Scientific letter
Sinusal reversion of supraventricular tachyarrhythmias after propofol administration. A case series
Reversión de taquiarritmias supraventriculares tras la administración de propofol. Serie de casos
J. Montero-Tinnirello
, M. Magaldi, J. Fontanals, P. Masgoret, J.C. Bravo
Corresponding author
Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic, Barcelona, Spain
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A case series" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "499" "paginaFinal" => "501" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Montero-Tinnirello, M. Magaldi, J. Fontanals, P. Masgoret, J.C. Bravo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Montero-Tinnirello" "email" => array:1 [ 0 => "jamontero@clinic.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Magaldi" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Fontanals" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Masgoret" ] 4 => array:2 [ "nombre" => "J.C." "apellidos" => "Bravo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reversión de taquiarritmias supraventriculares tras la administración de propofol. Serie de casos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Propofol is a widely used phenol derivative with sedative and hypnotic properties.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Among its cardiovascular effects we may find the dose-dependant reduction of pre-load, post-load, and myocardial contractility as the most widely known ones,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> although other effects have come up recently such as its potential protective role in the ischaemia-reperfusion damage,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> its influence on the cardiac conduction system,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> and its capacity to modify the action potential phases since it can act on the ionic channels of the myocyte membrane.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> These effects provide this drug with antiarrhythmic properties, even though the evidence and clinical experience on this field is still scarce.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–9</span></a> This is why we decided to conduct a retrospective analysis on the clinical histories of patients who got medical assistance in our hospital and presented with supraventricular tachyarrhythmias, and who restored their sinus rhythm after the administration of propofol without the need for any further manoeuvres. We designed a protocol for the collection of data aimed at homogenizing all information, and brought it to our hospital ethics committee that would later approve it (HCB Code/2016/0751, approval date October 24th, 2016).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Six patients were included in this analysis between January 2010 and April 2016. The age range of most women (83.33 per cent) was between 35 and 70<span class="elsevierStyleHsp" style=""></span>years of age (53.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.53). The arrhythmias detected were atrial fibrillation (AFib) (50 per cent), intranodal re-entrant tachycardia (INRT) (33.3 per cent), and atrial flutter (AF) (16.7 per cent). Nearly all cases presented at the ER with symptoms associated with any of these arrhythmias, being palpitations and chest pains the most common symptoms of all. Only one case happened in the ophthalmology operating room but the patient remained asymptomatic (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The cases of AFib were interpreted as episodes of paroxistic AFib, which is why pharmacological cardioversion was attempted with amiodarone (they received one IV bolus of 300<span class="elsevierStyleHsp" style=""></span>mg, and then continuous perfusion of 900<span class="elsevierStyleHsp" style=""></span>mg in 24<span class="elsevierStyleHsp" style=""></span>hours). The cases of INRT received carotid massages plus IV adenosine (up to 24<span class="elsevierStyleHsp" style=""></span>mg) before making any decision to perform electrical cardioversions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The administration of propofol in the cases that presented with AFib and INRT attempted to initiate a process of deep sedoanalgesia in order to perform an electric cardioversion procedure once other antiarrhythmic measures had failed. When it comes to the female patient with AF, the hypnotic drug was administered as an inducer to be able to perform the peribulbar ophtalmic blockade. The average dose administered was 45.8<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.4<span class="elsevierStyleHsp" style=""></span>mg (range 20–75<span class="elsevierStyleHsp" style=""></span>mg). The patients with INRT received lower doses (20–40<span class="elsevierStyleHsp" style=""></span>mg) compared to those with paroxistic AFib (50–75<span class="elsevierStyleHsp" style=""></span>mg). All of them received the hypnotic drug through one IV bolus and reversion to sinus rhythm occurred within the first two minutes after the administration of the drug. The 6 cases were discharged from the hospital in sinus rhythm after a period of 4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3<span class="elsevierStyleHsp" style=""></span>hours. None of the patients came back to the hospital days later with a new episode of arrhythmia in the 6-month follow-up that we conducted. These data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are isolated reports of reversion to sinus rhythm of supraventricular tachyarrhythmias after the administration of propofol in adult patients.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–9</span></a> Kannan and Sherwood<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> reported the case of a sixty-eight year old patient with a history of ischaemic heart condition who presented with atrial flutter that could be reversed after the administration of one IV bolus of 100<span class="elsevierStyleHsp" style=""></span>mg of propofol. Similarly, and in the same journal, Magaldi et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> reported one of the six cases collected in the analysis where they talked about the possible antiarrhythmic properties of the drug in a seventy year old patient with reversion of AF after the administration of 40<span class="elsevierStyleHsp" style=""></span>mg de propofol. Similarly, Choi and Jee<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> describe 2 cases of women with AF who received both remifentanil and propofol through target-controlled infusion during surgical acts (propofol dose of 3.7 and 2.5<span class="elsevierStyleHsp" style=""></span>μg/ml), achieving reversion to sinus rhythm 10 and 30<span class="elsevierStyleHsp" style=""></span>minutes after initiating the perfusion, respectively. The average dose administered to our patients was 45<span class="elsevierStyleHsp" style=""></span>mg. We should mention that the wide variability of the doses administered, also mentioned in the reference and in our patients might be due to a prior use of antiarrhythmic drugs, to the anthropometric characteristics of the subjects, and to the physiopathogenic mechanism of the arrhythmias (re-entrant, abnormal automacity, etc.).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although the cardiovascular effects of alkylphenol are well known since it was first introduced, the mechanisms through which it acts upon the cardiac conduction system are still under study today. In electrophysiological studies of patients with AFib, a decrease in the P-wave dispersion when homogenizing and regularizing the spreading compared to the atrial wall depolarization could be confirmed, being this effect even more relevant when the AFib was paroxistic.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> On the other hand, in experimental models of myocardial ischaemia-repefusion,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> propofol has proven beneficial effects since it reduces the trend towards action potential shortening in ischaemic regions, which in turn leads to a reduced incidence of functional re-entrant tachyarrhythmias. These intrinsic antiarrhythmic effects of propofol seem to be mediated by its proven inhibitory effects on the potassium channels responsible for the repolarization phases 1 and 3 (<span class="elsevierStyleItalic">I</span><span class="elsevierStyleInf"><span class="elsevierStyleBold">to</span></span>, and <span class="elsevierStyleItalic">I</span><span class="elsevierStyleInf"><span class="elsevierStyleBold">KUR</span></span>, and ATP-sensitive, respectively), and the calcium channels involved in repolarization phase 2 (<span class="elsevierStyleItalic">I</span><span class="elsevierStyleInf"><span class="elsevierStyleBold">Ca</span></span>).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">To the aforementioned direct effects of propofol on the myocardium and the myocardial conduction tissue, we should add its influence on the autonomic nervous system (ANS), which has indirect repercussions on the heart. Propofol supresses the activity within the ANS, though its effect is significantly greater on the adrenergic system.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The resulting parasympathetic predominance may be one of the mechanisms that condition the reduction of arrhythmias due to abnormal automaticity, as it is the case with myocardial ischaemia.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although our study shows the series with the largest number of patients ever recorded where the possible antiarrhythmic properties of propofol are shown, there are relevant plausible limitations that we should comment. In the first place, since it is a descriptive analysis, there is no way of confirming the real cause-effect hypothesis. Also, the very natural history of this type of arrhythmias may be limiting. The paroxistic AFib, the AF, and the INRT are arrhythmias that may appear occasionally and cause a spontaneous reversion to sinus rhythm, so it is possible that, while propofol was being administered, the arrhythmia just ceased. Lastly, the prior administration of amiodarone in cases of AFib may have had an influence on the reversion after the administration of propofol, although initially (after the total dose of 1200<span class="elsevierStyleHsp" style=""></span>mg of amiodarone in 24<span class="elsevierStyleHsp" style=""></span>hours) the goal of sinus rhythm control was not accomplished.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As a conclusion and with the evidence available today, we the authors believe that prospective and comparative trials should be conducted in order to assess the real effectiveness of this drug in the context of stable supraventricular tachyarrhythmias that do not respond to other medications.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest whatsoever or any financing from public or private entities, research centres, or foundations.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montero-Tinnirello J, Magaldi M, Fontanals J, Masgoret P, Bravo JC. Reversión de taquiarritmias supraventriculares tras la administración de propofol. Serie de casos. Med Intensiva. 2017;41:499–501.</p>" ] ] "multimedia" => array:1 [ 0 => 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 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AF: atrial flutter; AFib: atrial fibrillation; INRT: intranodal re-entrant tachycardia.</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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Sex \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">Age (years) \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">Medical history \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">Symptoms \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">Arrythmia and initial heart rate \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">Antiarrythmic drug previously prescribed \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">Dose of propofol \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">Case#1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Serious condition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palpitations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AFib 140<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amiodarone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50<span class="elsevierStyleHsp" style=""></span>mg \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">Case#2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discomfort, dizziness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AFib 135<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amiodarone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50<span class="elsevierStyleHsp" style=""></span>mg \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">Case#3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anxiety, chest pain, palpitations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AFib 145<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amiodarone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75<span class="elsevierStyleHsp" style=""></span>mg \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">Case#4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AF 120<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40<span class="elsevierStyleHsp" style=""></span>mg \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">Case#5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palpitations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">INRT 230<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adenosine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20<span class="elsevierStyleHsp" style=""></span>mg \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">Case#6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palpitations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">INRT 230<span class="elsevierStyleHsp" style=""></span>bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adenosine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577191.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristics of patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intravenous anesthetics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 3 | 4 |
| 2024 October | 60 | 55 | 115 |
| 2024 September | 64 | 43 | 107 |
| 2024 August | 83 | 46 | 129 |
| 2024 July | 49 | 35 | 84 |
| 2024 June | 57 | 52 | 109 |
| 2024 May | 40 | 33 | 73 |
| 2024 April | 46 | 38 | 84 |
| 2024 March | 54 | 18 | 72 |
| 2024 February | 45 | 30 | 75 |
| 2024 January | 46 | 32 | 78 |
| 2023 December | 46 | 45 | 91 |
| 2023 November | 77 | 36 | 113 |
| 2023 October | 63 | 46 | 109 |
| 2023 September | 54 | 38 | 92 |
| 2023 August | 61 | 20 | 81 |
| 2023 July | 59 | 35 | 94 |
| 2023 June | 64 | 13 | 77 |
| 2023 May | 83 | 32 | 115 |
| 2023 April | 49 | 25 | 74 |
| 2023 March | 111 | 31 | 142 |
| 2023 February | 89 | 38 | 127 |
| 2023 January | 86 | 24 | 110 |
| 2022 December | 88 | 39 | 127 |
| 2022 November | 79 | 39 | 118 |
| 2022 October | 101 | 45 | 146 |
| 2022 September | 39 | 32 | 71 |
| 2022 August | 42 | 53 | 95 |
| 2022 July | 29 | 38 | 67 |
| 2022 June | 30 | 38 | 68 |
| 2022 May | 39 | 30 | 69 |
| 2022 April | 34 | 44 | 78 |
| 2022 March | 48 | 51 | 99 |
| 2022 February | 28 | 41 | 69 |
| 2022 January | 33 | 31 | 64 |
| 2021 December | 37 | 47 | 84 |
| 2021 November | 35 | 36 | 71 |
| 2021 October | 44 | 68 | 112 |
| 2021 September | 37 | 32 | 69 |
| 2021 August | 33 | 34 | 67 |
| 2021 July | 23 | 23 | 46 |
| 2021 June | 32 | 28 | 60 |
| 2021 May | 39 | 53 | 92 |
| 2021 April | 56 | 69 | 125 |
| 2021 March | 93 | 33 | 126 |
| 2021 February | 80 | 32 | 112 |
| 2021 January | 52 | 33 | 85 |
| 2020 December | 39 | 12 | 51 |
| 2020 November | 48 | 18 | 66 |
| 2020 October | 35 | 29 | 64 |
| 2020 September | 40 | 18 | 58 |
| 2020 August | 30 | 13 | 43 |
| 2020 July | 37 | 16 | 53 |
| 2020 June | 50 | 21 | 71 |
| 2020 May | 35 | 19 | 54 |
| 2020 April | 27 | 9 | 36 |
| 2020 March | 20 | 6 | 26 |
| 2020 February | 83 | 31 | 114 |
| 2020 January | 31 | 23 | 54 |
| 2019 December | 37 | 22 | 59 |
| 2019 November | 31 | 20 | 51 |
| 2019 October | 39 | 21 | 60 |
| 2019 September | 28 | 29 | 57 |
| 2019 August | 34 | 22 | 56 |
| 2019 July | 29 | 21 | 50 |
| 2019 June | 16 | 9 | 25 |
| 2019 May | 52 | 38 | 90 |
| 2019 April | 27 | 14 | 41 |
| 2019 March | 21 | 21 | 42 |
| 2019 February | 23 | 30 | 53 |
| 2019 January | 22 | 37 | 59 |
| 2018 December | 20 | 48 | 68 |
| 2018 November | 80 | 84 | 164 |
| 2018 October | 142 | 17 | 159 |
| 2018 September | 44 | 15 | 59 |
| 2018 August | 28 | 9 | 37 |
| 2018 July | 47 | 15 | 62 |
| 2018 June | 47 | 14 | 61 |
| 2018 May | 21 | 6 | 27 |
| 2018 April | 59 | 21 | 80 |
| 2018 March | 25 | 4 | 29 |
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