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PostPosted: Mon Apr 25, 2011 5:04 pm 
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Anybody else know about this? Comments?

I've been reading about an interesting technique called Proctoclysis
Quote:
: proc·toc·ly·ses (-sz)
The slow, continuous, drop-by-drop administration of saline solution into the rectum and sigmoid colon. Also called Murphy drip.


Basically giving fluids like Pedialite, gatoraid or a solution of water/sugar/salt/bakingsoda,slowy thru the :roll: rectum. A tube, like a foley catheder is inserted 1-2 feet into the large intestine (got lube?) and upto 400 ml of fluid is given over a period of 20 minutes.

From what I've read... this is an alternative to needle IV when needles or experienced med personel are not available. Or when the patient is vomiting and cannot take oral fluids, or unconcious. Elderly and hospice patients sometimes prefer this to painful needle IV's with the associated infection risks.

Not to be confused with an emema, similar, but less fluid is absorbed in a shorter time. Murphy drip is given over a much longer time and adds up to much larger amounts of fluid absorbed.
The fluids are absorbed thru the colon and passed to the kidneys with selective uptake of salts. So there is much less danger of unstabilizing the patient with fluid or salt imbalance than traditional IV. Air in a murphy drip, at worst ,just results in a fart, rather than a dangerous embolisim that can kill the patient. Needle IV's have serious hazards that even trained medical personel have difficulty with in some cases. Unskilled laymen generally should not mess with needle IV's (unless you have to).

It won't deliver as much or as fast as a needle IV, but if all you need is a foley cat and some fluid and it could mean a big difference for someone in need if you can't get an IV. Not an everyday thing, but under austere circumstances this is a recommened alternative to a needle IV.

Nothing is free, there are some risks to be aware of. The precautions are the same for enemas:

Quote:
Precautions
Improper administration of an enema may cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.[16]

The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.

Colonic irrigation should not be used in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumors in the rectum or colon. It also should not be used soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or renal failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.[17]


http://en.wikipedia.org/wiki/Murphy_drip

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PostPosted: Mon Apr 25, 2011 7:13 pm 
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IIRC from school, the length of insertion is 10 to 20 cm. Less than 1 foot.

Like an IV, this route of administration bypasses the liver, so there is no first pass metabolism. Anything you KNOW you can put in a vein, you can pretty much put in here too. Things that should not go here is things like alcohol. http://www.seattlepi.com/default/articl ... 165596.php If you have not administered something in an IV, don't administer it PR either.


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PostPosted: Tue Apr 26, 2011 12:28 pm 
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Liff wrote:
Like an IV, this route of administration bypasses the liver, so there is no first pass metabolism.

I'm not quite sure that's how it works. The average rectumt is about 15 to 18 cm long. If you go in 20 cm to a feet, you are all the way to the sigmoid colon. And even if you only go 10 cm, that's still pretty far in. What's resorbed by the colon, or even by large parts of the rectum, first goes to the liver via the portal vein.
As far as I know only substances resorbed by the very last part of the rectum (like, when using a suppository, or small portions of an enema) mostly bypass the liver, because the [middle and/or inferior?] rectal veins are somehow connected to the inferior vena cava. So most stuff you aminister this way is probably still going to experience the first pass effect. Could be wrong on his, I'm a biologist, not a physician.

Anyhow, one of the main advantages of proctoclysis I see is the following:
It's relatively easy to make things sterile. You can boil the shit out of a lot of substances (and we are mainly talking saline here, right?), and a pressure cooker can be a decent makeshift autoclave. It is, however, practically impossible to make things pyrogen-free, or verify something is non-pyrogenic without elaborate equipment. And I'd rather shot potentially pyrogenic stuff up the ass than push it into a vein. So,if you are, for example, a midwife or nurse, in the middle of rural Africa who finds herself to be the only medical professional caring for thousands of people, this technique could prove very damn usefull indeed.

It obviously has its limits. I wouldn't try to to rehydrate someone suffering from severe diarrhea this way, when his intestines can't even hold his own shit long enough to absorb the water, I'm certainly not pushing more into there.

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PostPosted: Tue Apr 26, 2011 9:19 pm 
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I have heard of one family that survived a ship wreck with no water by using saltwater enemas.


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PostPosted: Wed Apr 27, 2011 1:56 am 
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In before a B. G. enema reference.

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PostPosted: Wed Apr 27, 2011 2:52 am 
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I stick a suppository up my bum once a day and have done so for about fifteen years now. I don't doubt that you CAN rehydrate someone with this "method" but when I think about the situation range that would make it necessary... Something tells me this is an academic exercise and nothing more.

If things are so bad that you have grandma unable to walk and begging for water, she's really not going to want to comply with you sticking a tube up her bum.

If she's so far out that you don't need to ask first - well - truthfully chances are really good you won't make a whole lot of difference anyway.

You don't need to plan for extreme emergencies - you just need to plan for the common ones.


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PostPosted: Wed Apr 27, 2011 3:34 am 
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What I remember, admittedly not nearly enough, from Jr High Biology class, is that the large intestine absorbs the fluids back out of the digested food from the small intestine, so I can see where this would work, on the "technical" end of it. Practically, I am having a hard time envisioning a situation where I might need to draw on the knowledge, but- that certainly doesn't mean the knowledge is useless. I'm not a medical professional, so my having any sort of hypodermic needles or IV setups isn't gonna happen, so if I DID need to get fluids into someone with me, and they couldn't drink them (illness or injury), then I could see the knowledge coming into play, along with a sworn secrecy between the two of us on the matter :lol:

Can you administer medications, or even anesthesia this way? I'm picturing the old "Dad did my appendectomy on the kitchen table" scenario, and short of hitting someone in the head to knock them out, or having them drink themselves senseless (both of which could give rise to even more medical issues), and lacking a bottle of nitrous in every home, I could see where knowing how to SAFELY sedate a patient (by this method or another) would be very useful.

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PostPosted: Wed Apr 27, 2011 1:47 pm 
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You can absolutely administer medicines this way. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000580/ This is the one I remember from school. It is designed to be administered there.

http://products.sanofi-aventis.us/kayex ... xalate.pdf Read at the top of page two. 20 cm is the right distance. And the point of going that far in is to get past the rectum and into the large intestine.

You can absorb 6 L/d of fluid in the large intestine according to this reference.

Quote:
And the final organ of the digestive tract is the large intestine, which includes the colon and rectum. The large intestine is the site for water resorption and the production of feces. Seldom does drug absorption take place in this region. The pH of the large intestine is 5.5-7, and like the buccal area, blood that drains the rectum is not first transported to the liver. So, absorption that takes place in the rectum (from rectal suppositories and enemas) goes into the systemic circulation without biotransformation that takes place due to liver enzymes.
I did the bolding. Weak reference alert, here. This is how an alcohol enema can kill a person.


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PostPosted: Wed Apr 27, 2011 2:19 pm 
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Ah, thanks for the reference. :) I don't doubt you can administer drugs this way, it's the whole "bypassing the liver" thing that leaves me kinda confused.

With a suppository (i.e. rectal application) we can avoid the first pass effect. My anatomy books tell me the middle and inferior rectal veins are connected to the iliac veins which drain into the inferior vena cava. So it's pretty clear that if you stick something up the arse and it is resorbed in the last two thirds of the rectum, the liver doesn't get to see it. I was wrong on that only happening in the very last part of the rectum.
However, the colon is a different story. The mesenteric veins from the colon ultimately drain into the portal vein, and to the liver it goes. And, like the linked pdf said, the tip of the catheter comes to rest well into the sigmoid colon.

I have also no doubt that everything which gets pumped into the colon ultimately ends up in the rectum, and we will have additional resorption there, but this obviously will take a few minutes. Dunno man, it looks like we are going to have a mix of both. Direct absoption into systemic circulation (from the rectum) AND a run through the liver (from the colon).

Or maybe not. Or something. :? :?:

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PostPosted: Thu Apr 28, 2011 8:05 am 
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Yeah, the way I was taught drug/pharmaceutical absorption was that "all" of the blood from the small intestine goes to the liver first, then out to systemic circulation. The whole large intestine and veins "do not" do this. Administration there goes back to the heart, then out to the body. Ultimately a portion of the cardiac output goes to the liver, but not all of the cardiac output, so the first pass of blood from the intestines to the liver is bypassed.

**Disclaimer: Pharmacists know a lot about physiology, but basically jack-squat about anatomy. Anything I say about anatomy is always suspect. Physiology, not so much.**

This is the same reason why 5 ml of pure alcohol injected IV or administered PR will make you legally drunk. Keep in mind, there is 60 ml in a standard shot, and it is 3 shots to be legally drunk, with 80 proof alcohol, that is 72 ml. So of the 72 ml of alcohol administered PO, the liver detoxifies 67 ml (about 93%) the first time through the liver (first pass effect). First pass is always something to consider for drugs that are metabolized by the liver.

Another good analogy is morphine PO vs. IV. (I am assuming people here have some experience with MSO4.) The standard initial dose for PO is 15 to 30 mg or so. The standard dose for IV is 2 to 10 mg or so. The first pass effect is the reason for the difference is the dose.


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PostPosted: Thu Apr 28, 2011 4:07 pm 
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It is certainly possible to administer medicine or fluids per rectum, either in the form of suppository or klysma. It is however a less reliable and predictable way than oral.
Hopefully, I can make the part about the portal circulation (blood from the stomach, intestines and colon going through the liver) and the first-pass effect a little bit clearer. If not, I'll try to elaborate.
Only the drainage of the most distal part of the rectum (the part closest to the anus) does not go to the liver. Blood in the inferior and middel rectal veins goes via the iliac vein directly to the inferior vena cava. Blood returning from the rest of the gastrointestinal tract goes through the liver via the portal vein. While it is often said that this means that there is no 'first-pass effect' when using suppositories, there is no solid experimental scientific base for this assumption (source from 2006).

B.t.w. I'm Pieter, a licensed physiotherapist and now a medical student from The Netherlands. Proper introduction tomorrow, but now it's bedtime over here in GMT+1.


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PostPosted: Fri Apr 29, 2011 1:45 pm 
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Pieter, glad to have you in on this discussion and on the boards.

Pieter wrote:
Blood in the inferior and middel rectal veins goes via the iliac vein directly to the inferior vena cava. Blood returning from the rest of the gastrointestinal tract goes through the liver via the portal vein.

How much blood from the inferior vena cava goes to the liver? The correct answer is that no blood from the IVC goes to the liver, all of that blood goes back to the heart, by passing the liver. In fact, the venous return from the liver also goes into the IVC. For everyone else, the iliac vein basically becomes the IVC at a different part in the body. Nice picture here.

Pieter wrote:
While it is often said that this means that there is no 'first-pass effect' when using suppositories, there is no solid experimental scientific base for this assumption (source from 2006).

I didn't see your source, sorry.

(Sorry for wiki reference, but it is the easiest to read from what I found.) It is 100% correct to say there is no first pass effect for medicines administered IV, IM, PR, via aerosol,, etc. The first pass effect only applies to the oral route. There would not (hopefully) be any studies that show how suppositories administered PR somehow are inserted so far that the suppository ends up in the stomach. So as long as you can assume that the suppository was not administered that far up, you are not actually assuming anything. It is the idea of this physiological feature of the body and drug metabolism that we are concerned with.

The recommendation still stands, any medicine/drug you know beyond a shadow of a doubt can be administered by some type of injection, then this may be an alternate way of administering the medication.


Last edited by Liff on Fri Apr 29, 2011 1:49 pm, edited 1 time in total.

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PostPosted: Fri Apr 29, 2011 1:48 pm 
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PostPosted: Fri Apr 29, 2011 3:22 pm 
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Liff wrote:
Pieter, glad to have you in on this discussion and on the boards.


Well, thank you very much!

Liff wrote:
Pieter wrote:
Blood in the inferior and middel rectal veins goes via the iliac vein directly to the inferior vena cava. Blood returning from the rest of the gastrointestinal tract goes through the liver via the portal vein.

How much blood from the inferior vena cava goes to the liver? The correct answer is that no blood from the IVC goes to the liver, all of that blood goes back to the heart, by passing the liver. In fact, the venous return from the liver also goes into the IVC. For everyone else, the iliac vein basically becomes the IVC at a different part in the body. Nice picture here.


That is exactly what I meant. Blood from the gastrointestinal tract goes through the liver first (the portal circulation) with the exception of the inferior and middel rectal veins (i.e. the last bit of the rectum). This picture is quite good.

Liff wrote:
Pieter wrote:
While it is often said that this means that there is no 'first-pass effect' when using suppositories, there is no solid experimental scientific base for this assumption (source from 2006).

I didn't see your source, sorry.


The source is a dutch textbook on pharmacology, if you do happen to speak dutch it's quite a good book (van Ree, Algemene farmacologie). If you are a pharmacist probably not so much, it's quite basic.

Liff wrote:
(Sorry for wiki reference, but it is the easiest to read from what I found.) It is 100% correct to say there is no first pass effect for medicines administered IV, IM, PR, via aerosol,, etc. The first pass effect only applies to the oral route. There would not (hopefully) be any studies that show how suppositories administered PR somehow are inserted so far that the suppository ends up in the stomach. So as long as you can assume that the suppository was not administered that far up, you are not actually assuming anything. It is the idea of this physiological feature of the body and drug metabolism that we are concerned with.


You are correct in that medicines administered IV, IM, PR, via aerosol, etc will not have the first-pass effect. However, the first-pass effect applies to the whole gastrointestinal tract (i.e. stomach, intestines, colon). This means not only the oral route but also the rectal route if you go up more than a few inches.

Liff wrote:
The recommendation still stands, any medicine/drug you know beyond a shadow of a doubt can be administered by some type of injection, then this may be an alternate way of administering the medication.


I agree with that, but because of the many variables compared to i.v., it is less reliable and finding the correct dosage may be difficult.

HTH

*edited for picture link


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PostPosted: Sat Apr 30, 2011 5:31 am 
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OK, so break this down for a poor, confused plumber. Setting aside the debate on first pass etc, how far into the rectum is this supposed to be for skipping the liver? Never having used a suppository myself, or had anything ELSE up there, I have no experience to go from. Would a suppository be inserted JUST till it was pass the rectal sphincter muscle? Given the job of this section of the LI, it seems to me that the fecal matter waiting there would slow things down quite a bit, or am I off base here? If you have to get the suppository further up, what's the recommended distance- I'm seeing several numbers in this thread, none of them agreeing, and I'd think that in order to prevent CREATING a problem, it would be good to know- perforating the colon has "BAD" written all over it.

Honestly, I don't know why this topic interests me- I cannot see this knowledge EVER being of use to me, but I'm one of those "knowledge for knowledge's sake" people.

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PostPosted: Sat Apr 30, 2011 6:06 am 
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KnightoftheRoc wrote:
OK, so break this down for a poor, confused plumber. Setting aside the debate on first pass etc, how far into the rectum is this supposed to be for skipping the liver?

Short. Just in. Which is good. I certainly wouldn't want to shove a suppository any further up, because I don't really find it pleasant.

The whole discussion is not of importance for a suppository, or for giving fluids via proctoclysis. It really only matters if you try application of IV drugs this way. It's more of a "austere medicine without clean needles" plan than solid first aid advice what we are talking here.

Oh, and I don't get why you would be confused. This whole debate IS almost exclusicely about plumbing, it's just that the pipes have fancy names. :lol:

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PostPosted: Sat Apr 30, 2011 8:23 am 
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Krustofski wrote:
Oh, and I don't get why you would be confused. This whole debate IS almost exclusicely about plumbing, it's just that the pipes have fancy names. :lol:


Damn, that was funny for me.

For fluid replacement, it looks like 20 cm is the best recommendation. For supps, just far enough in to stay in.

Pieter, thank you for the help. I have been doing this pharmacist thing for the last 7 years and I had my anatomy on the venous drainage of the LI off for longer than that. Fucking Zombie Squad teaching me about my damned job that I went to school for 7 years to do and I have been doing for the last 7 years, never mind my board certification (in one area of pharmacy). Way to go medical student Pieter. Another good picture of what is going on.

In my defense, I did say,
Liff wrote:
**Disclaimer: Pharmacists know a lot about physiology, but basically jack-squat about anatomy. Anything I say about anatomy is always suspect. Physiology, not so much.**
But F that defense, I was wrong about complete by pass of the liver.

And thanks for finding pictures labeled in English, I am an American, which means I speak one language =/.


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Krustofski wrote:
Oh, and I don't get why you would be confused. This whole debate IS almost exclusicely about plumbing, it's just that the pipes have fancy names. :lol:

Here we call urologists plumbers (well, when they're not around, anyway).

Liff wrote:
I have been doing this pharmacist thing for the last 7 years

My brother in law and his GF are both pharmacists; very interesting profession I think. I'l be working in a general practice with a pharmacy this summer; really looking forward to learn more about it!


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This whole thread is SICK & WRONG & VERY INFORMATIVE!!!

Thanks for teaching me shit I never thought I'd ever want to know...

By the way, what sort of gear should be used for this? IV tube? Small garden hose? Bicycle tire inner tube?

My oldest kid had to be medevac'd for dehydration as an infant, and it kinda traumatized my wife. Having some kind of therapy to treat dehydrated kids(or even us) when EMS is busy during an emergency is very useful to me.

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Kutter_0311 wrote:
By the way, what sort of gear should be used for this? IV tube? Small garden hose? Bicycle tire inner tube?

My honest answer is I have no clue. This booksays a naso-gastric tube.

I imagine you would want something with a certain amount of firmness, but not too much in diameter.

Kutter_0311 wrote:
This whole thread is SICK & WRONG & VERY INFORMATIVE!!!

Focus on the sick and wrong part. I am disappointed I posted this much in this thread, but in my defense, it was taught to me in school.


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I'm not a medical professional or anything, but from what I gather, running a feeding line up someone's ass is more of a poor man's stomach peg than a poor man's IV. If someone you love is out cold for days, and you can't get them to a hospital or professional care, then running a food tube up their poop-chute and pouring it full of broth, water, or saline gives them a much better chance of pulling through than dripping liquids into their mouths a drop at a time.

However, keep in mind that administering drugs anally isn't for the amateur. Before oral medication reaches the colon, it is processed in the stomach and duodenum. Much of a drug's potency is lost due to stomach acids and the natural digestion process. Running straight Ethanol, Oxycodone, Hydrocodone, and the like directly into a patient's colon can kill them, especially if the patient's colon is mostly empty. Want proof? take a look at the Milligram dosage of oral Compazine or Phenergan vs suppository dosages.

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darkaxel wrote:
However, keep in mind that administering drugs anally isn't for the amateur.


Aww shucks...




Correct me if I am wrong here (and good chance that I am), but if trying to replenish electrolytes (or give nutrients or whatnot via broth, pedialite, sugar, whatever), wouldn't the fluid have to be of a greater osmotic pressure than blood?


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PostPosted: Sun May 01, 2011 12:03 am 
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Krustofski wrote:
Oh, and I don't get why you would be confused. This whole debate IS almost exclusicely about plumbing, it's just that the pipes have fancy names. :lol:

See, now, here I've been resisting the urge to add plumbing jokes the entire thread...

As to the size of a tube to use, and type, I believe a naso-whatever tube- the one they shove up your nose till it goes into your stomache- yeah, you don't wanna be awake for that one... it's either a 1/4" outside diameter, or a 1/4" inside diameter clear vinyl tubing, which you can find at Lowe's, and I believe also at Home Depot, by the roll- just measure, cut, and pay for what you want on length. I'd say go for nothing bigger than a 1/4" OD tubing, if you plan on shoving it up the nose, simply for the consideration of size and discomfort. I have a siphon pump and tubing for water gathering in my BOB which I think would work well for this, if it came to it- and the pump would allow me to move the fluids in easier, as well as connect another container like it was an IV bag, for unattended application.

Is there a simple, field expedient recipe a person could mix for this? I'd like to know I could deal with a person's need for hydration, nourishment, restoring electrolytes, etc. if I had to. Would applying a dose of Gatorade this way work for two out of three? Could it be that simple?

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PostPosted: Sun May 01, 2011 2:55 am 
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KnightoftheRoc wrote:
Would applying a dose of Gatorade this way work for two out of three? Could it be that simple?

Gawd, I hope so!

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