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Controversies in weaning from mechanical ventilation and extubation in the neurocritical patient
Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico
a Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
b Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
c Unidad de Paciente Crítico, Clínica Indisa, Santiago de Chile, Chile
d Unidad de Cuidados Neurocríticos, Sanatorio Pasteur, Catamarca, Argentina
e Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina
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The arrows show the pneumopericardium and interstitial and subcutaneous emphysema.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y. Corcia-Palomo, L. Martín-Villén, S. Escalona-Rodríguez, A. Roldán Reina, A. Adsuar-Gómez, R. Martín-Bermúdez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Corcia-Palomo" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Martín-Villén" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Escalona-Rodríguez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Roldán Reina" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Adsuar-Gómez" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Martín-Bermúdez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569117302280" "doi" => "10.1016/j.medin.2017.07.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569117302280?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718301760?idApp=WMIE" "url" => "/21735727/0000004200000009/v1_201811250605/S2173572718301760/v1_201811250605/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572718302078" "issn" => "21735727" "doi" => "10.1016/j.medine.2018.07.009" "estado" => "S300" "fechaPublicacion" => "2018-12-01" "aid" => "1244" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Intensiva. 2018;42:547-50" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 986 "formatos" => array:3 [ "EPUB" => 141 "HTML" => 532 "PDF" => 313 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Life-support tools for improving performance of the Surviving Sepsis Campaign Hour-1 bundle" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "547" "paginaFinal" => "550" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herramientas de soporte vital para mejorar la ejecución del paquete de medidas de 1 hora de la <span class="elsevierStyleItalic">Surviving Sepsis Campaign</span>" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 2917 "Ancho" => 2314 "Tamanyo" => 694247 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Rational Life Support in Sepsis (RALSS) algorithm. This algorithm is based on the Surviving Sepsis Campaign (SSC) hour-1 bundle of care, as well as adapted to the institutional protocol and available resources. At time zero, clinician on charge should suggest verbally and share with other staff members the diagnosis (<span class="elsevierStyleItalic">say</span> sepsis), <span class="elsevierStyleItalic">look for</span> the source (and <span class="elsevierStyleItalic">consider</span> imaging studies), <span class="elsevierStyleItalic">attach</span> the monitor to the patient and <span class="elsevierStyleItalic">obtain</span> at least 2 blood and other cultures according to clinical suspicion (preferably before administration of broad-spectrum antibiotics) <span class="elsevierStyleBold">(box 1)</span>. Afterwards, administration of appropriate IV antibiotic(s) and the best strategy for control of sepsis source should be ensured (if a drainable focus of infection is present) <span class="elsevierStyleBold">(box 2)</span>. <span class="elsevierStyleItalic">Sepsis without hypotension</span><span class="elsevierStyleBold">(box 3)</span><span class="elsevierStyleItalic">or Sepsis and hypotension</span><span class="elsevierStyleBold">(box 4)</span> pathway should be followed according to patient status. If hypotension is present, <span class="elsevierStyleItalic">start</span> resuscitation with IV fluids (30<span class="elsevierStyleHsp" style=""></span>ml/kg) and re-measure lactate if initial value was >2<span class="elsevierStyleHsp" style=""></span>mmol/L or if clinical deterioration exists although the initial lactate was ≤2<span class="elsevierStyleHsp" style=""></span>mmol/L <span class="elsevierStyleBold">(box 5)</span>. If hypotension persists and lactate is >2<span class="elsevierStyleHsp" style=""></span>mmol/L start vasopressors <span class="elsevierStyleBold">only</span> in those patients who have received an initial resuscitation with IV fluids and are not considered to be hypovolemic <span class="elsevierStyleBold">(box 6 and box 7)</span>. In septic shock patients assess for fluid responsiveness and ask for an intensivist consultation <span class="elsevierStyleBold">(box 7)</span>. Continuous assessment of clinical and laboratory variables and control of focus of infection reassessment may be carried out to enhance initial resuscitation interventions <span class="elsevierStyleBold">(box 8)</span>. Complementary assessments may be requested, and institutional protocol activated. During all interventions continuous reassessment and ruling out of other sources of shock should be conducted <span class="elsevierStyleBold">(box 9</span>). <span class="elsevierStyleItalic">ID</span> denotes Infectious Diseases, <span class="elsevierStyleItalic">MAP</span> mean arterial pressure, <span class="elsevierStyleItalic">SAP</span> systolic arterial pressure, <span class="elsevierStyleItalic">DAP</span> diastolic arterial pressure, <span class="elsevierStyleItalic">ScVO<span class="elsevierStyleInf">2</span></span> central venous oxygen saturation, <span class="elsevierStyleItalic">PCO<span class="elsevierStyleInf">2</span></span> Partial pressure of carbon dioxide, <span class="elsevierStyleItalic">ICU</span> intensive care unit. <span class="elsevierStyleSup">a</span> Do not significantly delay antimicrobial therapy while awaiting for cultures or blood samples. Out-of-hospital approach should attempt to store baseline blood samples for rapid analysis at hospital admission. <span class="elsevierStyleSup">b</span> Broad-spectrum antibiotics considering the likely etiology of infection, specific drug properties and increased extra-renal drug elimination during sepsis/septic shock, history of multidrug-resistant microorganisms, presence of acute kidney injury (±renal replacement therapies) or liver failure and presence of obesity.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E.P. Plata-Menchaca, R. Ferrer" "autores" => array:2 [ 0 => array:2 [ "nombre" => "E.P." "apellidos" => "Plata-Menchaca" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Ferrer" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718302078?idApp=WMIE" "url" => "/21735727/0000004200000009/v1_201811250605/S2173572718302078/v1_201811250605/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Controversies in weaning from mechanical ventilation and extubation in the neurocritical patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "551" "paginaFinal" => "555" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Jibaja, J.L. Sufan, D.A. Godoy" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Jibaja" "email" => array:1 [ 0 => "mjibaja79@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.L." "apellidos" => "Sufan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "D.A." "apellidos" => "Godoy" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Paciente Crítico, Clínica Indisa, Santiago de Chile, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Cuidados Neurocríticos, Sanatorio Pasteur, Catamarca, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2573 "Ancho" => 2218 "Tamanyo" => 319698 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for weaning from MV and extubation in neurocritical patients.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The information available on the processes of weaning from mechanical ventilation (MV) and extubation after severe neurological injury is scarce.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1–4</span></a> The strategies used have been extrapolated from researches and protocols obtained from populations of patients without neurocritical conditions<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1,2</span></a> – situations that cannot be compared for several reasons. In the first place, most individuals with a brain injury are not ventilated because of a primary respiratory failure but because they show an altered state of consciousness due to their incapacity to keep their airways patent, meaning that the actual goal of artificial ventilation is to avoid fatal secondary damage factors such as hypoxemia, hypercapnia and hypocapnia.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3,4</span></a> In the second place, neurocritical patients usually remain long periods of time with MV and artificial airways.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2,4</span></a> Lastly, because it is not unusual to find, during ventilatory support and artificial airway withdrawal, several degrees of compromise of the state of consciousness followed by an inability to follow commands and move in order to obtain the classical parameters of MV and/or extubation withdrawal.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5–8</span></a> So, because of all these controversial issues we will be trying to expose our point of view through the following questions.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Question#1. What is the clinical evidence on weaning from MV in the neurocritical patient?</span><p id="par0010" class="elsevierStylePara elsevierViewall">The data available today is scarce if we take into consideration the high susceptibility of this population when it comes to developing respiratory complications. Also, the neurocritical condition ranks second on the need for MV.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1–3</span></a> On the other hand, one universally accepted criterion before initiating MV withdrawal is resolving the condition that triggered it – a situation that in neurocritical patients rarely happens.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3,9</span></a> One multicenter prospective observational study revealed that neurocritical patients are ventilated for longer periods of time and have higher rates of ventilator-induced pneumonia and mortality compared to the general population.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> MV withdrawal was difficult in almost 50% of the cases, and prolonged in 10% of the cases. Both the methods and duration of withdrawal and the rates of reintubation were similar to those of populations without neurological conditions.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> In the prospective randomized controlled study conducted by Navalesi et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> it was determined that approaching the process of withdrawal and extubation from a protocolized, multidisciplinary and controlled fashion reduces the rate of failure.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Question#2. Do conventional criteria apply when weaning from MV and extubation?</span><p id="par0015" class="elsevierStylePara elsevierViewall">There are different approaches here, since most criteria used cannot be obtained through the adequate technique or are impossible to implement because the state of consciousness has been compromised.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3–9</span></a> Recent studies confirm the systemic failure of the usual criteria of withdrawal/extubation in neurocritical patients.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5–7,9,12,13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When analyzing the predictors of failure in the process of withdrawal/extubation, we find that some of them are associated with characteristics of the critically ill patient per se such as age, heart failure, high levels of the b-type natriuretic peptide, or a positive hydric balance<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a>; while others may be considered specific of neurocritical patients such as low scores on the Glasgow scale (GS), inadequate functioning of the cough reflex, weak cough and/or presence of abundant tracheal secretions.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5–7,9,12,13</span></a> The evidence supporting these predictors is low.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> Recently, one prospective multicenter study determined, through multivariate analyses, the predictors of successful extubations in subjects with severe brain damage, from which they developed the VISAGE score including age (<40 years of age), capacity to swallow, trouble maintaining fixation with both eyes and GS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>10. Each item was given one (1) point; 90% of the patients extubated successfully scored ≥3 in this scale.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Question#3. Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation?</span><p id="par0025" class="elsevierStylePara elsevierViewall">Extubation is a controversial issue in individuals with mental disorders or who “do not follow commands”.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> The “incapacity to follow commands” has not been fully described and any assessments conducted among intubated patients using the GS are subject to error. Also, the cut-off point to establish the capacity to be extubated is controversial.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5–9,15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Namen et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> confirmed that in a heterogeneous neurocritical population of patients who scored ≥8 on the GS, failed extubation happened 25% of the times, and it went up to 63% in those who scored <8. Scoring ≥10 on the GS was associated with successful extubation procedures in another study.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The actual recommendations suggest that to initiate the withdrawal of MV, the patient should be awake and capable of following commands.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> However, in the case of brain injuries, this parameter is not strictly necessary.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3–7,9</span></a> Coplin et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> reported successful extubation rates in 80% of the patients who scored ≤8 on the GS and in 91% of those who scored ≤4 on such scale. Ko et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> used the Four Score to assess the patients’ neurological state, but they did not find any significant differences in the average score between those whose extubation failed and those whose extubation was successful. Similar results were reported by Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> using the GS. McCredie et al.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> confirmed that the GS is not associated with successful extubations.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Question#4. What are factors associated with successful extubation processes?</span><p id="par0040" class="elsevierStylePara elsevierViewall">Both the control of the airway and post-extubation complications play a key role in the success or failure of the entire process.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The airway care score (ACS) assesses the capacity to protect and maintain patent airways by checking on the vomiting reflex, the color and number of secretions, and the need for aspirations prior to the extubation procedure<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Scores ≤6 predicted successful extubations; but yet despite the fact that the ACS is very practical, neither the original ACS nor any of its modifications have been validated externally or through a large scale study.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11,13</span></a> Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> reported that the capacity of coughing effectively and the presence of the vomiting reflex are associated with successful extubation procedures. Spontaneous or provoked cough is an independent predictor factor of successful extubation procedures.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">When it comes to post-extubation complications, the incidence of stridor is between 1.5 and 26.3% while the rates of laryngeal swelling are somewhere between 5 and 54.4%, which can be explained by the lack of clear diagnostic criteria for this situation.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In general, the rates of reintubation in critically ill patients are between 18 and 69% for stridor and 15% for laryngeal swelling.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> Such complications can be predicted very accurately using the Cuff Leak Test. Different systematic reviews and clinical guidelines confirm this.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">17–22</span></a> The actual recommendations suggest using steroids whenever the Cuff Leak Test is positive.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Question#5. What is the extubation failure rate?</span><p id="par0060" class="elsevierStylePara elsevierViewall">In one (1) out of every five (5) patients the extubation procedure fails. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows data from the extubation failure rates in neurocritical patients available today at the actual medical literature.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Question#6. Tracheostomy: is it necessary? If so, when and how?</span><p id="par0065" class="elsevierStylePara elsevierViewall">Controversial issue with uncertain benefits. Two retrospective database studies conducted on severe brain trauma, one of them with associated thoracic trauma recommend conducting early tracheostomy procedures based on fewer pneumonias, days on MV and stay at the intensive care unit (ICU). Nevertheless, the mortality rate was similar in the group that underwent late tracheostomy procedures.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23,24</span></a> Other than the limitations of the methodological design of both studies per se, the reason why the tracheostomy was indicated was not specified.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23,24</span></a> In another open randomized controlled study with a small sample of ischemic and hemorrhagic stroke victims, early tracheostomies did not reduce the stay at the ICU, but they did reduce the mortality rate, although this was a secondary outcome measure.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> One recent systematic review and one meta-analysis including 10 studies with 503 patients with acute brain injuries showed that early tracheostomies did reduce the long-term mortality rate, the duration of the MV, and the stay at the ICU; however, in the sensitivity analysis conducted, when excluding one biased study, statistical significance went down.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> Even though the Panamerican Iberian consensus does not deal with neurocritical patients, it does not recommend conducting early tracheostomies because, even though this shortens the duration of MV, it does not reduce the rates of pneumonia, days at the ICU, or long-term mortality.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> The percutaneous tracheostomy is preferred to the surgical one due to its lower rate of infections.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> Certain situations favor conducting early tracheostomies: (a) severe cervical spine injuries; (b) infratentorial severe injuries; (c) repeated failed extubations; (d) prolonged MV and (e) poor neurological state.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3,27</span></a> The role played by primary tracheostomies is still controversial.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23–28</span></a> In our own opinion, most individuals meet the necessary conditions to be extubated before attempting primary tracheostomies. This is why we firmly believe that conducting one tracheostomy procedure with an organized protocol and team work is a valid option.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Question#7. Early mobility: does it really help?</span><p id="par0070" class="elsevierStylePara elsevierViewall">Traditionally, neurocritical patients used to remain at rest during the acute phase of their disease. One binational multicenter study backs up this statement, since 84% of individuals could not move during such phase.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> We are standing at the doors of what will be a change of paradigm and cultural approach when it comes to the early mobility of critically ill patients.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30–32</span></a> The available evidence today states that this new therapeutic approach is safe and feasible if conducted under controlled multidisciplinary programs.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30–32</span></a> One recent meta-analysis conducted among individuals who required prolonged intensive care confirmed that implementing early mobility protocols reduced the duration of MV, the stay at the hospital and mortality rate, and improved the functional state.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> Specific programs implemented among patients who have not moved for long periods of time confirm their positive effect on the final outcomes.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> These results are encouraging and require large-scale validation among different populations of patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">As far as we know no study today has been able to establish a correlation between early mobility and MV/extubation withdrawal, let alone among neurocritical patients. In patients with brain injuries, one prospective randomized observational uncontrolled Italian cohort reported better clinical and functional outcomes after implementing programs of early mobility, which opens promising approaches in the future.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">We need to conduct large scale studies that will allow us to make recommendations with a higher degree of certainty. In the meantime, we hereby present that:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Since we need one protocolized organized multidisciplinary algorithm for every neurocritical patient based on their individual needs when it comes to MV and extubation withdrawals, we hereby propose an algorithm we can use when having to deal with all these issues (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">The usual criteria to initiate the withdrawal of MV and extubation cannot be extrapolated to neurocritical patients.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Not answering to verbal commands or low scores on the GS does not mean delaying or contraindicating MV and/or extubation withdrawal.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">The airway care score (ACS) is a useful tool to predict the capability of keeping an open airway safely.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">The Cuff Leak Test predicts the odds of postoperative swelling and stridor.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Conducting one primary tracheostomy is advisable in groups at risk.</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Question#1. What is the clinical evidence on weaning from MV in the neurocritical patient?" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Question#2. Do conventional criteria apply when weaning from MV and extubation?" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Question#3. Is the capacity to respond to simple orders and follow commands indispensable prior to the process of weaning from MV and extubation?" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Question#4. What are factors associated with successful extubation processes?" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Question#5. What is the extubation failure rate?" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Question#6. Tracheostomy: is it necessary? If so, when and how?" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Question#7. Early mobility: does it really help?" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-14" "fechaAceptado" => "2018-04-24" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jibaja M, Sufan JL, Godoy DA. Controversias en la retirada de la ventilación mecánica y extubación en el paciente neurocrítico. Med Intensiva. 2018;42:551–555.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2573 "Ancho" => 2218 "Tamanyo" => 319698 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for weaning from MV and extubation in neurocritical patients.</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 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source: adapted from Coplin et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></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">Grade \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">Cough during the aspiration maneuver \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">Number of secretions (need for passes) \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">Color of secretions \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">Viscosity of secretions \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">Interval of aspiration of secretions \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">Vomiting reflex \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vigorous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Aqueous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">More than 3<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vigorous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clear brown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Frothy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Every 2–3<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weak \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yellow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dense \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Every 1–2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Green \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sticky \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absent \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1903365.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Airway care score (ACS).</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:1 [ "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">Author (year) \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">Patients included \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">Extubation failure rate \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">Coplin (2000)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">146 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.2 \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">Namen (2001)<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.0 \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">Manno (2008)<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.5 \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">Ko (2009)<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.4 \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">Karanjia (2011)<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1265 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.0 \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">Anderson (2011)<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">285 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.8 \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">McCredie (2017)<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">152 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.0 \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">Asehnoune (2017)<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">437 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1903364.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Extubation failure rate of neurocritical patients in different studies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolution of mortality over time in patients receiving mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 9 | 22 |
| 2024 October | 96 | 84 | 180 |
| 2024 September | 115 | 60 | 175 |
| 2024 August | 149 | 77 | 226 |
| 2024 July | 151 | 45 | 196 |
| 2024 June | 161 | 66 | 227 |
| 2024 May | 107 | 33 | 140 |
| 2024 April | 165 | 42 | 207 |
| 2024 March | 121 | 33 | 154 |
| 2024 February | 242 | 51 | 293 |
| 2024 January | 229 | 53 | 282 |
| 2023 December | 295 | 46 | 341 |
| 2023 November | 238 | 75 | 313 |
| 2023 October | 181 | 85 | 266 |
| 2023 September | 121 | 48 | 169 |
| 2023 August | 141 | 36 | 177 |
| 2023 July | 142 | 39 | 181 |
| 2023 June | 129 | 33 | 162 |
| 2023 May | 148 | 61 | 209 |
| 2023 April | 173 | 43 | 216 |
| 2023 March | 176 | 59 | 235 |
| 2023 February | 143 | 55 | 198 |
| 2023 January | 148 | 39 | 187 |
| 2022 December | 136 | 54 | 190 |
| 2022 November | 145 | 64 | 209 |
| 2022 October | 178 | 69 | 247 |
| 2022 September | 180 | 61 | 241 |
| 2022 August | 111 | 54 | 165 |
| 2022 July | 102 | 61 | 163 |
| 2022 June | 114 | 73 | 187 |
| 2022 May | 139 | 71 | 210 |
| 2022 April | 95 | 65 | 160 |
| 2022 March | 116 | 85 | 201 |
| 2022 February | 101 | 77 | 178 |
| 2022 January | 134 | 66 | 200 |
| 2021 December | 127 | 65 | 192 |
| 2021 November | 138 | 87 | 225 |
| 2021 October | 190 | 114 | 304 |
| 2021 September | 150 | 77 | 227 |
| 2021 August | 158 | 77 | 235 |
| 2021 July | 124 | 47 | 171 |
| 2021 June | 122 | 49 | 171 |
| 2021 May | 166 | 75 | 241 |
| 2021 April | 431 | 159 | 590 |
| 2021 March | 234 | 54 | 288 |
| 2021 February | 192 | 54 | 246 |
| 2021 January | 176 | 44 | 220 |
| 2020 December | 132 | 121 | 253 |
| 2020 November | 86 | 30 | 116 |
| 2020 October | 105 | 43 | 148 |
| 2020 September | 101 | 54 | 155 |
| 2020 August | 137 | 44 | 181 |
| 2020 July | 91 | 32 | 123 |
| 2020 June | 83 | 38 | 121 |
| 2020 May | 215 | 38 | 253 |
| 2020 April | 312 | 59 | 371 |
| 2020 March | 93 | 40 | 133 |
| 2020 February | 215 | 49 | 264 |
| 2020 January | 110 | 65 | 175 |
| 2019 December | 266 | 53 | 319 |
| 2019 November | 232 | 68 | 300 |
| 2019 October | 139 | 54 | 193 |
| 2019 September | 134 | 65 | 199 |
| 2019 August | 161 | 61 | 222 |
| 2019 July | 82 | 41 | 123 |
| 2019 June | 86 | 43 | 129 |
| 2019 May | 103 | 59 | 162 |
| 2019 April | 49 | 34 | 83 |
| 2019 March | 2 | 12 | 14 |
| 2019 February | 0 | 11 | 11 |
| 2019 January | 1 | 9 | 10 |
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