Recommendations for specialized nutritional-metabolic management of the critical patient
Recommendations for specialized nutritional-metabolic management of the critical patient: Digestive tract surgery. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)
Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: cirugía de aparato digestivo. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)
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Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "65" "paginaFinal" => "68" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.N. Alcázar Espín, L. Macaya Redín, E. Moreno Clarí, C. Sánchez Álvarez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.N." "apellidos" => "Alcázar Espín" "email" => array:1 [ 0 => "mavialcazar@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Macaya Redín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." 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Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The surgical critical patient presents a metabolic response characterized by increased energy expenditure, hypercatabolism, increased proteolysis, hyperglycemia, gradual loss of muscle mass, water retention and diminished visceral protein synthesis. Protein loss is even greater in the presence of intestinal fistulas and/or open abdomen. The patient is at risk of suffering malnutrition, with a resulting poor clinical course. In this context, nutritional management could reduce catabolism, improve the clinical course and shorten the recovery period.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Questions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">What patients can benefit from early postsurgery enteral nutrition?</span><p id="par0010" class="elsevierStylePara elsevierViewall">Patients at high nutritional risk according to the Nutritional Risk Screening (2002) suffer a greater number of complications during hospital stay.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Surgical critical patients are at high nutritional risk. On applying the prognostic Nutric Score,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> it is seen that patients with a high score present greater mortality after 28 days and 6 months. Specifically, mortality and the duration of mechanical ventilation (MV) increase with Nutric Score ≥ 5 (simplified score without considering IL-6). This scale allows us to identify critical patients who are more likely to benefit from more individualized energy-protein therapy. By definition, surgical critical patients are at nutritional risk due to the intense inflammatory response, augmented hypercatabolism and increased caloric-protein requirements. Early enteral nutrition (EN) is therefore advised.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is the most recommended feeding route in these patients? When is postpyloric nutrition indicated?</span><p id="par0020" class="elsevierStylePara elsevierViewall">Although traditionally the strategies referred to the early introduction of oral feeding and EN in patients after gastrointestinal surgery have been restrictive, in the last decade randomized and controlled trials have been made involving early EN in both upper digestive tract and colorectal surgery. Early EN (in the first 48<span class="elsevierStyleHsp" style=""></span>h) has been found to be associated to a decrease in infectious complications, fewer anastomotic dehiscences, lesser postoperative ileus, shorter hospital stay, and lower mortality.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The early postoperative administration of EN in the gastrointestinal tract distal to the anastomosis is safe and well tolerated, and can be regarded as the first nutritional management option in these patients. A meta-analysis conducted by Osland et al. revealed good tolerance of EN administered proximal to the anastomosis, with a significant decrease in postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">When is nutritional management with parenteral nutrition indicated?</span><p id="par0030" class="elsevierStylePara elsevierViewall">Parenteral nutrition (PN) is indicated in the presence of an absolute contraindication to EN (intestinal obstruction, bowel ischemia or acute peritonitis), or if the patient does not tolerate the enteral route.</p><p id="par0035" class="elsevierStylePara elsevierViewall">If there is no adequate tolerance of EN and the patient previously had a normal nutritional status, the introduction of PN should not be considered on such an early basis as in the case of EN, though it must be introduced once the patient is hemodynamically and metabolically stable, in order to avoid progressive caloric deficiency, which is associated to increased morbidity. In the case of previous malnutrition, PN should be introduced early (in the first 48<span class="elsevierStyleHsp" style=""></span>h), starting with low doses. Nevertheless, if the patient tolerates a certain amount of EN, the latter should be used, even if at trophic doses complemented with PN. Parenteral nutrition complementary to EN should be considered in patients at risk if after three days more than 60% of the caloric-protein requirements cannot be covered via the enteral route.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand, Harvey et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> recorded no differences in mortality after 30 days when comparing early EN versus early PN – thus indicating that PN is safe, provided it is used with a correct indication and at the required dose.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Is glutamine indicated in these patients?</span><p id="par0045" class="elsevierStylePara elsevierViewall">The use of glutamine (Gln) in PN has been the subject of controversy in recent years. Different studies and meta-analyses have revealed its benefits in the surgical critical patient. In the meta-analysis published by Wang et al., comparing PN with or without Gln in the surgical patient, a statistically significant decrease was observed in the duration of hospital stay and in the incidence of infections among the patients administered Gln.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Another meta-analysis recorded a decrease in the incidence of infections and a shorter hospital stay.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Chen et al. reported a decrease in nosocomial infectious processes among surgical patients, though with no reduction in either mortality or in the duration of hospital admission.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The study carried out by Grau et al. likewise associated Gln to a decrease in the number of nosocomial infections, a shorter stay in the Intensive Care Unit (ICU), lower mortality, and improved blood glucose control.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In these studies, the critical patients that benefitted most were postsurgical patients receiving PN with Gln. Administration of glutamine dipeptide at adequate doses (0.25–0.35<span class="elsevierStyleHsp" style=""></span>g of glutamine/kg body weight and day) is advised in the absence of contraindications, as part of the nutritional management of critical patients receiving PN.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">What is the most adequate formula for specialized nutritional management? Do diets enriched with arginine, pharmaconutrients and other substrates such as fiber play a role?</span><p id="par0055" class="elsevierStylePara elsevierViewall">There are no diets with specific characteristics indicated in EN among gastrointestinal surgery patients. The existing scientific evidence advises the perioperative supply of oral/enteral pharmaconutrition in the 5–7 days before surgery, since it reduces infectious complications and shortens hospital stay – though with no impact upon patient mortality.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In the postoperative period the evidence is less clear; recommendations therefore cannot be made in this regard.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In relation to the use of synbiotics and fiber in these patients, a study involving the perioperative administration of synbiotics (prebiotics/probiotics) in abdominal surgery patients has demonstrated optimization of the intestinal microbiota and a tendency towards fewer postoperative infections.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Early EN with soluble fiber in the postoperative phase of gastric or pancreatic surgery reduces the incidence of infectious complications.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Nevertheless, more studies are needed in order to establish recommendations regarding the use of synbiotics and fiber in the postsurgical critical patient.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Should patients with intestinal fistula and those with an open abdominal wall receive specific nutritional management in terms of quantity and quality? What is the most appropriate administration route?</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nutritional management is indicated after water, ion and vitamin corrective measures have been adopted. Monitoring is required of electrolytes such as phosphate, magnesium, potassium and sodium, together with the avoidance of refeeding syndrome.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nutritional management should start as soon as possible after hemodynamic stabilization of the patient, and preferably using the enteral route. Complementary PN is indicated if EN alone is unable to cover the caloric-protein requirements.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the case of patients with gastric or duodenal fistulas, and provided the rest of the intestine is functional, EN should be administered through a nasojejunal tube or via jejunostomy.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> Parenteral nutrition is indicated in the case of jejunal fistulas.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The loss of gastrointestinal fluids implies a loss of electrolytes, minerals and proteins – this in turn leading to dehydration, malnutrition and electrolyte imbalances. Due to the increased loss of proteins, in patients with a low fistular output (<500<span class="elsevierStyleHsp" style=""></span>ml/day), a protein supply of 1.2–1.5<span class="elsevierStyleHsp" style=""></span>g/kg/day is advised, while in the case of high output fistulas (>500<span class="elsevierStyleHsp" style=""></span>ml/day) the dose should be increased to 2<span class="elsevierStyleHsp" style=""></span>g/kg/day), with the administration of up to 2.5<span class="elsevierStyleHsp" style=""></span>g/kg/day in patients with enteroatmospheric fistulas.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,16</span></a> It is advisable to increase the supply of minerals, vitamins and oligoelements, especially in patients with high output fistulas.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with open abdomen have a high energy expenditure. There are difficulties in securing the early start of EN, due to the possibility of abdominal bloating, with the resulting incapacity to close the abdomen. Enteral nutrition should be administered at doses tolerated by the patient (even trophic doses are of benefit), with complementary PN if the caloric-protein requirements are not covered. A retrospective study involving patients with abdominal trauma and open abdomen, in which one-half of the subjects presented intestinal damage, found that EN could be administered without evidence of more complications.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Due to the important protein losses through the abdominal exudate, these patients should receive 2–2.5<span class="elsevierStyleHsp" style=""></span>g/kg/day of proteins, with adequate amounts of vitamins and oligoelementos.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">What is the most adequate nutritional management strategy in liver transplant patients?</span><p id="par0090" class="elsevierStylePara elsevierViewall">Nutritional management should be started in liver transplant patients within the first 24<span class="elsevierStyleHsp" style=""></span>h whenever possible.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The oral route is recommended, with EN as a second option, using a transpyloric access. These patients are characterized by an increase in both the energy and protein requirements. The administration of 25−35<span class="elsevierStyleHsp" style=""></span>kcal/kg/day and 1.5−2<span class="elsevierStyleHsp" style=""></span>g/kg/day of proteins is advised. No definitive recommendation regarding pharmaconutrient use can be made in these patients,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> since the findings of the different studies are contradictory.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Recommendations</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Nutritional risk should be evaluated in all digestive tract surgery patients admitted to intensive care. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Early enteral nutrition is advised in the presence of enteral access distal to the anastomosis. (Level of evidence: moderate. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">In post-abdominal surgery critical patients with enteral access proximal to the anastomosis, early EN is advised even if at trophic doses, provided there are no manifestations of intolerance or intestinal alarming signs. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Glutamine dipeptide at adequate doses is advised, in the absence of contraindications, as part of the nutritional management of post-abdominal surgery critical patients receiving PN. (Level of evidence: moderate. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Enteral nutrition is recommended in patients with open surgery, and proves safe. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">In patients with gastric and/or duodenal fistulas, EN should be administered in the jejunum through a nasojejunal tube. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Parenteral nutrition is recommended in patients with jejunal fistulas. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">In patients with a high output intestinal fistula and/or open abdomen, it is advisable to increase the protein supply to 2–2.5<span class="elsevierStyleHsp" style=""></span>g/kg/day. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">Vitamin and trace element supplementing is recommended in patients with high output gastrointestinal fistulas. (Level of evidence: low. Grade of recommendation: moderate).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">The administration of early EN is safe in liver transplant patients if oral feeding (the first choice option) is not possible. (Level of evidence: low. Grade of recommendation: moderate).</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">Dr. Alcázar-Espín has received payment from Vegenat and Abbott Nutrition for conferences in training courses. This does not imply any conflict affecting the recommendations of the present study, however. Dr. Macaya-Redín has received payment from Abbott Nutrition for conferences in training courses. This does not imply any conflict affecting the recommendations of the present study, however. Dr. Moreno-Clarí and Dr. Sánchez-Álvarez declare that they have no conflicts of interest.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Note to supplement</span><p id="par0145" class="elsevierStylePara elsevierViewall">This article forms part of the supplement “Recommendations for specialized nutritional-metabolic management of the critical patient. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)”, with the sponsorship of Abbott Nutrition.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Questions" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "What patients can benefit from early postsurgery enteral nutrition?" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "What is the most recommended feeding route in these patients? When is postpyloric nutrition indicated?" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "When is nutritional management with parenteral nutrition indicated?" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Is glutamine indicated in these patients?" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "What is the most adequate formula for specialized nutritional management? Do diets enriched with arginine, pharmaconutrients and other substrates such as fiber play a role?" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Should patients with intestinal fistula and those with an open abdominal wall receive specific nutritional management in terms of quantity and quality? What is the most appropriate administration route?" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "What is the most adequate nutritional management strategy in liver transplant patients?" ] ] ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Recommendations" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Note to supplement" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-11" "fechaAceptado" => "2019-12-20" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alcázar Espín MN, Macaya Redín L, Moreno Clarí E, Sánchez Álvarez C. Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: cirugía de aparato digestivo. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC). Med Intensiva. 2020;44:65–68.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Sorensen" 1 => "J. Kondrup" 2 => "J. Prokopowicz" 3 => "M. Schiesser" 4 => "L. Krähenbühl" 5 => "R. Meier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clnu.2008.03.012" "Revista" => array:7 [ "tituloSerie" => "Clin Nutr." 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| 2024 August | 45 | 43 | 88 |
| 2024 July | 30 | 37 | 67 |
| 2024 June | 39 | 56 | 95 |
| 2024 May | 38 | 32 | 70 |
| 2024 April | 39 | 35 | 74 |
| 2024 March | 27 | 23 | 50 |
| 2024 February | 31 | 38 | 69 |
| 2024 January | 26 | 32 | 58 |
| 2023 December | 26 | 46 | 72 |
| 2023 November | 70 | 43 | 113 |
| 2023 October | 74 | 37 | 111 |
| 2023 September | 52 | 39 | 91 |
| 2023 August | 21 | 16 | 37 |
| 2023 July | 25 | 32 | 57 |
| 2023 June | 38 | 16 | 54 |
| 2023 May | 33 | 35 | 68 |
| 2023 April | 26 | 20 | 46 |
| 2023 March | 60 | 32 | 92 |
| 2023 February | 48 | 34 | 82 |
| 2023 January | 27 | 20 | 47 |
| 2022 December | 72 | 27 | 99 |
| 2022 November | 53 | 33 | 86 |
| 2022 October | 48 | 24 | 72 |
| 2022 September | 31 | 29 | 60 |
| 2022 August | 33 | 30 | 63 |
| 2022 July | 23 | 33 | 56 |
| 2022 June | 25 | 29 | 54 |
| 2022 May | 29 | 39 | 68 |
| 2022 April | 32 | 23 | 55 |
| 2022 March | 25 | 33 | 58 |
| 2022 February | 20 | 28 | 48 |
| 2022 January | 18 | 24 | 42 |
| 2021 December | 20 | 39 | 59 |
| 2021 November | 20 | 38 | 58 |
| 2021 October | 28 | 60 | 88 |
| 2021 September | 14 | 22 | 36 |
| 2021 August | 13 | 35 | 48 |
| 2021 July | 10 | 26 | 36 |
| 2021 June | 12 | 19 | 31 |
| 2021 May | 19 | 47 | 66 |
| 2021 April | 20 | 35 | 55 |
| 2021 March | 18 | 40 | 58 |
| 2021 February | 10 | 18 | 28 |
| 2021 January | 13 | 15 | 28 |
| 2020 December | 20 | 19 | 39 |
| 2020 November | 10 | 18 | 28 |
| 2020 October | 6 | 8 | 14 |
| 2020 July | 10 | 15 | 25 |
| 2020 June | 1 | 2 | 3 |
Show all
