Case report
Haemodynamic management using non-invasive cardiac output monitoring for urgent craniotomy in fragile X syndrome: Case report
Manejo hemodinámico mediante monitor no invasivo de gasto cardiaco para craneotomía urgente en el síndrome X frágil: reporte de caso
Rosana Guerrero-Domíngueza,
, Daniel López-Herrera-Rodrígueza, Francisco Javier Beato-Lópezb, Ignacio Jiméneza
Corresponding author
rosanabixi7@hotmail.com
Corresponding author at: Avda Ramón Carande, N° 11, 4°E, 41013 Sevilla, Spain.
Corresponding author at: Avda Ramón Carande, N° 11, 4°E, 41013 Sevilla, Spain.
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"figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 777 "Ancho" => 975 "Tamanyo" => 133028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Non-invasive cardiac output monitoring display showing the various intraoperative haemodynamic parameters.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fragile X syndrome (FXS) is the most common cause of inherited mental retardation<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> accounting for 30% of the cases,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> with an associated connective tissue disorder that leads to mitral valve prolapse (MVP) in most subjects.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The goal in our clinical case was to individualize anaesthetic management in this syndrome given difficult airway control and the associated cardiovascular pathology. Non-invasive cardiac output monitoring was used during the emergency craniotomy in order to reduce morbidity with the help of goal-directed therapy and avoid delaying the surgery, considering that this approach only requires placement of a finger device that provides all the relevant information pertaining to the patient's haemodynamic status.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 38 year-old male patient with FXS, severe mental retardation, and refractory epileptic encephalopathy who suffered head injury following a tonic–clonic seizure, with acute left frontoparietal subdural haematoma requiring emergent craniotomy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Once monitoring with arterial blood pressure (ABP), electrocardiography (EKG), pulse oximetry, bispectral index (BIS) and non-invasive cardiac output (Nexfin<span class="elsevierStyleSup">®</span> – BMEYE, Amsterdam, The Netherlands) was established, cefazoline 2<span class="elsevierStyleHsp" style=""></span>g and midazolam 5<span class="elsevierStyleHsp" style=""></span>mg were given IV through a peripheral venous line because the patient was uncooperative. Propofol 120<span class="elsevierStyleHsp" style=""></span>mg, remifentanil 0.1<span class="elsevierStyleHsp" style=""></span>μg/kg/min and 50<span class="elsevierStyleHsp" style=""></span>mg of rocuronium were used for anaesthesia induction, with subsequent successful endotracheal intubation with the help of Glidescope<span class="elsevierStyleSup">®</span> videolaryngoscopy. Mechanical ventilation was started and right internal jugular venous access was established under ultrasound guidance.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Propofol and remifentanil were used for anaesthesia maintenance. Mannitol 25<span class="elsevierStyleHsp" style=""></span>g and furosemide 20<span class="elsevierStyleHsp" style=""></span>mg were required for lowering intracranial pressure (ICP) (from 22<span class="elsevierStyleHsp" style=""></span>mmHg initially down to 4<span class="elsevierStyleHsp" style=""></span>mmHg after haematoma removal). ICP was monitored using a subdural intracranial pressure sensor. Goal directed therapy (GDT) was implemented during the intraoperative period based on cardiac output values obtained after the initial administration of 1000<span class="elsevierStyleHsp" style=""></span>mL, increased to 4000<span class="elsevierStyleHsp" style=""></span>mL in response to signs of hypovolemia. An infusion of 0.1<span class="elsevierStyleHsp" style=""></span>μg/kg/min of noradrenaline was required in order to normalize extremely low initial values of systemic vascular resistance and to maintain mean arterial pressure at around 90<span class="elsevierStyleHsp" style=""></span>mmHg, promoting adequate cerebral perfusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Haemodynamic stability was maintained, vasoactive amine perfusion was removed and the patient was transferred to the intensive care unit with adequate sedation and analgesia, and under mechanical ventilation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Described by Martin and Bell in 1943,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> FXS has typical physical and behavioural characteristics.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Prevalence in males (1:3.600) is higher than in females (1:8.000), it is being associated with the X chromosome.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> It is caused by an abnormal expansion of the cytosine–guanine–guanine triplet (CGG) in the <span class="elsevierStyleItalic">FMR1</span> gene (<span class="elsevierStyleItalic">Fragile X Mental Retardation 1 gene</span>) on chromosome X(Xq27.3), blocking the production of the <span class="elsevierStyleItalic">FMR1</span> gene protein (FMRP).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The phenotypic characteristics of this syndrome may have significant anaesthetic implications, among other findings, because of craniofacial abnormalities. Physical characteristics include macrocephaly,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,6</span></a> hyperteolirsm, strabismus, prognathism,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> large prominent ears, and postpubertal marcroorchidism.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Dental implantation is abnormal, with abraded dental surfaces as well as large crowns that create severe bone–teeth discrepancies,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> limiting mouth opening and impairing the placement of the endotracheal tube.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our patient had prognathism as well as abnormal dental implantation limiting mouth opening to 3<span class="elsevierStyleHsp" style=""></span>cm. Because of an anticipated difficult airway, we decided to use the Glidescope<span class="elsevierStyleSup">®</span> videolaryngoscope,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> with successful endotracheal intubation and minimum stimulus, thus avoiding an increase in intracranial pressure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">FXS patients have excess joint laxity,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> flat feet, pectus excavatum and scoliosis. Patient positioning on the operating table with adequate support points is essential in order to prevent joint dislocations and gonadal compression.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In 80–90% of FXS cases there is moderate to severe mental retardation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Autism, hyperactivity, agitation and anxiety are also frequent,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> hence the need for adequate sedation before induction, because they are usually uncooperative.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In 15–20%<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> of cases there are partial complex and generalized tonic clonic seizures that are usually benign<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> and disappear before 20 years of age. The right premedication may reduce surgical stress by raising the convulsive threshold perioperatively.</p><p id="par0060" class="elsevierStylePara elsevierViewall">From the cardiovascular standpoint, 80% of cases may be associated with MVP with no previous episodes of chest pain or palpitations<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> but which may give rise to intraoperative arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Occasionally, there is also aortic root dilatation,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> in which case it is advisable to use adequate monitoring in order to implement GDT and create better conditions for improved results in major surgery.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Because our patient was transferred from another hospital as a vital emergency, we were unable to confirm the presence of a MVP. However, given the high incidence of this disorder and the fact that symptoms become exacerbated by anaesthesia induction, leading to cardiovascular collapse,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> we decided to perform non-invasive cardiac output monitoring.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The main objective of the anaesthetic management was to prevent any reduction in left ventricular volume during systole in order to reduce mitral valve prolapse.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Reduced venous return and vascular resistance, tachycardia and increased contractility are not well tolerated.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> During general anaesthesia, the use of vasopressors is recommended in order to maintain ABP, together with short-acting beta-blockers for heart rate control, end-diastolic and systolic volume preservation, and mitral prolapse control.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Management is different in cases associated with mitral regurgitation because maintenance of higher heart rates shortens diastolic time and reduces regurgitation volumes.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Pulse pressure variation (PPV) and systolic volume variation (SVV) are dynamic predictors of response to fluids in patients under mechanical ventilation. Their measurement is usually invasive by means of the signal derived from the ABP curve. Non-invasive CO monitoring using an inflatable cuff with an in-built photoelectric plethysmographic device provides continuous ABP measurement<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> based on the development of a pulsatile discharge from the arterial walls in the finger.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">SVV and PPV measurements without the need to use an intra-arterial catheter offers an advantage in emergency surgery, particularly in neurosurgery, where any delay in starting the intervention may determine worse clinical outcomes. GDT allows for early detection of pathophysiological changes and individualized adjustment of intraoperative haemodynamic management.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Invasive ABP monitoring with an intra-arterial catheter<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> is considered the gold standard.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> However, non-invasive measurement of dynamic predictors of response to fluid replacement has been shown to have high specificity and sensitivity,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> with improved safety and comfort.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> This system can be used on top of non-invasive ABP monitoring in haemodynamically stable patients under general anaesthesia, with the benefit of providing beat-to-beat ABP measurements.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> However, its concomitant use with the PICCO<span class="elsevierStyleSup">®</span> transpulmonary thermodilution monitor for measuring cardiac output is controversial.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In summary, we discuss the anaesthetic management of patients with FXS, given the low incidence of this disorders and the very few reports found in the anaesthesia literature. We believe that non-invasive cardiac output monitoring is a new option for emergency neurosurgical procedures and in patients with heart disease, considering that it shortens anaesthesia time and provides reliable parameters for GDT. Moreover, we believe that videolaryngoscopy is the first choice for managing a predictably difficult airway in which endotracheal intubation might result in a significant increase in ICP.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">We received no funding for our work.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">There are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres599845" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec614187" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres599844" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec614188" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-09-05" "fechaAceptado" => "2015-05-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec614187" "palabras" => array:5 [ 0 => "Blood pressure" 1 => "Hemodynamics" 2 => "Cerebrovascular trauma" 3 => "Heart valve diseases" 4 => "Fragile X syndrome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec614188" "palabras" => array:5 [ 0 => "Presión sanguínea" 1 => "Hemodinámica" 2 => "Traumatismos cerebrovasculares" 3 => "Enfermedades de las válvulas cardiacas" 4 => "Síndrome del cromosoma X frágil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fragile X syndrome is an inherited form of mental retardation with a connective tissue component involving mitral valve prolapse. The most frequent manifestations of fragile X syndrome are learning disability, orofacial morphological alterations and macroorchidism.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The usefulness of advanced haemodynamic monitoring for goal-directed therapy is increasingly high during neurosurgical procedures. Non-invasive cardiac output monitoring may be considered as a new alternative for emergency neurosurgical procedures.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Our aim was to detect haemodynamic changes in a syndromic fragile X patient, given the usual concomitant presentation of cardiovascular disease, such as mitral valve prolapse and dilated aortic root, in an attempt at obtaining the best intraoperative and postoperative neurological outcomes without worsening cardiovascular function, by means of individualized intra-operative goal directed therapy. This type of non-invasive monitoring allows surgery to proceed without delay and provides excellent information of the haemodynamic status.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This syndrome is relevant due to its anaesthetic implications and the paucity of cases published to date.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El síndrome X frágil es una forma hereditaria de retraso mental con una afectación de tejido conectivo que produce prolapso de la válvula mitral. Las manifestaciones más frecuentes del síndrome X frágil son la dificultad en el aprendizaje, alteraciones morfológicas orofaciales y macroorquidismo.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La utilidad de la monitorización hemodinámica avanzada para terapia dirigida por objetivos es cada vez mayor durante los procedimientos neuroquirúrgicos. La monitorización no invasiva de gasto cardiaco puede considerarse una nueva alternativa en los procedimientos neuroquirúrgicos emergentes.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue detectar los cambios hemodinámicos en un paciente sindrómico X frágil que suelen presentar patología cardiovascular, como prolapso mitral y dilatación de la raíz aórtica, intentando obtener los mejores resultados neurológicos intraoperatorios y posoperatorios sin deteriorar la función cardiovascular individualizada por una terapia guiada por objetivos. Este tipo de monitorización no invasiva permite desarrollar la intervención quirúrgica sin demora, aportando gran información del estado hemodinámico. Este síndrome es relevante debido a sus implicaciones anestésicas y los pocos casos publicados hasta la fecha.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Guerrero-Domínguez R, López-Herrera-Rodríguez D, Beato-López FJ, Jiménez I. Manejo hemodinámico mediante monitor no invasivo de gasto cardiaco para craneotomía urgente en el síndrome x frágil: reporte de caso. Rev Colomb Anestesiol. 2016;44:48–51.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 777 "Ancho" => 975 "Tamanyo" => 133028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Non-invasive cardiac output monitoring display showing the various intraoperative haemodynamic parameters.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manifestaciones neurológicas en el adulto con premutación X frágil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 14 | 0 | 14 |
| 2024 September | 24 | 3 | 27 |
| 2024 August | 8 | 3 | 11 |
| 2024 July | 13 | 2 | 15 |
| 2024 June | 16 | 1 | 17 |
| 2024 May | 9 | 6 | 15 |
| 2024 April | 10 | 5 | 15 |
| 2024 March | 15 | 10 | 25 |
| 2024 February | 14 | 2 | 16 |
| 2024 January | 20 | 3 | 23 |
| 2023 December | 33 | 10 | 43 |
| 2023 November | 33 | 13 | 46 |
| 2023 October | 31 | 3 | 34 |
| 2023 September | 16 | 3 | 19 |
| 2023 August | 22 | 4 | 26 |
| 2023 July | 19 | 5 | 24 |
| 2023 June | 36 | 2 | 38 |
| 2023 May | 60 | 7 | 67 |
| 2023 April | 56 | 1 | 57 |
| 2023 March | 48 | 3 | 51 |
| 2023 February | 34 | 7 | 41 |
| 2023 January | 30 | 3 | 33 |
| 2022 December | 54 | 8 | 62 |
| 2022 November | 23 | 4 | 27 |
| 2022 October | 20 | 8 | 28 |
| 2022 September | 25 | 15 | 40 |
| 2022 August | 29 | 5 | 34 |
| 2022 July | 28 | 13 | 41 |
| 2022 June | 16 | 3 | 19 |
| 2022 May | 20 | 5 | 25 |
| 2022 April | 20 | 13 | 33 |
| 2022 March | 69 | 8 | 77 |
| 2022 February | 34 | 5 | 39 |
| 2022 January | 63 | 6 | 69 |
| 2021 December | 40 | 11 | 51 |
| 2021 November | 45 | 9 | 54 |
| 2021 October | 62 | 8 | 70 |
| 2021 September | 52 | 5 | 57 |
| 2021 August | 41 | 7 | 48 |
| 2021 July | 14 | 4 | 18 |
| 2021 June | 16 | 9 | 25 |
| 2021 May | 20 | 5 | 25 |
| 2021 April | 52 | 13 | 65 |
| 2021 March | 42 | 14 | 56 |
| 2021 February | 22 | 7 | 29 |
| 2021 January | 25 | 7 | 32 |
| 2020 December | 30 | 8 | 38 |
| 2020 November | 29 | 6 | 35 |
| 2020 October | 15 | 6 | 21 |
| 2020 September | 8 | 6 | 14 |
| 2020 August | 14 | 11 | 25 |
| 2020 July | 10 | 9 | 19 |
| 2020 June | 11 | 4 | 15 |
| 2020 May | 8 | 3 | 11 |
| 2020 April | 2 | 3 | 5 |
| 2020 March | 9 | 0 | 9 |
| 2020 February | 8 | 3 | 11 |
| 2020 January | 7 | 3 | 10 |
| 2019 December | 9 | 6 | 15 |
| 2019 November | 9 | 1 | 10 |
| 2019 October | 3 | 1 | 4 |
| 2019 September | 2 | 2 | 4 |
| 2019 July | 2 | 6 | 8 |
| 2019 June | 1 | 4 | 5 |
| 2019 May | 4 | 9 | 13 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 3 | 1 | 4 |
| 2018 May | 29 | 7 | 36 |
| 2018 April | 39 | 10 | 49 |
| 2018 March | 15 | 9 | 24 |
| 2018 February | 21 | 8 | 29 |
| 2018 January | 26 | 7 | 33 |
| 2017 December | 20 | 7 | 27 |
| 2017 November | 15 | 5 | 20 |
| 2017 October | 17 | 7 | 24 |
| 2017 September | 25 | 8 | 33 |
| 2017 August | 27 | 6 | 33 |
| 2017 July | 16 | 5 | 21 |
| 2017 June | 22 | 6 | 28 |
| 2017 May | 36 | 8 | 44 |
| 2017 April | 36 | 9 | 45 |
| 2017 March | 16 | 5 | 21 |
| 2017 February | 17 | 1 | 18 |
| 2017 January | 7 | 4 | 11 |
| 2016 December | 33 | 16 | 49 |
| 2016 November | 30 | 6 | 36 |
| 2016 October | 44 | 7 | 51 |
| 2016 September | 44 | 10 | 54 |
| 2016 August | 29 | 5 | 34 |
| 2016 July | 17 | 15 | 32 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 2 | 0 | 2 |
| 2016 April | 0 | 22 | 22 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 4 | 27 | 31 |
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