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Discharge Instructions for Pulmonary AVM Embolization

 

What is a pulmonary AVM embolization?

A pulmonary AVM (arteriovenous malformation) embolization is a minimally invasive procedure. It blocks (embolizes) blood flow to an area of tangled arteries and veins called an AVM. The doctor gets into the veins by placing a catheter (long tube) into a large vein in the groin, usually on the right side of the body. Contrast dye visible to an x-ray machine is injected into these veins. X-rays help your doctor guide the catheter to the blood vessels feeding the AVM. They are then blocked.

 

How can you care for yourself at home?

This care sheet gives you a general idea about how long it will take to recover. Please remember, each person recovers at a different speed. 

 

Recovering from anesthesia

You had local anesthesia (a shot to numb the area). You may feel some pain and discomfort as it wears off. You had anesthesia to help you sleep through the procedure. It is usually given in a vein (by IV). You may feel some of the effects of anesthesia for several hours. Common side effects include:

  • Feeling sleepy. Your doctors and nurses will make sure you are not too sleepy to go home.
  • Nausea and vomiting. This usually does not last long. It can be treated with over-the-counter medication.
  • A sore throat.
  • Muscle aches or weakness.
  • For the next 24 hours, please avoid:
  • Alcoholic beverages
  • Making important personal, business, and legal decisions
  • Driving, operating heavy machinery, or doing anything that requires coordination and balance
  • Strenuous activity, sudden position changes, heavy lifting, and straining

 

Recovery Instructions

You may have a moderate level of pain at the puncture site (where the catheter entered your skin) over the next few days. This is normal and expected. Our goal is to treat your pain safely. Sometimes, pain may not go away completely.  We will do our best to help you feel better.

 

You can expect to have mild shortness of breath and chest pain. Call 911 if these symptoms become very bad.

  

Diet:

  • You can eat and drink fluids as tolerated. Start with clear liquids and work up to solid foods. Drink plenty of fluids unless otherwise directed by your doctor. Extra fluids will help flush the contrast dye used during the procedure from your body.

 

Activity:

  • Do not lift anything heavier than 5 pounds for the first 3 days after the procedure.
  • Avoid strenuous activities and heavy lifting for 2 weeks.
  • Rest when you feel tired, especially for the first 48 hours. Getting enough sleep will help you recover.
  • You can go back to normal activities as you feel up to it. Start slowly and listen to your body, do not overdo it. Most people are ready to return to work 7 to 10 days after the procedure if not sooner.
  • You can drive 2 days after the procedure if you are not taking any opioid pain medications.
  • You can shower 24 hours after your procedure.

 

Caring for the puncture site: 

You may have a small amount of bruising at the puncture site (where the catheter entered your skin). This is normal and should go away over the next several days.

  • Remove the bandage after 24 hours.
  • Gently clean the puncture site and the skin around it with soap and water. Do not use hydrogen peroxide or alcohol, which may slow healing.
  • Gently pat the puncture site dry. Apply new gauze and tape or a Band-Aid.
  • Change the bandage and clean the puncture site every day until it has healed completely (usually 2-3 days).
  • Do not use any lotion or powder near the puncture site.
  • Do not take a bath or swim until it has healed completely.
  • There should be no or very little bleeding from the puncture site.
    • If you notice bleeding, lie down. Apply direct pressure to the area for 20 minutes. Notify the Interventional Radiologist right away.

 

Medication Instructions

Below are the medications that you may take at home. Be safe with medicines. Read and follow all instructions on the label.  If you take Glucophage (metformin), do NOT take for 2 days after the procedure.

 

Mild pain and/or low grade fever (fever less than 101.5̊ F (38° C))

  • If you have pain, do not be afraid to say so. Pain medicine works better if you take it before the pain gets bad.
  • You can take over-the-counter (OTC) medication such as ibuprofen (Advil®/Motrin®), naproxen (Aleve®) or acetaminophen (Tylenol®) for mild pain and/or low grade fever.
  • Take ibuprofen and naproxen with food as they may upset your stomach.
  • If you have a fever over 101.5̊ F (38° C) that does not go down with medication, please contact your Interventional Radiologist and Oncologist.

 

Very bad pain that does not get better with OTC medications

  • You will get a prescription for an opioid (strong pain medication) if the OTC medication does not give you enough pain control.
    • Take only as prescribed and only as needed

 

Constipation

  • Opioid pain medications give you constipation. If you are taking them, you should also take a stool softener. You can take Colace or Senokot.
    • Colace – stool softener; helps prevent constipation while taking a narcotic.
    • Senokot – mild laxative; take until you have a regular bowel pattern and then stop.

 

Follow-Up Care

  • Make a follow-up appointment with Interventional Radiology for 2 weeks after your procedure date.
  • Your referring doctor will arrange a follow-up MRI or CT scan to see how well your treatment worked.
  • Be sure to make and go to all appointments, and call your doctor if you are having problems. It is also a good idea to know your test results and keep an up-to-date list of the medications you take.

 

When should you call for help?

Call 911 anytime you think you may need emergency care. For example, call if:

  • You pass out (lose consciousness)
  • You have very bad chest pain or trouble breathing.

 

Call your doctor or seek medical care right away if:

  • You have very bad pain (other than chest pain) that does not get better with medication.
  • Bright red blood has soaked through the bandage.
  • You have numbness, tingling or difficulty moving your hand (if you had a radial or wrist puncture).
  • You feel like your heart is racing.
  • You have increasing weakness or dizziness.
  • You have trouble urinating or inability to urinate within 8 hours of discharge.
  • You have persistent nausea/vomiting or the inability to keep fluids or food down.
  • You have signs of infection such as:
    • Increased pain, swelling, warmth, or redness around the puncture site
    • Pus draining or red streaks leading from the area
    • A fever over 101.5̊ F (38°C) that does not go down with over-the-counter medications and lasts longer than 24 hours, chills, or body aches

 

You can speak to a provider in Interventional Radiology:

  • Monday-Friday 9AM-4:30PM, call 212-263-5898.
  • Weekdays after 5PM or weekends, call 212-263-5230 and ask the front desk to contact the Vascular Interventional Radiologist on-call.

 

Watch closely for changes in your health, and be sure to contact your doctor if you do not get better as expected.

 

© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.

Discharge Instructions for Pulmonary AVM Embolization

 

What is a pulmonary AVM embolization?

A pulmonary AVM (arteriovenous malformation) embolization is a minimally invasive procedure. It blocks (embolizes) blood flow to an area of tangled arteries and veins called an AVM. The doctor gets into the veins by placing a catheter (long tube) into a large vein in the groin, usually on the right side of the body. Contrast dye visible to an x-ray machine is injected into these veins. X-rays help your doctor guide the catheter to the blood vessels feeding the AVM. They are then blocked.

 

How can you care for yourself at home?

This care sheet gives you a general idea about how long it will take to recover. Please remember, each person recovers at a different speed. 

 

Recovering from anesthesia

You had local anesthesia (a shot to numb the area). You may feel some pain and discomfort as it wears off. You had anesthesia to help you sleep through the procedure. It is usually given in a vein (by IV). You may feel some of the effects of anesthesia for several hours. Common side effects include:

  • Feeling sleepy. Your doctors and nurses will make sure you are not too sleepy to go home.
  • Nausea and vomiting. This usually does not last long. It can be treated with over-the-counter medication.
  • A sore throat.
  • Muscle aches or weakness.
  • For the next 24 hours, please avoid:
  • Alcoholic beverages
  • Making important personal, business, and legal decisions
  • Driving, operating heavy machinery, or doing anything that requires coordination and balance
  • Strenuous activity, sudden position changes, heavy lifting, and straining

 

Recovery Instructions

You may have a moderate level of pain at the puncture site (where the catheter entered your skin) over the next few days. This is normal and expected. Our goal is to treat your pain safely. Sometimes, pain may not go away completely.  We will do our best to help you feel better.

 

You can expect to have mild shortness of breath and chest pain. Call 911 if these symptoms become very bad.

  

Diet:

  • You can eat and drink fluids as tolerated. Start with clear liquids and work up to solid foods. Drink plenty of fluids unless otherwise directed by your doctor. Extra fluids will help flush the contrast dye used during the procedure from your body.

 

Activity:

  • Do not lift anything heavier than 5 pounds for the first 3 days after the procedure.
  • Avoid strenuous activities and heavy lifting for 2 weeks.
  • Rest when you feel tired, especially for the first 48 hours. Getting enough sleep will help you recover.
  • You can go back to normal activities as you feel up to it. Start slowly and listen to your body, do not overdo it. Most people are ready to return to work 7 to 10 days after the procedure if not sooner.
  • You can drive 2 days after the procedure if you are not taking any opioid pain medications.
  • You can shower 24 hours after your procedure.

 

Caring for the puncture site: 

You may have a small amount of bruising at the puncture site (where the catheter entered your skin). This is normal and should go away over the next several days.

  • Remove the bandage after 24 hours.
  • Gently clean the puncture site and the skin around it with soap and water. Do not use hydrogen peroxide or alcohol, which may slow healing.
  • Gently pat the puncture site dry. Apply new gauze and tape or a Band-Aid.
  • Change the bandage and clean the puncture site every day until it has healed completely (usually 2-3 days).
  • Do not use any lotion or powder near the puncture site.
  • Do not take a bath or swim until it has healed completely.
  • There should be no or very little bleeding from the puncture site.
    • If you notice bleeding, lie down. Apply direct pressure to the area for 20 minutes. Notify the Interventional Radiologist right away.

 

Medication Instructions

Below are the medications that you may take at home. Be safe with medicines. Read and follow all instructions on the label.  If you take Glucophage (metformin), do NOT take for 2 days after the procedure.

 

Mild pain and/or low grade fever (fever less than 101.5̊ F (38° C))

  • If you have pain, do not be afraid to say so. Pain medicine works better if you take it before the pain gets bad.
  • You can take over-the-counter (OTC) medication such as ibuprofen (Advil®/Motrin®), naproxen (Aleve®) or acetaminophen (Tylenol®) for mild pain and/or low grade fever.
  • Take ibuprofen and naproxen with food as they may upset your stomach.
  • If you have a fever over 101.5̊ F (38° C) that does not go down with medication, please contact your Interventional Radiologist and Oncologist.

 

Very bad pain that does not get better with OTC medications

  • You will get a prescription for an opioid (strong pain medication) if the OTC medication does not give you enough pain control.
    • Take only as prescribed and only as needed

 

Constipation

  • Opioid pain medications give you constipation. If you are taking them, you should also take a stool softener. You can take Colace or Senokot.
    • Colace – stool softener; helps prevent constipation while taking a narcotic.
    • Senokot – mild laxative; take until you have a regular bowel pattern and then stop.

 

Follow-Up Care

  • Make a follow-up appointment with Interventional Radiology for 2 weeks after your procedure date.
  • Your referring doctor will arrange a follow-up MRI or CT scan to see how well your treatment worked.
  • Be sure to make and go to all appointments, and call your doctor if you are having problems. It is also a good idea to know your test results and keep an up-to-date list of the medications you take.

 

When should you call for help?

Call 911 anytime you think you may need emergency care. For example, call if:

  • You pass out (lose consciousness)
  • You have very bad chest pain or trouble breathing.

 

Call your doctor or seek medical care right away if:

  • You have very bad pain (other than chest pain) that does not get better with medication.
  • Bright red blood has soaked through the bandage.
  • You have numbness, tingling or difficulty moving your hand (if you had a radial or wrist puncture).
  • You feel like your heart is racing.
  • You have increasing weakness or dizziness.
  • You have trouble urinating or inability to urinate within 8 hours of discharge.
  • You have persistent nausea/vomiting or the inability to keep fluids or food down.
  • You have signs of infection such as:
    • Increased pain, swelling, warmth, or redness around the puncture site
    • Pus draining or red streaks leading from the area
    • A fever over 101.5̊ F (38°C) that does not go down with over-the-counter medications and lasts longer than 24 hours, chills, or body aches

 

You can speak to a provider in Interventional Radiology:

  • Monday-Friday 9AM-4:30PM, call 212-263-5898.
  • Weekdays after 5PM or weekends, call 212-263-5230 and ask the front desk to contact the Vascular Interventional Radiologist on-call.

 

Watch closely for changes in your health, and be sure to contact your doctor if you do not get better as expected.

 

© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.

Discharge Instructions for Pulmonary AVM Embolization

 

What is a pulmonary AVM embolization?

A pulmonary AVM (arteriovenous malformation) embolization is a minimally invasive procedure. It blocks (embolizes) blood flow to an area of tangled arteries and veins called an AVM. The doctor gets into the veins by placing a catheter (long tube) into a large vein in the groin, usually on the right side of the body. Contrast dye visible to an x-ray machine is injected into these veins. X-rays help your doctor guide the catheter to the blood vessels feeding the AVM. They are then blocked.

 

How can you care for yourself at home?

This care sheet gives you a general idea about how long it will take to recover. Please remember, each person recovers at a different speed. 

 

Recovering from anesthesia

You had local anesthesia (a shot to numb the area). You may feel some pain and discomfort as it wears off. You had anesthesia to help you sleep through the procedure. It is usually given in a vein (by IV). You may feel some of the effects of anesthesia for several hours. Common side effects include:

  • Feeling sleepy. Your doctors and nurses will make sure you are not too sleepy to go home.
  • Nausea and vomiting. This usually does not last long. It can be treated with over-the-counter medication.
  • A sore throat.
  • Muscle aches or weakness.
  • For the next 24 hours, please avoid:
  • Alcoholic beverages
  • Making important personal, business, and legal decisions
  • Driving, operating heavy machinery, or doing anything that requires coordination and balance
  • Strenuous activity, sudden position changes, heavy lifting, and straining

 

Recovery Instructions

You may have a moderate level of pain at the puncture site (where the catheter entered your skin) over the next few days. This is normal and expected. Our goal is to treat your pain safely. Sometimes, pain may not go away completely.  We will do our best to help you feel better.

 

You can expect to have mild shortness of breath and chest pain. Call 911 if these symptoms become very bad.

  

Diet:

  • You can eat and drink fluids as tolerated. Start with clear liquids and work up to solid foods. Drink plenty of fluids unless otherwise directed by your doctor. Extra fluids will help flush the contrast dye used during the procedure from your body.

 

Activity:

  • Do not lift anything heavier than 5 pounds for the first 3 days after the procedure.
  • Avoid strenuous activities and heavy lifting for 2 weeks.
  • Rest when you feel tired, especially for the first 48 hours. Getting enough sleep will help you recover.
  • You can go back to normal activities as you feel up to it. Start slowly and listen to your body, do not overdo it. Most people are ready to return to work 7 to 10 days after the procedure if not sooner.
  • You can drive 2 days after the procedure if you are not taking any opioid pain medications.
  • You can shower 24 hours after your procedure.

 

Caring for the puncture site: 

You may have a small amount of bruising at the puncture site (where the catheter entered your skin). This is normal and should go away over the next several days.

  • Remove the bandage after 24 hours.
  • Gently clean the puncture site and the skin around it with soap and water. Do not use hydrogen peroxide or alcohol, which may slow healing.
  • Gently pat the puncture site dry. Apply new gauze and tape or a Band-Aid.
  • Change the bandage and clean the puncture site every day until it has healed completely (usually 2-3 days).
  • Do not use any lotion or powder near the puncture site.
  • Do not take a bath or swim until it has healed completely.
  • There should be no or very little bleeding from the puncture site.
    • If you notice bleeding, lie down. Apply direct pressure to the area for 20 minutes. Notify the Interventional Radiologist right away.

 

Medication Instructions

Below are the medications that you may take at home. Be safe with medicines. Read and follow all instructions on the label.  If you take Glucophage (metformin), do NOT take for 2 days after the procedure.

 

Mild pain and/or low grade fever (fever less than 101.5̊ F (38° C))

  • If you have pain, do not be afraid to say so. Pain medicine works better if you take it before the pain gets bad.
  • You can take over-the-counter (OTC) medication such as ibuprofen (Advil®/Motrin®), naproxen (Aleve®) or acetaminophen (Tylenol®) for mild pain and/or low grade fever.
  • Take ibuprofen and naproxen with food as they may upset your stomach.
  • If you have a fever over 101.5̊ F (38° C) that does not go down with medication, please contact your Interventional Radiologist and Oncologist.

 

Very bad pain that does not get better with OTC medications

  • You will get a prescription for an opioid (strong pain medication) if the OTC medication does not give you enough pain control.
    • Take only as prescribed and only as needed

 

Constipation

  • Opioid pain medications give you constipation. If you are taking them, you should also take a stool softener. You can take Colace or Senokot.
    • Colace – stool softener; helps prevent constipation while taking a narcotic.
    • Senokot – mild laxative; take until you have a regular bowel pattern and then stop.

 

Follow-Up Care

  • Make a follow-up appointment with Interventional Radiology for 2 weeks after your procedure date.
  • Your referring doctor will arrange a follow-up MRI or CT scan to see how well your treatment worked.
  • Be sure to make and go to all appointments, and call your doctor if you are having problems. It is also a good idea to know your test results and keep an up-to-date list of the medications you take.

 

When should you call for help?

Call 911 anytime you think you may need emergency care. For example, call if:

  • You pass out (lose consciousness)
  • You have very bad chest pain or trouble breathing.

 

Call your doctor or seek medical care right away if:

  • You have very bad pain (other than chest pain) that does not get better with medication.
  • Bright red blood has soaked through the bandage.
  • You have numbness, tingling or difficulty moving your hand (if you had a radial or wrist puncture).
  • You feel like your heart is racing.
  • You have increasing weakness or dizziness.
  • You have trouble urinating or inability to urinate within 8 hours of discharge.
  • You have persistent nausea/vomiting or the inability to keep fluids or food down.
  • You have signs of infection such as:
    • Increased pain, swelling, warmth, or redness around the puncture site
    • Pus draining or red streaks leading from the area
    • A fever over 101.5̊ F (38°C) that does not go down with over-the-counter medications and lasts longer than 24 hours, chills, or body aches

 

You can speak to a provider in Interventional Radiology:

  • Monday-Friday 9AM-4:30PM, call 212-263-5898.
  • Weekdays after 5PM or weekends, call 212-263-5230 and ask the front desk to contact the Vascular Interventional Radiologist on-call.

 

Watch closely for changes in your health, and be sure to contact your doctor if you do not get better as expected.

 

© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.

Discharge Instructions for Pulmonary AVM Embolization

 

What is a pulmonary AVM embolization?

A pulmonary AVM (arteriovenous malformation) embolization is a minimally invasive procedure. It blocks (embolizes) blood flow to an area of tangled arteries and veins called an AVM. The doctor gets into the veins by placing a catheter (long tube) into a large vein in the groin, usually on the right side of the body. Contrast dye visible to an x-ray machine is injected into these veins. X-rays help your doctor guide the catheter to the blood vessels feeding the AVM. They are then blocked.

 

How can you care for yourself at home?

This care sheet gives you a general idea about how long it will take to recover. Please remember, each person recovers at a different speed. 

 

Recovering from anesthesia

You had local anesthesia (a shot to numb the area). You may feel some pain and discomfort as it wears off. You had anesthesia to help you sleep through the procedure. It is usually given in a vein (by IV). You may feel some of the effects of anesthesia for several hours. Common side effects include:

  • Feeling sleepy. Your doctors and nurses will make sure you are not too sleepy to go home.
  • Nausea and vomiting. This usually does not last long. It can be treated with over-the-counter medication.
  • A sore throat.
  • Muscle aches or weakness.
  • For the next 24 hours, please avoid:
  • Alcoholic beverages
  • Making important personal, business, and legal decisions
  • Driving, operating heavy machinery, or doing anything that requires coordination and balance
  • Strenuous activity, sudden position changes, heavy lifting, and straining

 

Recovery Instructions

You may have a moderate level of pain at the puncture site (where the catheter entered your skin) over the next few days. This is normal and expected. Our goal is to treat your pain safely. Sometimes, pain may not go away completely.  We will do our best to help you feel better.

 

You can expect to have mild shortness of breath and chest pain. Call 911 if these symptoms become very bad.

  

Diet:

  • You can eat and drink fluids as tolerated. Start with clear liquids and work up to solid foods. Drink plenty of fluids unless otherwise directed by your doctor. Extra fluids will help flush the contrast dye used during the procedure from your body.

 

Activity:

  • Do not lift anything heavier than 5 pounds for the first 3 days after the procedure.
  • Avoid strenuous activities and heavy lifting for 2 weeks.
  • Rest when you feel tired, especially for the first 48 hours. Getting enough sleep will help you recover.
  • You can go back to normal activities as you feel up to it. Start slowly and listen to your body, do not overdo it. Most people are ready to return to work 7 to 10 days after the procedure if not sooner.
  • You can drive 2 days after the procedure if you are not taking any opioid pain medications.
  • You can shower 24 hours after your procedure.

 

Caring for the puncture site: 

You may have a small amount of bruising at the puncture site (where the catheter entered your skin). This is normal and should go away over the next several days.

  • Remove the bandage after 24 hours.
  • Gently clean the puncture site and the skin around it with soap and water. Do not use hydrogen peroxide or alcohol, which may slow healing.
  • Gently pat the puncture site dry. Apply new gauze and tape or a Band-Aid.
  • Change the bandage and clean the puncture site every day until it has healed completely (usually 2-3 days).
  • Do not use any lotion or powder near the puncture site.
  • Do not take a bath or swim until it has healed completely.
  • There should be no or very little bleeding from the puncture site.
    • If you notice bleeding, lie down. Apply direct pressure to the area for 20 minutes. Notify the Interventional Radiologist right away.

 

Medication Instructions

Below are the medications that you may take at home. Be safe with medicines. Read and follow all instructions on the label.  If you take Glucophage (metformin), do NOT take for 2 days after the procedure.

 

Mild pain and/or low grade fever (fever less than 101.5̊ F (38° C))

  • If you have pain, do not be afraid to say so. Pain medicine works better if you take it before the pain gets bad.
  • You can take over-the-counter (OTC) medication such as ibuprofen (Advil®/Motrin®), naproxen (Aleve®) or acetaminophen (Tylenol®) for mild pain and/or low grade fever.
  • Take ibuprofen and naproxen with food as they may upset your stomach.
  • If you have a fever over 101.5̊ F (38° C) that does not go down with medication, please contact your Interventional Radiologist and Oncologist.

 

Very bad pain that does not get better with OTC medications

  • You will get a prescription for an opioid (strong pain medication) if the OTC medication does not give you enough pain control.
    • Take only as prescribed and only as needed

 

Constipation

  • Opioid pain medications give you constipation. If you are taking them, you should also take a stool softener. You can take Colace or Senokot.
    • Colace – stool softener; helps prevent constipation while taking a narcotic.
    • Senokot – mild laxative; take until you have a regular bowel pattern and then stop.

 

Follow-Up Care

  • Make a follow-up appointment with Interventional Radiology for 2 weeks after your procedure date.
  • Your referring doctor will arrange a follow-up MRI or CT scan to see how well your treatment worked.
  • Be sure to make and go to all appointments, and call your doctor if you are having problems. It is also a good idea to know your test results and keep an up-to-date list of the medications you take.

 

When should you call for help?

Call 911 anytime you think you may need emergency care. For example, call if:

  • You pass out (lose consciousness)
  • You have very bad chest pain or trouble breathing.

 

Call your doctor or seek medical care right away if:

  • You have very bad pain (other than chest pain) that does not get better with medication.
  • Bright red blood has soaked through the bandage.
  • You have numbness, tingling or difficulty moving your hand (if you had a radial or wrist puncture).
  • You feel like your heart is racing.
  • You have increasing weakness or dizziness.
  • You have trouble urinating or inability to urinate within 8 hours of discharge.
  • You have persistent nausea/vomiting or the inability to keep fluids or food down.
  • You have signs of infection such as:
    • Increased pain, swelling, warmth, or redness around the puncture site
    • Pus draining or red streaks leading from the area
    • A fever over 101.5̊ F (38°C) that does not go down with over-the-counter medications and lasts longer than 24 hours, chills, or body aches

 

You can speak to a provider in Interventional Radiology:

  • Monday-Friday 9AM-4:30PM, call 212-263-5898.
  • Weekdays after 5PM or weekends, call 212-263-5230 and ask the front desk to contact the Vascular Interventional Radiologist on-call.

 

Watch closely for changes in your health, and be sure to contact your doctor if you do not get better as expected.

 

© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.