Ketalar: Uses, Dosage & Side Effects
A dissociative general anesthetic used for induction and maintenance of anesthesia during surgical and diagnostic procedures in adults and children
Ketalar (ketamine) is a dissociative general anesthetic listed on the WHO Model List of Essential Medicines. It produces a unique state of analgesia, sedation, amnesia, and immobility while preserving airway reflexes and spontaneous breathing. Ketamine is administered intravenously or intramuscularly by qualified anesthesiologists for surgical procedures, diagnostic interventions, and procedural sedation in both adults and children. Unlike most other general anesthetics, ketamine stimulates the cardiovascular system rather than depressing it, making it valuable in specific clinical scenarios such as hypovolemic patients and emergency settings.
Quick Facts: Ketalar
Key Takeaways
- Ketalar (ketamine) is a WHO essential medicine used as a dissociative general anesthetic for surgical and diagnostic procedures in adults and children.
- Unlike most anesthetics, ketamine preserves airway reflexes and stimulates the cardiovascular system, making it particularly useful in emergency and resource-limited settings.
- Emergence reactions (hallucinations, vivid dreams, confusion) are common during recovery and can be minimized with benzodiazepines and a calm environment.
- Ketamine must not be used in patients where elevated blood pressure poses a serious risk, or in patients with eclampsia or preeclampsia.
- Long-term use or abuse of ketamine is associated with urinary tract damage, liver problems, and risk of dependence, and it is not intended for prolonged administration.
What Is Ketalar and What Is It Used For?
Ketamine belongs to the pharmacological group of general anesthetics and produces a unique type of anesthesia known as dissociative anesthesia. First synthesized in 1962 and approved for medical use in 1970, ketamine has become one of the most widely used anesthetics globally, particularly in emergency medicine and resource-limited settings. The World Health Organization includes ketamine on its Model List of Essential Medicines, reflecting its critical importance in healthcare systems worldwide.
The dissociative anesthetic state produced by ketamine is characterized by profound analgesia (pain relief), sedation, immobility, and amnesia, while the patient may appear to be awake with eyes open and preserved reflexes. This distinguishes ketamine from other general anesthetics that produce a state of complete unconsciousness. The mechanism involves non-competitive antagonism of the N-methyl-D-aspartate (NMDA) glutamate receptor in the central nervous system, along with interactions with opioid receptors, monoaminergic systems, and voltage-gated ion channels.
Ketalar is primarily used in the following clinical scenarios:
- Sole anesthetic agent: Ketamine can provide complete anesthesia for short surgical and diagnostic procedures without the need for additional anesthetic agents, which is particularly advantageous in resource-limited settings.
- Induction of anesthesia: Used to induce anesthesia before maintenance with other agents, especially in hemodynamically unstable patients where its cardiovascular-stimulating properties are beneficial.
- Supplement to regional anesthesia: Ketamine can be used before or as an adjunct to regional (local) anesthesia techniques such as nerve blocks or spinal anesthesia.
- Procedural sedation: Widely used in emergency departments for painful procedures such as fracture reduction, wound debridement, and abscess drainage.
- Pediatric anesthesia: Ketamine is particularly valuable in children because it can be administered intramuscularly, avoiding the need for intravenous access in uncooperative patients.
One of ketamine's most distinctive properties is its ability to preserve pharyngeal and laryngeal protective reflexes, maintain spontaneous breathing, and stimulate rather than depress the cardiovascular system. These characteristics make it uniquely suited for situations where maintaining airway patency and hemodynamic stability is critical, such as in patients with hypovolemia, trauma, or when advanced airway management equipment is unavailable.
Ketamine is listed on the WHO Model List of Essential Medicines (23rd List, 2023) as a general anesthetic. It is considered one of the safest and most effective medications needed in a healthcare system due to its unique pharmacological profile that preserves respiratory drive and airway reflexes.
What Should You Know Before Receiving Ketalar?
Contraindications
There are specific conditions where Ketalar must not be administered. Your anesthesiologist will carefully assess these before proceeding with ketamine anesthesia:
- You are allergic to ketamine or any of the other ingredients in the formulation
- You have a condition where a significant elevation in blood pressure would constitute a serious hazard (e.g., severe uncontrolled hypertension, recent stroke, aortic dissection)
- You have eclampsia or preeclampsia (a serious pregnancy complication causing dangerously high blood pressure)
Warnings and Precautions
Before receiving Ketalar, inform your doctor or anesthesiologist if any of the following conditions apply to you. This information helps them determine whether ketamine is appropriate and what monitoring or dose adjustments may be necessary:
- Cardiovascular conditions: Reduced blood volume (hypovolemia), dehydration, heart disease (particularly coronary artery disease), heart failure, angina, or previous heart attack. Ketamine stimulates the cardiovascular system and can increase heart rate and blood pressure.
- Elevated blood pressure or rapid heart rate: Pre-existing hypertension or tachycardia may be worsened by ketamine administration.
- Raised intracranial pressure: Conditions involving increased pressure in the brain or spinal cord, including head injuries, brain lesions, or hydrocephalus, as ketamine may further elevate intracranial pressure.
- Eye conditions: Raised intraocular pressure (e.g., glaucoma), open globe injury, or planned eye surgery where elevated eye pressure is undesirable.
- Alcohol-related issues: Current alcohol intoxication or chronic alcohol abuse, as interactions with ketamine can be unpredictable.
- Psychiatric conditions: Schizophrenia, acute psychosis, or other severe mental health disorders, as ketamine can exacerbate psychotic symptoms and cause significant psychological disturbances.
- Acute intermittent porphyria: A rare metabolic disorder affecting the blood-forming enzymes that can be triggered by certain medications.
- Thyroid disorders: Overactive thyroid (hyperthyroidism) or current treatment with thyroid hormone replacement, as these patients have an increased risk of developing severe hypertension and tachycardia when receiving ketamine.
- Respiratory infections: Active lung infections or upper respiratory tract infections, as ketamine increases salivary and bronchial secretions which can complicate airway management.
- Liver disease: Ketamine is metabolized in the liver, and hepatic impairment can affect drug clearance and increase the risk of adverse effects.
- History of substance abuse or dependence: Ketamine has potential for abuse, and individuals with a history of substance use disorders may be at increased risk of developing dependence.
After receiving Ketalar in an outpatient setting, you must not go home unaccompanied. You should abstain from alcohol for at least 24 hours and must not drive or operate machinery for at least 24 hours following administration.
Long-Term Use and Abuse Risks
Ketalar is not intended or recommended for long-term use. When used daily for several weeks, tolerance and dependence can develop, particularly in individuals with a current or previous history of substance abuse. Prolonged use (more than 3 days) or recreational abuse of ketamine has been associated with serious complications including:
- Urinary tract damage: Ketamine cystitis, characterized by bladder inflammation, urinary frequency, urgency, pain, and sometimes blood in the urine. This can lead to irreversible bladder damage in severe cases.
- Liver damage: Abnormal liver function tests and hepatotoxicity have been reported with prolonged exposure.
- Cognitive impairment: Memory problems and difficulty concentrating have been observed with chronic ketamine use.
Pregnancy and Breastfeeding
If you are pregnant, breastfeeding, think you may be pregnant, or are planning to have a baby, inform your doctor before receiving Ketalar.
Pregnancy: Ketamine use during pregnancy is not recommended, with the exception of use during delivery (either vaginal delivery or Caesarean section). If ketamine is administered during childbirth, it may affect the newborn's respiratory rate, and appropriate neonatal monitoring should be available. Animal studies have raised concerns about potential effects on the developing brain, and the FDA has issued warnings about repeated or prolonged use of general anesthetics in the third trimester.
Breastfeeding: Ketamine can pass into breast milk. However, at recommended clinical doses, the risk of adverse effects on the breastfed infant is considered low. Despite this, breastfeeding is generally not recommended immediately after ketamine administration. Consult your healthcare provider about the appropriate time to resume breastfeeding.
Driving and Operating Machinery
Do not drive a car or operate machinery for at least 24 hours after receiving Ketalar. Ketamine significantly impairs reaction time, judgment, coordination, and cognitive function. These effects may persist well beyond the period of apparent clinical recovery. You are responsible for assessing whether you are fit to drive or perform tasks requiring alertness, and you should discuss this with your healthcare provider if you are uncertain.
How Does Ketalar Interact with Other Drugs?
Ketamine has a complex pharmacological profile and can interact with many different classes of medications. These interactions can affect the efficacy of ketamine, alter its side effect profile, or create potentially dangerous combinations. Your anesthesiologist will carefully review your medication list before administering Ketalar and may need to adjust the dose or choose alternative medications.
Major Interactions
The following drug interactions are considered clinically significant and may require dose adjustment, avoidance of the combination, or enhanced monitoring:
| Interacting Drug | Effect | Clinical Significance |
|---|---|---|
| Theophylline / Aminophylline | Increased risk of seizures | Combination should be avoided. Both drugs lower seizure threshold. |
| Halogenated anesthetics (sevoflurane, isoflurane, desflurane) | Bradycardia, hypotension, reduced cardiac output | Increased risk of cardiac depression, especially with high ketamine doses or rapid administration. |
| Sympathomimetics (epinephrine, norepinephrine) | Severe hypertension, tachycardia, cardiac arrhythmias | Additive cardiovascular stimulation. Monitor blood pressure and heart rate closely. |
| Ergometrine | Dangerous blood pressure elevation | Avoid concurrent use, particularly in obstetric settings. |
| Vasopressin | Enhanced hypertensive effect | Combined pressor effects may lead to severe hypertension. |
| Suxamethonium (succinylcholine) | Prolonged neuromuscular blockade | Extended muscle relaxation duration. Monitor neuromuscular function. |
Moderate Interactions
The following interactions are clinically relevant and require careful monitoring or dose adjustment:
| Interacting Drug | Effect | Clinical Significance |
|---|---|---|
| Diazepam (and other benzodiazepines) | Enhanced and prolonged ketamine effects | May be therapeutically useful to reduce emergence reactions, but dose reduction of ketamine may be needed. |
| Barbiturates and opioid analgesics | Prolonged recovery time from anesthesia | Extended monitoring required during recovery period. |
| Atracurium (and other non-depolarizing muscle relaxants) | Enhanced neuromuscular blockade, respiratory depression | Dose reduction of muscle relaxant may be required. Monitor respiratory function. |
| CNS depressants (ethanol, phenothiazines, sedating antihistamines) | Enhanced central nervous system depression, respiratory depression | Dose reduction of ketamine may be necessary. Enhanced respiratory monitoring required. |
| CYP3A4 inhibitors (itraconazole, fluconazole, clarithromycin, erythromycin, verapamil, diltiazem) | Increased ketamine plasma levels | Reduced ketamine dose may be necessary due to decreased metabolism. |
| CYP3A4 inducers (phenytoin, carbamazepine, St. John's Wort) | Decreased ketamine plasma levels | Higher ketamine dose may be needed due to increased metabolism. |
| Thyroid hormones | Increased risk of hypertension and tachycardia | Patients on thyroid replacement therapy require careful cardiovascular monitoring. |
| Antihypertensive medications | Increased risk of hypotension | The cardiovascular effects of ketamine may be unpredictable when combined with antihypertensives. |
Ketamine antagonizes the hypnotic effect of thiopental (thiopentone). If these two agents are used in sequence, the expected clinical effects of thiopental may be diminished. Additionally, ketamine is chemically incompatible with barbiturates and will precipitate if mixed in the same syringe or infusion line.
Food, Drink, and Alcohol
Patients should fast for 4-6 hours before any procedure involving ketamine anesthesia, following standard preoperative fasting guidelines. This reduces the risk of aspiration, although ketamine does preserve protective airway reflexes to a greater degree than most other general anesthetics. Alcohol must not be consumed within 24 hours after receiving Ketalar, as the combination can cause severe central nervous system depression and impaired psychomotor function.
What Is the Correct Dosage of Ketalar?
Ketalar must only be administered by or under the direct supervision of a qualified anesthesiologist. The drug is available as a solution for injection in two concentrations: 10 mg/ml and 50 mg/ml. Dosing is always individualized based on the patient's body weight, age, physical status, clinical indication, type of procedure, and concurrent medications. Equipment to maintain vital functions must be immediately available whenever ketamine is used.
Intravenous (IV) Administration
Induction of Anesthesia
The recommended intravenous induction dose is 1.0 to 4.5 mg/kg body weight, administered as a slow injection over 60 seconds. A dose of approximately 2 mg/kg IV produces surgical anesthesia within 30 seconds of injection, with a duration of 5-10 minutes. Rapid injection should be avoided as it may cause respiratory depression and enhanced pressor response.
Maintenance of Anesthesia
Maintenance may be achieved with repeated bolus doses of half the initial induction dose when signs of lightening anesthesia appear (purposeful movement). Alternatively, a continuous intravenous infusion of 10-45 mcg/kg/min (approximately 1-3 mg/min) may be used, diluted in 0.9% sodium chloride or 5% glucose solution.
Intramuscular (IM) Administration
Induction of Anesthesia
The recommended intramuscular dose is 6.5 to 13 mg/kg body weight. A dose of 10 mg/kg IM typically produces surgical anesthesia within 3-4 minutes of injection, with a duration of 12-25 minutes. The intramuscular route is particularly useful in pediatric patients and in situations where intravenous access is difficult to establish.
Pediatric Dosing
Children
Ketamine is approved for use in children of all ages. Pediatric dosing follows the same weight-based guidelines as adult dosing. Children generally require slightly higher doses per kilogram compared to adults due to faster drug metabolism. The intramuscular route is commonly preferred in younger children who may not cooperate with intravenous access. The attending anesthesiologist will determine the appropriate dose based on the child's age, weight, and the planned procedure.
Elderly Patients
Dose Adjustments in Older Adults
Elderly patients may require lower doses of ketamine due to age-related changes in drug distribution and metabolism. Reduced renal and hepatic function in older adults can prolong the duration of action. Careful titration and enhanced monitoring of cardiovascular parameters are recommended, as elderly patients may be more susceptible to the blood pressure-elevating effects of ketamine.
Overdose
Since Ketalar is exclusively administered by trained healthcare professionals in controlled clinical settings, accidental overdose is extremely unlikely. In the event of an overdose, symptoms would include prolonged anesthesia, respiratory depression, and exaggerated cardiovascular stimulation. Treatment is supportive, with maintenance of airway, breathing, and circulation. There is no specific antidote for ketamine. Mechanical ventilation may be required if respiratory depression occurs.
What Are the Side Effects of Ketalar?
Like all medicines, Ketalar can cause side effects, although not everybody gets them. Side effects are mostly related to the dose administered and the speed of injection, and they generally resolve without specific treatment. Emergence reactions (psychological effects during recovery from anesthesia) are among the most notable side effects and are more common in adults than in children.
Common
May affect up to 1 in 10 patients
- Psychiatric: Hallucinations, abnormal dreams, nightmares, confusion, agitation, abnormal behavior (emergence reactions)
- Neurological: Increased body movements (myoclonus) that may resemble seizures, enhanced eye movements (nystagmus)
- Vision: Double vision (diplopia)
- Cardiovascular: Elevated blood pressure (hypertension), rapid heart rate (tachycardia)
- Respiratory: Increased breathing rate (tachypnea)
- Gastrointestinal: Nausea, vomiting, increased salivation (hypersalivation)
- Skin: Skin flushing (erythema), measles-like rash (morbilliform rash)
Uncommon
May affect up to 1 in 100 patients
- Metabolic: Loss of appetite (anorexia)
- Psychiatric: Anxiety, restlessness
- Eye: Increased intraocular pressure
- Cardiovascular: Irregular heartbeat (arrhythmia), slow heart rate (bradycardia)
- Cardiovascular: Low blood pressure (hypotension)
- Respiratory: Respiratory depression, laryngospasm (spasm of the voice box muscles)
- Skin: Skin rash
- Musculoskeletal: Increased muscle tone (hypertonia)
- Local: Pain and/or rash at the injection site
Rare
May affect up to 1 in 1,000 patients
- Immune: Severe allergic reactions (anaphylaxis)
- Psychiatric: Delirium, flashback phenomena, depression, insomnia, disorientation
- Respiratory: Pulmonary complications, dyspnea (difficulty breathing)
Not Known
Frequency cannot be estimated from available data
- Hepatic: Abnormal liver function tests, liver damage (hepatotoxicity) with prolonged use (>3 days) or drug abuse
- Urological: Cystitis (bladder inflammation), urinary tract symptoms with prolonged use or abuse
Emergence Reactions
Emergence reactions are the most characteristic side effect of ketamine and deserve special discussion. These psychological phenomena occur during the recovery period as the dissociative anesthetic effect wears off. They are reported in approximately 10-30% of adult patients and include vivid, often pleasant dreams, out-of-body experiences, floating sensations, visual hallucinations, confusion, agitation, and delirium. In some patients, these experiences can be distressing and may include nightmares or feelings of anxiety.
Several strategies are used to minimize emergence reactions:
- Benzodiazepine premedication: Administration of diazepam or midazolam before or during ketamine anesthesia significantly reduces the incidence and severity of emergence reactions.
- Recovery environment: Patients should recover in a calm, quiet, dimly lit room with minimal verbal and physical stimulation until fully alert.
- Patient selection: Emergence reactions are more common in adults (particularly those aged 16-65), in females, in patients with a history of personality disorders, and in those who normally dream frequently. They are significantly less common in children.
- Dose optimization: Using the lowest effective dose and slower injection rates can reduce the incidence of emergence phenomena.
It is important to report suspected side effects after a medicine has been authorized. This helps to continuously monitor the benefit-risk balance of the medicine. Healthcare professionals and patients are encouraged to report any suspected adverse reactions to their national pharmacovigilance authority.
How Should Ketalar Be Stored?
Proper storage of Ketalar is essential to maintain its safety and effectiveness. As this medication is exclusively used in healthcare settings, storage is managed by hospital pharmacy staff and healthcare professionals. However, the following storage requirements apply:
- Keep out of reach of children: Store in a secure location inaccessible to children and unauthorized persons. As a controlled substance in many jurisdictions, ketamine requires additional security measures for storage.
- Store in original packaging: Keep the vials in their original carton to protect from light exposure. Ketamine solution is photosensitive and degradation can occur with prolonged light exposure.
- Do not freeze: Ketalar solution must not be frozen. Store at room temperature as specified on the packaging.
- Check expiry date: Do not use Ketalar after the expiry date stated on the carton and label (EXP). The expiry date refers to the last day of the stated month.
- After dilution: Once diluted for infusion (in 0.9% sodium chloride or 5% glucose), the solution should be used within 12 hours.
- After opening: Once the vial is opened, the product should be used immediately from a microbiological standpoint. Any unused portion should be discarded after dosing.
- Visual inspection: Parenteral medications should be inspected visually for particulate matter and discoloration before administration whenever possible. Do not use if the solution appears cloudy or contains particles.
Medicines should not be disposed of via wastewater or household waste. Unused ketamine should be returned to the hospital pharmacy for proper disposal according to local regulations for controlled substances. These measures help protect the environment and prevent misuse.
What Does Ketalar Contain?
Active Ingredient
Each milliliter of Ketalar solution contains ketamine hydrochloride equivalent to either 10 mg or 50 mg of ketamine base. Ketamine hydrochloride is a white crystalline powder that is freely soluble in water, producing a clear, colorless to slightly yellowish solution.
Inactive Ingredients (Excipients)
The inactive ingredients vary slightly between the two available concentrations:
- Ketalar 10 mg/ml: Sodium chloride (for isotonicity), benzethonium chloride (preservative), and water for injections
- Ketalar 50 mg/ml: Benzethonium chloride (preservative) and water for injections
Sodium Content
The 10 mg/ml formulation contains 53 mg of sodium per 20 ml vial, which corresponds to 2.65% of the WHO recommended maximum daily intake of 2 g sodium for an adult. This should be considered for patients on sodium-restricted diets. The 50 mg/ml formulation does not contain added sodium chloride.
Packaging
Ketalar is supplied in glass injection vials in the following presentations:
- 10 mg/ml: 1 x 20 ml vial
- 50 mg/ml: 1 x 10 ml vial, 10 x 10 ml vials
Not all pack sizes may be marketed in every country.
Compatibility
Ketalar is compatible with 5% glucose solution and 0.9% sodium chloride solution for dilution prior to infusion. It is chemically incompatible with barbiturates (precipitation occurs), and these must never be administered through the same cannula or mixed in the same syringe.
Frequently Asked Questions About Ketalar
Ketalar (ketamine) is a general anesthetic used for induction and maintenance of anesthesia during surgical and diagnostic procedures. It produces a unique dissociative anesthetic state with profound analgesia while preserving airway reflexes and spontaneous breathing. It can be used as the sole anesthetic agent, in combination with other anesthetics, or as a supplement to regional anesthesia. Ketamine is suitable for both adults and children and is listed on the WHO Model List of Essential Medicines.
Ketalar is administered only by or under the supervision of a qualified anesthesiologist. It can be given as a slow intravenous (IV) injection, intramuscular (IM) injection, or continuous IV infusion. The route and dosage are determined by the anesthesiologist based on the patient's weight, age, health status, and the type of procedure being performed. It is not available as a tablet or oral solution for anesthesia purposes.
Emergence reactions are psychological phenomena that occur during recovery from ketamine anesthesia, affecting approximately 10-30% of adult patients. They include vivid dreams, hallucinations, out-of-body experiences, confusion, and sometimes agitation or delirium. These reactions can be significantly reduced by premedication with a benzodiazepine (such as diazepam or midazolam), maintaining a quiet and calm recovery environment, minimizing physical and verbal stimulation, and using the lowest effective dose. Emergence reactions are much less common in children than in adults.
Unlike most other general anesthetics that depress the cardiovascular system, ketamine stimulates it by increasing sympathetic nervous system activity. This results in elevated blood pressure, increased heart rate, and increased cardiac output. This property makes ketamine particularly valuable for anesthetizing patients with low blood pressure, hypovolemia (reduced blood volume), or in emergency/trauma situations. However, this cardiovascular stimulation also means ketamine must be avoided in patients where elevated blood pressure could be dangerous, such as those with severe uncontrolled hypertension.
Yes, ketamine is considered safe for use in children of all ages when administered by qualified healthcare professionals. In fact, it is one of the most commonly used anesthetics in pediatric emergency medicine and in developing countries. Children generally tolerate ketamine well, experience fewer emergence reactions than adults, and benefit from the fact that it can be given intramuscularly (avoiding the need for an IV line in uncooperative young patients). The FDA has issued general warnings about prolonged or repeated exposure to general anesthetics in children under 3, but short-term single-use ketamine for procedures is considered safe.
Ketamine is generally not recommended during pregnancy, with the exception of use during childbirth. It can be used for Caesarean section or vaginal delivery when clinically indicated. However, if given during delivery, ketamine may affect the newborn's respiratory rate, so appropriate neonatal resuscitation equipment should be available. Ketamine crosses the placenta and animal studies suggest potential developmental concerns, which is why it is avoided during the first and second trimesters unless the benefit clearly outweighs the risk.
References
- World Health Organization (WHO). WHO Model List of Essential Medicines - 23rd List (2023). Geneva: WHO; 2023. Available at: who.int/publications
- European Medicines Agency (EMA). Ketalar - Summary of Product Characteristics. Last updated 2023. Available at: ema.europa.eu
- U.S. Food and Drug Administration (FDA). Ketamine Hydrochloride Injection - Prescribing Information. Reference ID: 4983816. Revised 2024.
- Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med. 2011;57(5):449-461. doi:10.1016/j.annemergmed.2010.11.030
- Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014;8(3):283-290. doi:10.4103/0259-1162.143110
- Mion G, Villevieille T. Ketamine pharmacology: an update (pharmacodynamics and molecular aspects, recent findings). CNS Neurosci Ther. 2013;19(6):370-380. doi:10.1111/cns.12099
- American Society of Anesthesiologists (ASA). Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018. Anesthesiology. 2018;128(3):437-479.
- Peltoniemi MA, Hagelberg NM, Olkkola KT, Saari TI. Ketamine: A Review of Clinical Pharmacokinetics and Pharmacodynamics in Anesthesia and Pain Therapy. Clin Pharmacokinet. 2016;55(9):1059-1077. doi:10.1007/s40262-016-0383-6
- Gao M, Rejaei D, Liu H. Ketamine use in current clinical practice. Acta Pharmacol Sin. 2016;37(7):865-872. doi:10.1038/aps.2016.5
- British National Formulary (BNF). Ketamine. National Institute for Health and Care Excellence (NICE). Updated 2025. Available at: bnf.nice.org.uk
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