Original article
Undersedation is a risk factor for the development of subglottic stenosis in intubated children
Subsedação é um fato de risco para o desenvolvimento de estenose subglótica em crianças intubadas
Cláudia Schweigera,b,
, Denise Manicaa,b, Denise Rotta Rutkay Pereirab, Paulo Roberto Antonacci Carvalhob,c, Jefferson Pedro Pivab,c, Gabriel Kuhla,d, Leo Sekinee, Paulo José Cauduro Marosticab,f
Corresponding author
a Hospital de Clínicas de Porto Alegre, Unidade de Otorrinolaringologia, Porto Alegre, RS, Brazil
b Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Porto Alegre, RS, Brazil
c Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil
d Universidade Federal do Rio Grande do Sul (UFRGS), Departamento de Otorrinolaringologia e Oftalmologia, Porto Alegre, RS, Brazil
e Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brazil
f Hospital de Clínicas de Porto Alegre, Unidade de Pneumologia Pediátrica, Porto Alegre, RS, Brazil
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da Criança e do Adolescente, Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul (UFRGS), Departamento de Otorrinolaringologia e Oftalmologia, Porto Alegre, RS, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brazil" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital de Clínicas de Porto Alegre, Unidade de Pneumologia Pediátrica, Porto Alegre, RS, Brazil" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Subsedação é um fato de risco para o desenvolvimento de estenose subglótica em crianças intubadas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2052 "Ancho" => 1501 "Tamanyo" => 140939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Percentages of COMFORT-B scores in each category. SGS, subglottic stenosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acquired subglottic stenosis (SGS) is most commonly a consequence of prolonged endotracheal intubation, with a reported incidence of 2.8–11.3%.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–3</span></a> There are several risk factors already under consideration; however, there are only a few studies with sufficiently adequate design to ascertain its association.</p><p id="par0010" class="elsevierStylePara elsevierViewall">While previous publications have suggested that inadequate sedation is a risk factor for the development of SGS,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,5</span></a> these studies were either expert opinions or retrospective reviews with no control group. The proposed mechanism of injury is that the agitation of the child could cause excessive movement of the endotracheal tube (ETT) in the airway, predisposing to laryngeal stenosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2007, a study from the present research group enrolling 35 pediatric patients showed that the number of additional doses of sedation that the child received during the intubation period was a risk factor for SGS.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Later, another article by the same group including 142 children confirmed that the number of extra doses of sedation was effectively a risk factor, and also identified prolonged intubation time as a significant predictor of the development of SGS. However, solely from the data collected, it could not be concluded whether the reason for the larynx injury was trauma because of the child's excessive agitation, or hypoperfusion and local ischemia because of excessive sedation, which, along with the trauma due to the ETT in contact with the airway mucosa, culminated in the development of SGS.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to clarify this issue in children beyond the neonatal period, the authors conducted research in the pediatric intensive care unit (PICU) of this hospital, collecting data regarding the sedation of patients. The aim of this study was therefore to verify if there is any association between the degree of sedation during the intubation period and the development of SGS after extubation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a prospective cohort study that included all children from 30 days to 5 years of age who were intubated in the PICU of Hospital de Clínicas de Porto Alegre (HCPA), between 2013 and 2014, and whose parents or guardians agreed to participate by signing an informed consent. Patients were excluded if they had signs of previous laryngeal disease, such as dysphonia and stridor, prior intubation, current or past tracheostomy, craniofacial malformations, or children in poor general condition. The protocol was approved by the Research and Ethics Committee of HCPA.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Intubation procedures followed a protocol of fast intubation sequence, with the use of midazolam, fentanyl, and rocuronium. Children were then sedated with midazolam 0.2<span class="elsevierStyleHsp" style=""></span>mg/kg/h and fentanyl 2<span class="elsevierStyleHsp" style=""></span>mcg/kg/h during the entire intubation period. All extra sedative medication doses were considered “additional doses of sedation.”</p><p id="par0035" class="elsevierStylePara elsevierViewall">All children were monitored daily in the PICU after intubation, and data such as number of additional sedation doses received, number of days intubated, need for reintubation, and need for ETT repositioning were collected. The size of the ETT was determined by guidelines from the American Heart Association.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Verification of tube size adequacy is performed by evaluating the difference of inspiratory and expiratory tidal volumes, as measured by the PICU assistant; tube size is considered adequate when there is a difference of around 20–25% between the two measured volumes. If the difference is greater than that, then PICU staff upsize the ETT. If the difference is smaller, they downsize it.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In 2013, the application of the COMFORT-B sedation scale was implemented at the PICU of HCPA in order to measure the level of sedation and to assist in evaluating the need for additional doses of sedation. Nurses who had been previously trained applied this scale every three hours. It evaluates items such as level of consciousness, calmness/agitation, respiratory response, physical movement, muscle tone, and facial tension.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients underwent flexible fiber-optic laryngoscopy (FFL) in the PICU within eight hours after extubation, with nasal topical anesthesia and without sedation. All children used supplemental oxygen due to the recent extubation. The patients were positioned, and oxygen saturation and heart rate were monitored throughout the examination. The examinations were recorded and later examined by a blinded reviewer, who classified them in Group 1 – no laryngeal injuries or mild injuries, or Group 2 – moderate to severe laryngeal lesions, according to a criteria previously published by the authors.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">All children were followed-up after discharge from the PICU. Those with moderate to severe lesions on the initial post-extubation FFL, and any additional children with laryngeal symptoms during follow-up, underwent a second FFL seven to ten days after extubation, and were followed up further. Those with persistent laryngeal lesions received subsequent microlaryngoscopy to evaluate for possible SGS.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Families were asked to bring their children exclusively to the research medical staff whenever respiratory symptoms developed. None of the patients had a diagnosis of SGS established without microlaryngoscopy being performed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were then divided into two final groups: those who developed SGS and those who did not. Children in the SGS group were enrolled in a follow-up program and were treated by the otolaryngology team.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The program Predictive Analytics Software (PASW) version 17.0.2 (Somers, NY, USA) was used for statistical analysis. Quantitative variables were expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD when they had normal distribution. Otherwise, they were described as median, 25th and 75th percentiles, as well as minimum and maximum values. The Mann–Whitney <span class="elsevierStyleItalic">U</span>-test was used for calculating the difference between the groups. Categorical variables were expressed as number of patients (<span class="elsevierStyleItalic">n</span>) and percentage (%). Fisher's exact test with chi-squared distribution was used to calculate the difference between the proportions. For calculation of the 95% confidence interval (95% CI), the Wilson score method was used.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">During the two-year period of research in PICU, 45 children were eligible for the study. Of these, nine children were not included because their parents refused to participate (two children), they underwent tracheostomy for prolonged mechanical ventilation (three children), died before extubation (two children), or died after the initial assessment (two children). Thus, there was an eventual loss of 20% of patients, and 36 children were included.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The median age of the included children was 2.6 months (25th–75th percentiles: 1.9–7.2) and 50% (18) were male.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the initial FFL, 16 children (44.4%) had moderate to severe injuries. The incidence of SGS at the end of follow-up was 11.1% (four children; 95% CI, 4.17–29.60).</p><p id="par0085" class="elsevierStylePara elsevierViewall">Data regarding population characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Data regarding other possible risk factors, including the number of days of intubation, additional doses of sedation/days of intubation, number of intubations/days of intubation, and the presence of a cuffed tube, are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Univariate analysis showed no statistically significance for these variables.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Children who developed SGS had a mean COMFORT-B score of 16.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.76, while the mean COMFORT-B score of those who did not develop SGS was 12.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.13, with a statistically significant difference (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.006). Children with SGS had a higher percentage of COMFORT-B scores between 23 and 30 than those who did not develop SGS (15.8% <span class="elsevierStyleItalic">vs.</span> 3.65%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004). Data are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Owing to the complexity of SGS management and the associated morbidity, it is important to identify risk factors associated with its development. There are few prospective studies on this subject, and most of them were held in neonatal intensive care units.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The authors’ previous studies identified the duration of intubation<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> and number of additional doses of sedation received by the child<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7</span></a> as risk factors for SGS. The number of reintubation attempts and the use of a cuffed tube were not considered significant.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Sedation was mentioned in some articles as a potential factor for the development of SGS,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,7</span></a> although to date this association has not been characterized, because no prospective study has targeted this question directly.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The ideal approach for assessing the degree of sedation of patients is to use existing standard scales. Sedation scales have been increasingly used in pediatric intensive care units to guide the administration of sedatives, evaluating the need to increase the dose of the basal sedation and the need to administer extra doses of sedation.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The COMFORT-B scale is widely used in studies assessing children's sedation levels and it has proven to be adequate for the management of intubated children in mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9,13</span></a> This scale was validated for the Portuguese language by Amoretti et al., in 2008.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> A recent study showed that the COMFORT-B scale also detects treatment-related changes in pain or distress intensity, and can effectively be used to guide sedation treatment in critically ill children.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The results of the present study show that children who developed SGS are potentially those that are undersedated in the PICU, which was confirmed by two variables: “mean COMFORT-B score” and “percentage of COMFORT-B scores between 23 and 30 (undersedated children).” Due to restlessness, these children required more doses of additional sedation, <span class="elsevierStyleItalic">i.e.</span>, doses beyond those prescribed routinely by an intensive care team. This explains the findings in previous studies, in which the number of additional doses of sedation systematically emerged as an independent risk factor for SGS.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The lack of sedation and the consequent movement of the ETT in the airway have been already cited by experts in the field of pediatric laryngology as risk factors for SGS,<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16,17</span></a> but this is the first prospective study with objective measures of the level of sedation to prove this fact in the pediatric population.</p><p id="par0135" class="elsevierStylePara elsevierViewall">This study failed to demonstrate “days intubated” and “number of additional doses of sedation/days intubated” as significant risk factors, probably because of the limited number of patients. However, these factors were already proved to be significant in the previous studies published.</p><p id="par0140" class="elsevierStylePara elsevierViewall">It is paradoxical that currently the etiology of most SGS is endotracheal intubation, but on the other hand that the ETT itself is indicated by experts to treat acute injuries after intubation, serving as a stent for the healing of glottic and subglottic injuries.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> It could be inferred, therefore, that the problem is probably not the tube itself – considering that this is of the proper size for the child – but the child's excessive movement and the length of time the tube remains in the airway.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion, in this prospective study including only children beyond the neonatal period, children who developed SGS were less sedated during the time they needed an ETT than children who did not develop SGS, as measured by the COMFORT-B scale.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres872796" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec861524" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres872797" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec861525" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-04" "fechaAceptado" => "2016-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec861524" "palabras" => array:3 [ 0 => "Larynx" 1 => "Airway stenosis/reconstruction" 2 => "Children" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec861525" "palabras" => array:3 [ 0 => "Laringe" 1 => "Estenose/Reconstrução das vias aéreas" 2 => "Crianças" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the level of sedation in intubated children as a risk factor for the development of subglottic stenosis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">All patients between 30 days and 5 years of age who required endotracheal intubation in the pediatric intensive care unit between 2013 and 2014 were included in this prospective study. They were monitored daily and COMFORT-B scores were obtained. Flexible fiber-optic laryngoscopy was performed within eight hours of extubation, and repeated seven to ten days later if the first examination showed moderate to severe laryngeal injuries. If these lesions persisted and/or if the child developed symptoms in the follow-up period, microlaryngoscopy under general anesthesia was performed to evaluate for subglottic stenosis.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 36 children. Incidence of subglottic stenosis was 11.1%. Children with subglottic stenosis had a higher percentage of COMFORT-B scores between 23 and 30 (undersedated) than those who did not develop subglottic stenosis (15.8% <span class="elsevierStyleItalic">vs.</span> 3.65%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Children who developed subglottic stenosis were less sedated than children who did not develop subglottic stenosis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analisar o nível de sedação em crianças intubadas como um fator de risco para o desenvolvimento de estenose subglótica (ES).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Todos os pacientes entre 30 dias e 5 anos de idades que necessitaram de intubação endotraqueal na Unidade de Terapia Intensiva Pediátrica entre 2013 e 2014 foram incluídos neste estudo prospectivo. Eles foram monitorados diariamente e foram obtidos os escores da escala COMFORT-B. Foi feita laringoscopia com tubo flexível de fibra óptica em 8 horas da extubação e repetida 7-10 dias depois, caso o primeiro exame tenha mostrado lesões laríngeas moderadas a graves. Caso essas lesões tenham persistido e/ou caso a criança tenha desenvolvido sintomas no período de acompanhamento, foi feita microlaringoscopia sob anestesia geral para avaliar a ES.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Incluímos 36 crianças. A incidência da ES foi de 11,1%. As crianças com ES apresentaram um maior percentual de escores da escala COMFORT-B entre 23 e 30 (subsedados) que os que não desenvolveram ES (15,8% em comparação a 3,65%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,004).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As crianças que desenvolveram ES foram menos sedadas que as crianças que não desenvolveram ES.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Please cite this article as: Schweiger C, Manica D, Pereira DR, Carvalho PR, Piva JP, Kuhl G, et al. Undersedation is a risk factor for the development of subglottic stenosis in intubated children. J Pediatr (Rio J). 2017;93:351–5.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0060">This study was performed in the Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2052 "Ancho" => 1501 "Tamanyo" => 140939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Percentages of COMFORT-B scores in each category. SGS, subglottic stenosis.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Distribution \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6 (1.9–7.2)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (50.0%)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gestational age (weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.0 (35.2–39.0)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Attempted intubations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.0 (1.0–2.0)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reintubations/days intubated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 (0.0–2.0)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days intubated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.0 (5.0–8.5)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Additional doses of sedation/days intubated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5 (4.3)<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cuffed tube \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (27.8%)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1472864.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Median (interquartile range, P25–P75).</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Number of patients (percentage).</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Median (range, minimum–maximum).</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Mean (standard deviation).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Population characteristics (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">SGS, subglottic stenosis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No SGS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>32) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SGS (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (53.1%)<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (25.0%)<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Attempted intubations<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1–2)<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1–1)<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days intubated<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.0–9.0)<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">e</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (2.7–7.0)<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">e</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Additional doses of sedation/days intubated<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9 (4.0)<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">f</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.1 (4.3)<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">f</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cuffed tube<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (28.1%)<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (25.0%)<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reintubations/days intubated<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–0.18)<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–0.20)<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1472866.png" ] ] ] "notaPie" => array:6 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Pearson's chi-squared.</p>" ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Mann–Whitney <span class="elsevierStyleItalic">U</span>-test.</p>" ] 2 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Number of patients (percentage).</p>" ] 3 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Median (range, minimum–maximum).</p>" ] 4 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "e" "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Median (interquartile range, P25–P75).</p>" ] 5 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "f" "nota" => "<p class="elsevierStyleNotepara" id="npar0050">Mean (standard deviation).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Analysis of isolated risk factor for subglottic stenosis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">SGS, subglottic stenosis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SGS <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normal larynx <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>32 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean COMFORT-B score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% of COMFORT-B scores between 23 and 30 (undersedated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.65% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% of COMFORT B scores between 11 and 22 (adequately sedated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.511 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% of COMFORT B scores between 6 and 10 (oversedated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.95% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1472865.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">COMFORT-B scores: comparison between the two groups (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of post-intubation subglottic stenosis in children: prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Schweiger" 1 => "M.M. Smith" 2 => "D. Manica" 3 => "G. Kuhl" 4 => "P.R.A. Carvalho" 5 => "P.J. Marostica" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1017/S002221511300025X" "Revista" => array:6 [ "tituloSerie" => "J Laryngol Otol" "fecha" => "2013" "volumen" => "127" "paginaInicial" => "399" "paginaFinal" => "403" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23448431" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Possible risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Cordeiro" 1 => "J.C. Fernandes" 2 => "E.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 15 | 24 | 39 |
| 2024 September | 26 | 19 | 45 |
| 2024 August | 35 | 27 | 62 |
| 2024 July | 32 | 39 | 71 |
| 2024 June | 20 | 23 | 43 |
| 2024 May | 18 | 14 | 32 |
| 2024 April | 24 | 25 | 49 |
| 2024 March | 26 | 18 | 44 |
| 2024 February | 30 | 23 | 53 |
| 2024 January | 23 | 26 | 49 |
| 2023 December | 16 | 16 | 32 |
| 2023 November | 23 | 26 | 49 |
| 2023 October | 18 | 34 | 52 |
| 2023 September | 20 | 35 | 55 |
| 2023 August | 15 | 15 | 30 |
| 2023 July | 23 | 9 | 32 |
| 2023 June | 9 | 10 | 19 |
| 2023 May | 16 | 14 | 30 |
| 2023 April | 17 | 11 | 28 |
| 2023 March | 26 | 21 | 47 |
| 2023 February | 20 | 14 | 34 |
| 2023 January | 22 | 21 | 43 |
| 2022 December | 31 | 19 | 50 |
| 2022 November | 20 | 17 | 37 |
| 2022 October | 43 | 35 | 78 |
| 2022 September | 17 | 19 | 36 |
| 2022 August | 31 | 34 | 65 |
| 2022 July | 34 | 25 | 59 |
| 2022 June | 28 | 24 | 52 |
| 2022 May | 22 | 25 | 47 |
| 2022 April | 31 | 27 | 58 |
| 2022 March | 25 | 36 | 61 |
| 2022 February | 13 | 16 | 29 |
| 2022 January | 13 | 15 | 28 |
| 2021 December | 13 | 18 | 31 |
| 2021 November | 10 | 9 | 19 |
| 2021 October | 15 | 31 | 46 |
| 2021 September | 7 | 10 | 17 |
| 2021 August | 11 | 8 | 19 |
| 2021 July | 5 | 5 | 10 |
| 2021 June | 4 | 6 | 10 |
| 2021 May | 8 | 11 | 19 |
| 2021 April | 34 | 20 | 54 |
| 2021 March | 7 | 7 | 14 |
| 2021 February | 6 | 5 | 11 |
| 2021 January | 5 | 5 | 10 |
| 2020 December | 7 | 7 | 14 |
| 2020 November | 10 | 9 | 19 |
| 2020 October | 7 | 7 | 14 |
| 2020 September | 12 | 10 | 22 |
| 2020 August | 2 | 0 | 2 |
| 2020 July | 3 | 4 | 7 |
| 2020 June | 5 | 3 | 8 |
| 2020 May | 4 | 2 | 6 |
| 2020 April | 5 | 7 | 12 |
| 2020 March | 4 | 4 | 8 |
| 2020 February | 7 | 13 | 20 |
| 2020 January | 19 | 12 | 31 |
| 2019 December | 12 | 8 | 20 |
| 2019 November | 8 | 7 | 15 |
| 2019 October | 12 | 7 | 19 |
| 2019 September | 8 | 8 | 16 |
| 2019 August | 10 | 8 | 18 |
| 2019 July | 14 | 8 | 22 |
| 2019 June | 17 | 7 | 24 |
| 2019 May | 23 | 5 | 28 |
| 2019 April | 25 | 9 | 34 |
| 2019 March | 13 | 5 | 18 |
| 2019 February | 12 | 3 | 15 |
| 2019 January | 11 | 5 | 16 |
| 2018 December | 17 | 5 | 22 |
| 2018 November | 51 | 3 | 54 |
| 2018 October | 180 | 10 | 190 |
| 2018 September | 18 | 5 | 23 |
| 2018 August | 17 | 5 | 22 |
| 2018 July | 16 | 2 | 18 |
| 2018 June | 19 | 4 | 23 |
| 2018 May | 20 | 8 | 28 |
| 2018 April | 26 | 0 | 26 |
| 2018 March | 27 | 3 | 30 |
| 2018 February | 19 | 3 | 22 |
| 2018 January | 9 | 3 | 12 |
| 2017 December | 6 | 4 | 10 |
| 2017 November | 16 | 5 | 21 |
| 2017 October | 20 | 7 | 27 |
| 2017 September | 17 | 10 | 27 |
| 2017 August | 22 | 16 | 38 |
| 2017 July | 7 | 6 | 13 |
| 2017 June | 1 | 13 | 14 |
| 2017 May | 1 | 4 | 5 |
| 2017 April | 2 | 6 | 8 |
| 2017 March | 0 | 5 | 5 |
| 2017 February | 0 | 8 | 8 |
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