The present disclosure relates to medical devices and methods for preventing infections. More specifically, the disclosure relates to medical devices and methods for eliminating and/or reducing aerosol emitted from a heater/cooler unit in an operating room environment for cardiac surgery.
Heater/cooler units or devices are important tools in surgeries involving the heart, lungs, and other cardiothoracic surgeries. Heater/cooler units can be used to warm or cool a patient, the patient's blood, and/or other fluids used during surgery. Heater/cooler units include tanks that provide temperature-controlled water to external heat exchangers or to warming/cooling blankets through closed water circuits. For example, in cardiopulmonary bypass (CPB) surgeries, a heater/cooler unit can be used with a heart-lung machine featuring separate temperature control for extracorporeal perfusions. The heater/cooler water or fluid circuits are used for heating and cooling blood in the oxygenator, hypothermia blankets, and cardioplegic solutions.
It is often recommended that heater/cooler units be cleaned on a regular basis, such as every two weeks. Cleaning a heater/cooler unit may include completely draining the fluid tanks and rinsing the water circuits with sanitizing agents. If the heater/cooler is not cleaned regularly, micro-organisms may grow inside the unit. These micro-organisms may exit the heater/cooler unit, be dispersed in the operating room, and reach the surgical operating theatre, potentially causing infections in the patient.
A first example system of the disclosure includes a filter configured to be fluidly coupled by tubing to a vacuum source and to a tank or an internal space of a heater/cooler unit by the tubing. The filter includes a filter container having negative air pressure therein provided by the vacuum source to suction aerosol from the heater/cooler unit internal space (or tank) into the filter container and eliminate or reduce the aerosol emitted from the heater/cooler unit. The aerosol is segregated from the heater/cooler unit and prevented from being dispersed in the operating theatre.
A second example system of the disclosure includes tubing including a first tube and a second tube, a vacuum source, and a filter fluidly coupled to the vacuum source by the first tube and an internal space in a heater/cooler unit by the second tube. The vacuum source provides negative air pressure to the filter to suction aerosol from the heater/cooler unit.
A third example system of the disclosure includes tubing and a filter configured to be fluidly coupled to a vacuum source and to an internal space (or tank) of a heater/cooler unit by the tubing, such that the filter receives negative air pressure from the vacuum source to suction aerosol from the heater/cooler unit into the filter. At least one of the tubing and the filter is disposable to reduce contamination and prevent build-up of contamination.
A fourth example system of the disclosure includes a disposable unit to be fluidly coupled to a vacuum source and to an internal space of a heater/cooler unit, the disposable unit having an aerosol filter and tubing to couple the disposable unit to the vacuum source and to the internal space of the heater/cooler unit.
A first example method of the disclosure includes eliminating or reducing aerosol emitted from a heater/cooler unit by fluidly coupling a filter to a vacuum source and to either an internal space or a tank of the heater/cooler unit by tubing and activating the vacuum source for a time to provide negative air pressure in the filter and suction the aerosol from the heater/cooler unit into the filter. A sensor may be provided to sense the presence of aerosols, or conditions likely to result in the production of aerosols, in the heater/cooler unit. The sensor may be used to activate or deactivate the vacuum source.
A second example method of the disclosure includes reducing aerosol emitted from a heater/cooler unit operable during a surgical procedure on a patient, the heater/cooler unit comprising a heater, an internal space comprising a fluid tank, and an overflow port, by connecting a filter to a vacuum source and the overflow port of the heater/cooler unit by tubing, activating the vacuum source for at least a limited time during at least a portion of an operation of the heater to provide negative air pressure in the filter and suction aerosol from the internal space (or the tank) of the heater/cooler unit into the filter, disconnecting the filter and tubing from the vacuum source and the overflow port after completion of the surgical procedure, and disposing of the filter and tubing
While multiple embodiments are disclosed, still other embodiments of the present disclosure will become apparent to those skilled in the art from the following detailed description, which shows and describes illustrative embodiments of the disclosure. Accordingly, the drawings and detailed description are illustrative in nature and not restrictive.
While the disclosure is amenable to various modifications and alternative forms, specific embodiments have been shown by way of example in the drawings and are described in detail below. The intention, however, is not to limit the disclosure to the particular embodiments described. On the contrary, the disclosure is intended to cover all modifications, equivalents, and alternatives falling within the scope of the disclosure as defined by the appended claims.
The system 20 further includes tubing 24 and a filter unit 26. The filter unit 26 is fluidly coupled to the heater/cooler unit 22 and to a vacuum source 28 by the tubing 24. In some embodiments, the tubing 24 is configured to be detachably coupled to at least one of the filter unit 26, the heater/cooler unit 22, and the vacuum source 28. In some embodiments, the filter unit 26 is configured to be detachably coupled to at least one of the tubing 24, the heater/cooler unit 22, and the vacuum source 28. In some embodiments, at least one of the tubing 24 and the filter unit 26 is disposable, such that contamination from the disposable part(s) is discarded and build-up of contamination is prevented. In some embodiments, both the tubing and the filter unit are disposable, either as individual items or together as part of a single disposable unit. In still further embodiments, a sterile disposable unit having an aerosol filter unit and tubing may be provided in a sealed container.
Referring again to
In some embodiments, a disposable aerosol removal kits for coupling to an existing overflow port 30 on a heater/cooler unit 22 may include a filter unit 26 and tubing 24. Optionally, a disposable vacuum element may also be included in the disposable kit. The disposable kit may be provided as a sterile unit in a sealed container.
In operation, the vacuum source 28 is activated to provide a vacuum or a negative air pressure relative to the external air pressure to the filter unit 26. In some embodiments, the vacuum source 28 is manually activated. In some embodiments, the vacuum source 28 includes an electronic control circuit 32 that activates the vacuum source 28 for a limited duration to remove the aerosol from the heater/cooler unit 22. In some embodiments, the vacuum source 28 includes an electronic control circuit 32 that activates the vacuum source 28 for at least 10 minutes to remove the aerosol from the heater/cooler unit 22. In some embodiments, the vacuum source 28 includes an electronic control circuit 32 that activates the vacuum source 28 whenever the heater/cooler unit 22 is activated to remove the aerosol from the internal space 22a of the heater/cooler unit 22. In some embodiments, the vacuum source 28 is turned on before the heater/cooler unit 22 is turned on. In some embodiments, the vacuum source 28 is turned on at the same time the heater/cooler unit 22 is turned on.
In some embodiments, the heater/cooler unit 22 includes a pressure sensor 25 to determine the pressure in at least one of the internal space 22a and the one or more tanks 23. In some embodiments, the pressure sensor 25 is communicatively coupled to the electronic control circuit 32, such as by wire or wirelessly. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from the pressure sensor 25 indicating that the pressure equals or exceeds a pressure where aerosols may escape from the heater/cooler unit 22 and into the environment. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from the pressure sensor 25 indicating that the pressure equals or exceeds the current ambient pressure, also referred to as zero herein. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from the pressure sensor 25 indicating that the pressure equals or exceeds the current atmospheric pressure. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from the pressure sensor 25 indicating the pressure equals or exceeds a pressure threshold. In some embodiments, the pressure threshold is a factory preset threshold. In some embodiments, the pressure threshold is set by an operator and/or the electronic control circuit 32. In some embodiments, the pressure threshold is zero or the current ambient pressure. In some embodiments, electronic control circuit 32 activates the vacuum source 28 for a predetermined duration. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 until the signal from the pressure sensor 25 indicates the pressure has been reduced, such that the danger of aerosols escaping has been eliminated. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 until the signal from the pressure sensor 25 indicates the pressure is below the pressure threshold. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 in response to the signal from the pressure sensor 25 indicating the pressure is a non-negative pressure, such as equal to or greater than the current ambient pressure. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 based on the signal from the pressure sensor 25 to maintain a negative pressure, such as less than the current ambient pressure, in at least one of the internal space 22a and the one or more tanks 23 to prevent aerosols from escaping from the heater/cooler unit 22 and into the surrounding environment.
In some embodiments, the heater/cooler unit 22 includes a sensor 34 to determine an aerosols concentration in the internal space 22a of the heater/cooler unit. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from sensor 34 indicating that any aerosols have been detected. In some embodiments, electronic control circuit 32 activates the vacuum source 28 based on a signal from sensor 34 indicating an aerosols concentration exceeding an aerosol concentration threshold. In some embodiments, the aerosol concentration threshold is a factory preset threshold. In some embodiments, the aerosol concentration threshold is set by an operator. In some embodiments, electronic control circuit 32 activates the vacuum source 28 for a predetermined duration. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 until the signal from sensor 34 indicates all aerosols have been eliminated. In some embodiments, the electronic control circuit 32 activates the vacuum source 28 until the signal from sensor 34 indicates an aerosols concentration below a threshold. In some embodiments, sensor 34 may be located outside the heater/cooler unit 22, such as in tubing 24b connecting heater/cooler 22 and filter unit 26.
The filter unit 26 includes a filter container or bottle and the negative air pressure is provided to the filter container to suction aerosol from the heater/cooler unit 22 into the filter container. This eliminates and/or reduces the amount of aerosol that escapes from the heater/cooler unit 22 and diffuses into the ambient air of the operating theatre. In some embodiments, the filter unit 26 includes an antibacterial filter element. In some embodiments, the filter unit 26 includes an antibacterial filter element that includes at least one of a hydrophobic filter element and a hydrophilic filter element. In some embodiments, systems of the present disclosure, such as system 20, are capable of substantially removing all aerosols and/or bacteria from the system, and prevent any aerosol or bacteria from entering the operating room environment. In some embodiments, systems of the present disclosure, such as system 20, reduce the aerosol emitted from the heater/cooler unit 22 by at least 95%.
In one embodiment, the filter cap 40 also includes a pour spout 48, and a tandem port 50. The pour spout 48 is configured to be used for emptying the filter container 42 or connecting the filter unit 26 to a specimen collector. The tandem port 50 is configured to be used to connect multiple filters, such as a second filter unit (not shown), in series or parallel with filter unit 26, to collect and filter aerosol. In some embodiments, the filter cap 40 further includes attached port caps 52a and 52b for capping the first connection 44 and the second connection 46, respectively. In some embodiments, port cap 52c is provided for capping the pour spout 48, and port cap 52d is provided for capping the tandem port 50. The port caps 52a-52d can be used to eliminate cap loss and allow for quick and secure capping of the filter unit 26.
In some embodiments, the filter cap 40 includes an antibacterial filter element. In some embodiments, the filter cap 40 includes an antibacterial filter element that includes at least one of a hydrophobic filter element and a hydrophilic filter element. In some embodiments, the antibacterial filter element includes a hydrophobic filter element 54, attached below the first connection 44 and to the underside of the filter cap 40. The filter unit 26 filters the aerosol received from the heater/cooler unit 22 at or near the first connection 44, which is coupled to the vacuum source 28. The filter unit 26 captures contaminants in the hydrophobic filter element 54, and prevents contaminants, such as bacteria, from entering the vacuum source 28. In some embodiments, the filter unit 26 filters the aerosol received from the heater/cooler unit 22 at or near the second connection 46, which is coupled to the heater/cooler unit 22, to capture contaminants in the hydrophobic filter 54 and prevent contaminants, such as bacteria, from entering the filter container 42. In some embodiments, the filter unit 26 includes a hydrophobic filter 54 configured to filter up to 99.99 percent of aerosolized micro-organisms and particulate matter in the aerosol received from the heater/cooler unit 22. In some embodiments, the antibacterial filter element includes a hydrophilic filter element.
In some embodiments, the hydrophobic filter stage 56 filters the aerosol received from the heater/cooler unit 22 at or near the first connection 44, which is coupled to the vacuum source 28. In some embodiments, the hydrophobic filter 56 filters the aerosol received from the heater/cooler unit 22 at or near the second connection 46, which is coupled to the heater/cooler unit 22. In still further embodiments, two hydrophobic filter stages 56 are provided, one at or near each of the first and second connections 44 and 46, respectively.
Vacuum source 110 includes a vacuum source unit 112 and a vacuum valve 114 for providing a vacuum or negative air pressure relative to the external air pressure to the filter 106. In some embodiments, the vacuum source 110 including the vacuum source unit 112 includes the house vacuum of the medical facility. In some embodiments, the vacuum source unit 112 is a non-disposable vacuum source unit. In some embodiments, the vacuum source unit 112 is a disposable vacuum source unit that may be discarded.
The filter 106 is fluidly coupled to the vacuum valve 114 by the tubing 104 and to the sensor 108 by the tubing 104. The vacuum valve 114 is fluidly coupled to the vacuum source unit 112 by the tubing 104, and the sensor 108 is fluidly coupled to the internal space 102a (or the tank) of the heater/cooler unit 102 by the tubing 104. In some embodiments, the tubing 104 is configured to be detachably coupled to at least one of the filter 106, the vacuum valve 114, the sensor 108, the heater/cooler unit 102, and the vacuum source unit 112. In some embodiments, the filter 106 is configured to be detachably coupled to at least one of the tubing 104, the vacuum valve 114, the sensor 108, the heater/cooler unit 102, and the vacuum source unit 112. In some embodiments, at least one of the tubing 104, the filter 106, the vacuum source unit 112, the vacuum valve 114, and the sensor 108 is disposable, such that contamination from the disposable part(s) is discarded and build-up of contamination is prevented.
The filter 106 is fluidly coupled to the vacuum valve 114 by a first tube 104a and to the sensor 108 by a second tube 104b. The vacuum valve 114 is fluidly coupled to the vacuum source unit 112 by a third tube 104c and the sensor 108 is fluidly coupled to the internal space 102a (or the tank) of the heater/cooler unit 102 by a fourth tube 104d. In some embodiments, the vacuum source unit 112 is the house vacuum provided by the medical facility, such as through a wall vacuum socket. In some embodiments, the vacuum source unit 112 is a standalone, external vacuum source that can be provided with the system 100. In some embodiments, the fourth tube 104d is coupled to an existing overflow port 116 on the heater/cooler unit 102, where the existing overflow port 116 is provided for fluid overflow of one or more of the tanks in the heater/cooler unit 102. Connecting the fourth tube 104d to an existing overflow port 116 enables the system 100 to be retrofit to an existing heater/cooler unit 102.
The sensor 108 is configured to detect aerosols and/or contaminants, such as bacteria, in the tubing 104, suctioned from the internal space 102a (or the tank) of the heater/cooler unit 102. The sensor 108 is communicatively coupled to the vacuum valve 114 via communications path 118. In some embodiments, the sensor 108 is installed in the internal space 102a (or the tank) of the heater/cooler unit 102 (dashed arrow), such as in or near the overflow port 116 to sense or detect aerosols and/or contaminants in the internal space 102a (or the tank) of the heater/cooler unit 102.
The sensor 108 includes control electronics 120, such as a processor, configured to provide an output signal in response to detecting aerosols and/or contaminants. In some embodiments, the sensor 108 activates the vacuum valve 114 via the output signal to open the vacuum valve 114 and provide a vacuum or negative air pressure relative to the external air pressure from the vacuum source unit 112 to the filter 106 in response to detecting a contaminant or an aerosol. In some embodiments, the sensor 108 is configured to activate the vacuum valve 114 via the output signal to open the vacuum valve 114 for a limited time to provide the vacuum or negative air pressure relative to the external air pressure to the filter 106 in response to detecting a contaminant or an aerosol. In some embodiments, the sensor 108 is configured to activate the vacuum valve 114 via the output signal to open the vacuum valve 114 for less than 10 minutes to provide the vacuum or negative air pressure relative to the external air pressure to the filter 106 in response to detecting a contaminant or an aerosol. In some embodiments, the sensor 108 activates the vacuum valve 114 via the output signal for as long as an aerosol condition is detected. In some embodiments, the sensor 108 activates the vacuum valve 114 via the output signal for as long as an aerosol concentration exceeds an aerosol concentration threshold.
In some embodiments, the sensor 108 activates an alarm or display on the sensor 108 via the output signal in response to detecting a contaminant or an aerosol. In some embodiments, the system 100 can be provided without a vacuum valve 114, such that the vacuum source 110 including the vacuum source unit 112 is manually activated to provide a vacuum or negative air pressure relative to the external air pressure to the filter 106, such as in response to an alarm or display on the sensor 108 indicating the presence of a contaminant, aerosols, or an aerosol concentration exceeding an aerosol concentration threshold.
In some embodiments, the system 100 can be provided without a vacuum valve 114 and the sensor 108 is communicatively coupled to the vacuum source unit 112 via communications path 122 (dashed line), such that the sensor 108 activates the vacuum source unit 112 directly to provide a vacuum or negative air pressure relative to the external air pressure to the filter 106 in response to sensing or detecting a contaminant, an aerosol, or an aerosol concentration. In some embodiments, the system 100 can be provided without a vacuum valve 114 and the sensor 108 is communicatively coupled to the vacuum source unit 112 via communications path 122 (dashed line), such that the sensor 108 activates the vacuum source unit 112 directly for a limited time to provide a vacuum or negative air pressure relative to the external air pressure to the filter 106 in response to sensing or detecting a contaminant or an aerosol. In some embodiments, the sensor 108 activates the vacuum source unit 112 directly to provide a vacuum or negative air pressure to the filter 106 for a duration defined by the time that the contaminant, aerosol, or aerosol concentration remains detected, i.e., for as long as an undesired sensed condition is detected.
In operation, the vacuum source 110 is activated to provide a vacuum or negative air pressure relative to the external air pressure to the filter 106. In some embodiments, the vacuum source 110 is activated via the sensor 108. In some embodiments, the vacuum source 110 is activated manually.
In some embodiments, the vacuum source 110 includes an electronic control unit 124, which is one or more of electronic control unit 124a in vacuum source unit 112 and electronic control unit 124b in vacuum valve 114. In some embodiments, the electronic control circuit 124 activates the vacuum source 110 for a limited time to remove the aerosol from the heater/cooler unit 102. In some embodiments, the electronic control circuit 124 activates the vacuum source 110 for a limited time when an operational condition of the heater/cooler unit 102 indicates a likelihood of aerosol production. In one embodiment, the operational condition indicating a likelihood of aerosol production includes activating a heating source within the heater/cooler unit 102. In some embodiments, the electronic control circuit 124 activates the vacuum source 110 when a contaminant aerosol, or aerosol concentration is detected for as long as the detection condition remains present. In some embodiments, the electronic control unit 124 is in communication with the heater/cooler unit 102, such as by a wire (not shown for clarity) or wireless communications. In some embodiments, the vacuum source 110 is turned on before the heater/cooler unit 102 is turned on. In some embodiments, the vacuum source 110 is turned on at the same time the heater/cooler unit 102 is turned on.
The filter 106 includes a filter container and the negative air pressure is provided to the filter container to suction aerosol from the heater/cooler unit 102 into the filter container. This eliminates and/or reduces the amount of aerosol that escapes from the heater/cooler unit 102 and the amount of aerosol that diffuses into the ambient air of the operating theatre. In some embodiments, the system 20 reduces the aerosol emitted from the heater/cooler unit 102 by at least 95%.
At 200, the method includes fluidly coupling a filter to a vacuum source and to an internal space (or a tank) of a heater/cooler unit by using tubing. In some embodiments, the filter includes a hydrophobic filter configured to filter up to 99.99 percent of aerosolized micro-organisms and particulate matter in the aerosol received from the heater/cooler unit. In some embodiments, this coupling includes one or more tubes and/or devices coupled between the filter and each of the vacuum source and the heater cooler unit. In one embodiment, a sensor for detecting aerosol is provided in the tubing coupling the heater/cooler unit and the filter. In one embodiment, a vacuum valve is provided in the tubing coupling the vacuum source and the filter.
In some embodiments, portions of the systems 20 and 100 are disposable, where ease of attachment and detachment provides for easy disposability. In some embodiments, the tubing is detachably coupled, such that it is configured to be easily attached and detached, to one or more of the filter, the vacuum source, and the heater/cooler unit. In some embodiments, the filter is detachably coupled, such that it is configured to be easily attached and detached, to one or more of the tubing, the vacuum source, and the heater/cooler unit. In some embodiments, at least some of the tubing is disposable, such that at least some of the tubing can be disposed of to reduce contamination and build-up of contamination in the tubing. In some embodiments, the filter is disposable, such that the filter can be disposed of to reduce contamination and build-up of contamination in the filter. In some embodiments, a disposable unit is provided that includes the filter and tubing to couple the filter to each of the heater/cooler unit and the vacuum source. In a further embodiment, a disposable unit is provided that includes the filter, a vacuum source, and tubing to couple the filter to the heater/cooler unit. Optionally, additional tubing may be provided to couple the filter to the vacuum source.
Referring again to
In some embodiments (not shown in
At 312, the heater/cooler unit has not yet started heating the heater/cooler fluid, which may be water, and the temperature of the fluid is about 20 C. At 314, at the five minute mark, the heater/cooler unit begins to heat the fluid from 20 C to about 41 C at 316, between the 10 and 11 minute marks. During this five to six minute heating time, the heater/cooler unit most heavily emits aerosols near the air fan.
The aerosol particle count measured in the air exiting the fan of the heater/cooler unit that does not have an attached aerosol reduction system 300 is at a particle count of about zero or below zero at 318. The particle count begins to increase almost immediately at 320, after the heater/cooler unit begins to heat the fluid at the five minute mark. The aerosol particle count increases to a maximum level of about 4800-4900 particles at 322, between the 11 and 12 minute marks. Thereafter, the particle count decreases at 324 to a relatively stable level of about 500 particles at 326, where it remains for the rest of the time.
In contrast, the aerosol particle count measured in the air exiting the fan of the heater/cooler unit that has an attached and activated aerosol reduction system is at a particle count of about −500 or below at 330. This particle count increases slightly at 332, to a particle count of about zero, which is about the same as the initial particle count measured in the air exiting the fan of the heater/cooler unit that does not have an attached aerosol reduction system at 318. Thereafter, the particle count remains at about zero for the remainder of the time, decreasing slightly at the 30 minute mark at 334.
The difference in the graph of the aerosol particle count emitted by the heater/cooler system that does not include an aerosol reduction system (line 300) and the graph of the aerosol particle count emitted by the heater/cooler system that does include an aerosol reduction system (line 302), exemplifies the improvement achieved by the aerosol reduction system described in this disclosure.
At 412, the heater/cooler unit has not yet started heating the heater/cooler fluid, which may be water, and the temperature of the fluid is about 20 C. At 414, at the five minute mark, the heater/cooler unit begins to heat the fluid from 20 C to about 41 C at 416, between the 10 and 11 minute marks. During this five to six minute heating time, the heater/cooler unit most heavily emits aerosols into the air.
The aerosol particle mass in the air exiting the fan of the heater/cooler unit that does not have an attached aerosol reduction system is at a particle mass of about zero at 418. The particle mass begins to increase at 420 at the nine and a half minute mark, after the heater/cooler unit begins to heat the fluid at the five minute mark. The aerosol particle mass increases to a maximum level of about 110 at 422 between the 11 and 12 minute marks. Thereafter, the particle mass decreases at 424 to a relatively stable level of about zero at 426, where it remains for the rest of the time.
In contrast, the aerosol particle mass in the air exiting the fan of the heater/cooler unit that has an attached and activated aerosol reduction system is at a particle mass of about zero at 430 and remains at about zero for the remainder of the time at 432.
The difference in the graph of the aerosol particle mass emitted by the heater/cooler system that does not include an aerosol reduction system (line 400) and the graph of the aerosol particle mass emitted by the heater/cooler system that does include an aerosol reduction system (line 402), exemplifies the improvement achieved by the aerosol reduction system described in this disclosure.
Various modifications and additions can be made to the exemplary embodiments discussed without departing from the scope of the present disclosure. For example, while the embodiments described above refer to particular features, the scope of this disclosure also includes embodiments having different combinations of features and embodiments that do not include all of the described features. Accordingly, the scope of the present disclosure is intended to embrace all such alternatives, modifications, and variations as fall within the scope of the claims, together with all equivalents thereof.
This application is a continuation of U.S. patent application Ser. No. 16/304,460, filed Nov. 26, 2018, which is a 371 of International Application No. PCT/IB2016/055470, filed Sep. 14, 2016, the disclosures of which are incorporated herein by reference.
Number | Date | Country | |
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Parent | 16304460 | Nov 2018 | US |
Child | 18119648 | US |