins. Bisacdyl suppsitry as rdered. Senna-dcustae p QD Physical therapy (PT) t see patient twice a day until cleared. Dangle n edge f bed with PT. Up t chair, begin ambulating. Light breakfast first pst p day then advance as tlerated. Pst-p: Day 2 and 3 Cntinue all applicable items frm previus day. Dscntinue fley if able t ambulate t bathrm. IVF may cap PRN. Start ibuprfen when ketrlac discntinued. Oral pain meds prn after 48 hurs.diazepam as needed PT t assist with standing, sitting in chair, and ambulatin. Encurage patient t dress when fley discntinued. Advance as tlerated Remaining Days t Discharge Dressing ptins If mepilex/ medihney/steri strips: change dressing day befre r day f discharge. Use medihney and mepilex. Leave n fr 3 mre days at hme. If prine: remve mepilex prir t discharge and then leave pen t air and have family remve in 3 weeks. Zipline Remve medihney and mepilex befre discharge. D nt replace mepilex prir t discharge. Caregiver may remve zipline 3 weeks after discharge by applying baby il alng the whle length f the zipline, which will allw fr gentle separatin frm the skin. The zipline is allwed t get wet in the shwer (n bathing) and can take up t 2-3 days t remve. Orals every 4 t 6 hrs pm. Diazepam as needed. Nursing and parent f child t get patient up at least fur times a day t ambulate Patient and parent f child shuld practice and be cmpetent with independent transfers. Encurage well-balanced, high fiber diet with small frequent meals. Increase calric intake fr healing. Page 10 f 17

11 Table 1. Develpmentally Nrmal Spine Fusin Care Path cntinued Time frame Within 1-2 mnths f scheduled spine fusin Pre-p/ Day f Surgery Treatments NA CHG wash night befre surgery. SCD stckings VTE prtcl. Respiratry incentive spirmeter (IS) 10x every hur while awake. Begin ezpap (if unable t d IS) 14ml/kg cnsistently per lung expansin prtcl. Teaching Pre-p spine class and hspital tur (can be dne pre-p day if can t attend class) Meet with PA r resident t sign cnsent frms. Review teaching with Spine RN. Pst-p/ Day f Surgery Oxygen t keep sats greater than 92%. Ice pack pm. SCD stckings per VTE prtcl. Respiratry incentive spirmeter (IS) 10x every hur while awake. Begin ezpap (if unable t d IS) 14ml/kg cnsistently per lung expansin prtcl. Plan f care. Orient t unit. Teach parent f child t fill cld therapy unit, have help with lgrll Pst-p: Day 1 Respiratry incentive spirmeter (IS) 10x every hur while awake. Begin ezpap (if unable t d IS) 14ml/kg cnsistently per lung expansin prtcl. Pain cntrl plan. Encurage further parent invlvement in lgrlling and ambulating. Distractin and guided imagery techniques. Have parent review handut Guide t Pstp Pain Management fr Idipathic Spine Patients and handuts under Ging Hme tab in spine bk Pst-p: Day 2 and 3 Cntinue all applicable items frm previus day Begin discussing discharge plans. Encurage parent f child t prblem slve fr hme. Have patient and parent f child try things independently with standby assist frm RN/CA. Cmplete discharge check list in spine bk. Remaining Days t Discharge Cntinue all applicable items frm previus day Review spine fusin discharge instructin handut, pain medicatins, and weaning cnstipatin management, shwering. Have parent f child take hme cld therapy unit. Page 11 f 17

12 Table 2. Suggested Medicatins fr the Pre-perative Perid Page 12 f 17

13 Table 3. Suggested Medicatins fr the Pst-perative Perid Page 13 f 17

14 Table 3. Suggested Medicatins fr the Pst-perative Perid cntinued CAREGIVER EDUCATION MATERIALS See the Spine Prgram bk given t the patient at the pre-perative visit. Page 14 f 17

15 REFERENCES Health Literacy 1. Yin HS, Jhnsn M, Mendelshn AL, Abrams MA, Sanders LM, Dreyer BP. The health literacy f parents in the United States: a natinally representative study. Pediatrics 2009; 124 Suppl 3:S DeWalt DA, Hink A. Health literacy and child health utcmes: a systematic review f the literature. Pediatrics 2009; 124 Suppl 3 :S Pre-perative, Intra-perative, and pst-perative measures 1. Hatlen T, Sng K, Shurtleff D, Duguay S. Cntributry factrs t pstperative spinal fusin cmplicatins fr children with myelmeningcele. Spine 2010; 35: Practice guideline fr preperative fasting and the use f pharmaclgic agents t reduce the risk f pulmnary aspiratin: applicatin t healthy patients underging elective prcedures: an updated reprt by the American Sciety f Anesthesilgists Cmmittee n Standards and Practice Parameters. Anesthesilgy 2011; 114: Edmistn CE, Okli O, Graham MB, Sinski S, Seabrk GR. Evidence fr using chlrhexidine glucnate preperative cleansing t reduce the risk f surgical site infectin. AORN J 2010; 92: Epstein NE. Preperative, intraperative, pstperative measures t further reduce spinal infectins. Surg Neurl Int 2011; 2:17. Gabapentin literature 1. Khurana G, et al. Pstperative pain and lng-term functinal utcme after administratin f gabapentin and Ppegabalin in patients underging spinal surgery. Spine (6): E Mathiesen O, et al. A cmprehensive multimdal pain treatment reduces piid cnsumptin after multilevel spine surgery. Eur Spine J (9): Pandey, CK. Des preemptive use f gabapentin have n effect n pstperative pain and mrphine cnsumptin fllwing lumbar laminectmy and discectmy. J Neursurg Anesthesil (3); Pandey CK, et al. Evaluatin f the ptimal preemptive dse f gabapentin fr pstperative pain relief after lumbar diskectmy: a randmized, duble-blind, placeb-cntrlled study. J Neursurg Anesthesil (2): Pandey CK, et al. Preemptive gabapentin decreases pstperative pain after lumbar discectmy. Can J Anaesth (10): Rusy, LM et al. Gabapentin use in pediatric spinal fusin patients. Anesthesia & Analgesia (5): Van Elstraete, AC, et al. The median effective dse f preemptive gabapentin n pstperative mrphine cnsumptin after psterir lumbar spinal fusin. Anesth Analg (1): 305. Page 15 f 17

16 CLINICAL IMPROVEMENT TEAM MEMBERS Sumeet Garg, MD Orthpedic Surgery Mindy Chen, MD Anesthesilgy Mark Ericksn, MD Orthpedic Surgery Elise Benefield, RN Clinical Nurse IV Suzanne Evans, RN Clinical Nurse IV Rachel Lvria, PharmD Clinical Pharmacist Aimee Bernard, PhD Clinical Care Guideline Crdinatr APPROVED BY Clinical Care Guideline and Measures Review Cmmittee April 18, 2016 Pharmacy & Therapeutics Cmmittee March 3, 2016 MANUAL/DEPARTMENT ORIGINATION DATE Clinical Care Guidelines/Quality February 2, 2012 LAST DATE OF REVIEW OR REVISION April 18, 2016 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW/REVISION SCHEDULE Scheduled fr full review n April 18, 2020 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 16 f 17

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