Stylianos Voulgarelis

Medical College of Wisconsin

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Johnny C. Hong

Penn State Milton S. Hershey Medical Center

Bernadette Vitola

MedStar Georgetown University Hospital

John P. Scott

Children's Hospital of Wisconsin

Stacee M. Lerret

Marquette University

Astrid G. Stucke

Medical College of Wisconsin

Michael A. Zimmerman

University of Utah

Joohyun Kim

Vanderbilt University Medical Center

Faraneh Fathi

University of Kentucky

Richard J. Berens

Medical College of Wisconsin

Grzegorz Telega

Medical College of Wisconsin

Cooperative Institutions

Improvement Service

Medical College of Wisconsin

Children's Hospital of Wisconsin

Universidade de São Paulo

Amsterdam University Medical Centers

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Universidade Brasil

Chania General Hospital ”St. George”

Inserm

Erasmus MC

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A novel escalation from veno-venous bypass to veno-venous ECMO during orthotopic liver transplantation. A case report

Perfusion (2020)

Stylianos Voulgarelis Johnny C. Hong Michael Zimmerman Joohyun Kim John P. Scott

We describe the challenging perioperative course of a 55-year-old patient with hepatic failure requiring liver transplantation (LT). Different modalities of the extracorporeal device were successfully used, ranging from veno-veno bypass to partial and full veno-veno extracorporeal membrane oxygenation (ECMO) in order to optimize preload, reduce bleeding from the collateral circulation, optimize acid base balance and/or improve oxygenation. The case highlights the potential use of the device as a rescue method in challenging cases. Furthermore this is the first documented case that extracorporeal CO 2 removal (ECCO 2 R) is used to optimize the biochemistry profile intraoperatively during a LT. The patient was weaned off the device at the end of the case and has been discharged home.

Extracorporeal circulation

Extracorporeal

Orthotopic liver transplantation

10.1177/0267659120973592

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Citations (5)

Variation in immunosuppression practices among pediatric liver transplant centers—Society of Pediatric Liver Transplantation survey results

Pediatric Transplantation (2020)

Voytek Slowik Stacee M. Lerret Steven J. Lobritto Stylianos Voulgarelis Bernadette Vitola

Variation in IS exists among pediatric liver transplant centers. While individual centers may publish their practice paradigms, current data on practices as a whole are lacking. This study sought to ascertain the IS protocols of pediatric liver transplant centers within the SPLIT to better understand variability and similarities among peer institutions.A 27-item questionnaire was developed within the SPLIT Quality Improvement and Clinical Care Committee. The survey collected data regarding center demographics, IS practices, and treatment of acute cellular rejection.Twenty-eight (64%) SPLIT centers responded with 22 (79%) centers performing more than 10 transplants per year and 17 (61%) following more than 100 post-transplant recipients. All centers use a written protocol, and 25 (89%) have a dedicated transplant pharmacist/PharmD. Twenty-five (89%) centers use steroids for induction alone or in combination with thymoglobulin/interleukin-2 antibodies. All centers use tacrolimus for initial maintenance therapy. Most centers have specialized protocols for ABO-incompatible transplants, recipients with renal dysfunction, autoimmune liver diseases, and liver tumors. Treatment of rejection varied but was associated with escalation in IS.IS practices among pediatric liver transplant centers are similar including the use of written protocols, pharmacy involvement, steroids for induction, tacrolimus as initial IS, tacrolimus reduction/delay for renal dysfunction, and escalation of IS with rejection severity. However, other IS practices show wide variability including treatment for ABO-incompatible grafts and presumed rejection. This study serves as a foundation to guide prospective research linking IS practice to outcomes to determine best practice.

Thymoglobulin

Immunosuppression

10.1111/petr.13873

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Monitoring for Nonoperating Room Anesthesia

Anesthesiology Clinics (2017)

Stylianos Voulgarelis John P. Scott

Capnography

Pulse Oximetry

10.1016/j.anclin.2017.07.004

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Citations (8)

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery

Case Reports in Anesthesiology (2021)

Stylianos Voulgarelis Gregory M. Halenda Justinn M. Tanem

We describe the use of liposomal bupivacaine (Exparel) in erector spinae plane blocks for two patients undergoing pediatric cardiac surgery with cardiopulmonary bypass and one undergoing division of the compressive vascular ring. The perioperative course of all patients was remarkable for low pain and sedation scores, especially after chest tube removal. Erector spinae plane blocks are an expanding pain-control technique in both adult and pediatric cardiac surgery for postoperative analgesia. Liposomal bupivacaine offers prolonged analgesia and may be an attractive option for this indication.

10.1155/2021/5521136

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Perioperative anticoagulation practices for pediatric liver transplantation

Pediatric Transplantation (2018)

Stylianos Voulgarelis Bernadette Vitola Stacee M. Lerret Johnny C. Hong John P. Scott

Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.

Portal vein thrombosis

Vascular occlusion

10.1111/petr.13193

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Citations (20)

Evaluation of visible diffuse reflectance spectroscopy in liver tissue: validation of tissue saturations using extracorporeal circulation

Journal of Biomedical Optics (2021)

Stylianos Voulgarelis Faraneh Fathi Astrid G. Stucke Kevin D. Daley Joohyun Kim

Significance: Real-time information about oxygen delivery to the hepatic graft is important to direct care and diagnose vascular compromise in the immediate post-transplant period. Aim: The current study was designed to determine the utility of visible diffuse reflectance spectroscopy (vis-DRS) for measuring liver tissue saturation in vivo. Approach: A custom-built vis-DRS probe was calibrated using phantoms with hemoglobin (Hb) and polystyrene microspheres. Ex vivo (extracorporeal circulation) and in vivo protocols were used in a swine model (n = 15) with validation via blood gas analysis. Results:In vivo absorption and scattering measured by vis-DRS with and without biliverdin correction correlated closely between analyses. Lin's concordance correlation coefficients are 0.991 for μa and 0.959 for μs ′ . Hb measured by blood test and vis-DRS with (R2 = 0.81) and without (R2 = 0.85) biliverdin correction were compared. Vis-DRS data obtained from the ex vivo protocol plotted against the PO2 derived from blood gas analysis showed a good fit for a Hill coefficient of 1.67 and P50 = 34 mmHg (R2 = 0.81). A conversion formula was developed to account for the systematic deviation, which resulted in a goodness-of-fit R2 = 0.76 with the expected oxygen dissociation curve. Conclusions: We show that vis-DRS allows for real-time measurement of liver tissue saturation, an indicator for liver perfusion and oxygen delivery.

Ex vivo

Extracorporeal circulation

Oxygen Saturation

10.1117/1.jbo.26.5.055002

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Hepatic artery flow, inspired oxygen, and hemoglobin determine liver tissue saturation measured with visible diffuse reflectance spectroscopy (vis‐DRS) in an in vivo swine model

Pediatric Transplantation (2022)

Stylianos Voulgarelis Faraneh Fathi Bing Yu Barbara Palković Nikolaos Chatzizacharias

Prompt diagnosis of vascular compromise following pediatric liver transplantation and restoration of oxygen delivery to the liver improves organ survival. vis-DRS allows for real-time measurement of liver tissue saturation.The current study used vis-DRS to determine changes in liver saturation during clinically relevant conditions of reduced oxygen delivery. In an in vivo swine model (n = 15), we determined liver tissue saturation (St O2 ) during stepwise reduction in hepatic artery flow, different inspiratory oxygen fraction (FiO2 ), and increasing hemodilution. A custom vis-DRS probe was placed directly on the organ.Liver tissue saturation decreased significantly with a decrease in hepatic artery flow. A reduction in hepatic artery flow to 25% of baseline reduced the St O2 by 15.3 ± 1.4% at FiO2 0.3 (mean ± SE, p < .0013), and by 8.3 ± 1.9% at FiO2 1.0 (p = .0013). After hemodilution to 7-8 g/dl, St O2 was reduced by 31.8% ± 2.7%, p < .001 (FiO2 0.3) and 26.6 ± 2.7%, p < .001 (FiO2 : 1.0) respectively. Portal venous saturation during low hepatic artery flow was consistently higher at FiO2 1.0. The gradient between portal venous saturation and liver tissue saturation was consistently greater at lower hemoglobin levels (7.0 ± 1.6% per g/dl hemoglobin, p < .001).Vis-DRS showed prompt changes in liver tissue saturation with decreases in hepatic artery blood flow. At hepatic artery flows below 50% of baseline, liver saturation depended on FiO2 and hemoglobin concentration suggesting that during hepatic artery occlusion, packed red blood cell transfusion and increased FiO2 may be useful measures to reduce hypoxic damage until surgical revascularization.

Oxygen Saturation

Saturation (graph theory)

10.1111/petr.14230

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Citations (1)

Use of Liposomal Bupivacaine in Pediatric Peripheral Nerve Blocks after Traumatic Amputation

Case Reports in Anesthesiology (2021)

Gregory M. Halenda Stylianos Voulgarelis

Liposomal bupivacaine has been explored for indications in regional anesthesia, but little has been reported about its use in pediatric patients. In March 2021, the FDA approved an indication for liposomal bupivacaine as an infiltrated local anesthetic in children older than the age of six. Despite this recently expanded indication, the literature lacks reports of use for peripheral nerve blockade in children. We describe a case where liposomal bupivacaine was used for femoral and sciatic nerve blocks in a 5-year-old child with traumatic amputation of his lower leg. Pain control was excellent, with no pain or opioid use reported during the first 62 hours. After the regional anesthesia subsided, the patient required in total 4 oral doses of oxycodone 0.1 mg/kg prior to discharge. The patient did not develop chronic pain or phantom limb syndrome. While liposomal bupivacaine is not currently FDA-approved for peripheral nerve blockade in children, this case highlights a potentially effective use of this drug and possible area for further investigation.

10.1155/2021/8092204

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Conservative therapy for blunt abdominal and thoracic traumas

Critical Care (1998)

Stylianos Voulgarelis K loannis Decavalas Georgios A loannis K Antonios

Background: Whole body hyperthermia induced by radiative systems has been used in therapy of malignant diseases for more than ten years.Von Ardenne and co-workers have developed the 'systemiche Krebs-Mehrschritt-Therapic' (sKMT), a combined regime including whole body hyperthermia of 42°C, induced hyperglycaemia and relative hyperoxaemia with additional application of chemotherapy.This concept has been employed in a phase I/II clinical study for patients with metastatic colorectal carcinoma at the Virchow-Klinikum since January 1997.Methods: The sKMT concept was performed eleven times under intravenous general anaesthesia, avoiding volatile anaesthetics.Core temperatures of up to 42°C were reached stepwise by warming with infrared-A-radiation (IRATHERM 2000®).During the whole procedure blood glucose levels of 380-450 mg/dl were maintained as well as PaO 2 levels above 200 mmHg.Extensive invasive monitoring was performed in all patients including measurements with the REF-Ox-Pulmonary artery catheter with continuous measuring of mixed venous saturation (Baxter Explorer®) and invasive monitoring of arterial blood pressure.Data for calculation of hemodynamic and gas exchange parameters were collected four times, at temperatures of 37°C, 40°C, 41.8-42°C and 39°C, during measurements FiO 2 was 1.0 at all times.Fluids were given in order to keep central-venous and Wedge pressure within normal range during the whole procedure.Statistics were performed using the Wilcoxon Test.Results: Statistically significant differences were found between heart rate, cardiac index and systemic vascular resistance comparing data at 37°C and 42°C.Heart rate and cardiac index increased to a maximum at 42°C (P < 0.0001) whereas systemic vascular resistance had its minimum at 42°C (P < 0.0001).Mean arterial pressure dropped with increasing temperature, differences were not significant.Calculation of stroke volume index and ventricular volumes showed only a slight decrease in endsystolic volumes with increasing temperature, the resulting differences in right ventricular ejection fraction were marginally significant (P = 0.038) comparing 42°C to baseline.Right ventricular stroke work index as well as mean pulmonary arterial pressure increased at 42°C (P = 0.0115 and P = 0.0037), pulmonary vascular resistance only dropped little compared to systemic vascular resistance, left ventricular stroke work index even dropped with increasing temperature, though showing no significant difference.Values for mixed venous oxygen saturation did not vary during therapy, pulmonary right-left shunt showed a temperature associated increase (P = 0.0323) to a maximum at 42°C.Conclusion: Under the procedure of sKMT cardiac function in patients, who do not have any pre-existing cardiac impairment, can be maintained almost unchanged, ie with normal right and left ventricular pressure, despite an increase in right ventricular stroke work

Thoracic trauma

Conservative Management

Conservative Treatment

10.1186/cc280

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Retrieving multiple magnetic foreign bodies from the glottic entrance and stomach

Saudi Journal of Anaesthesia (2021)

Stylianos Voulgarelis Astrid G. Stucke

Aspiration and ingestion of foreign bodies present a frequent challenge in pediatric anesthesia practice that requires careful planning of the time and the method of retrieval. We discuss the management of a 20-month-old boy who had ingested multiple small magnetic beads and presented emergently to the operating room with two beads lodged in the vallecula and eighteen more forming a chain in the stomach. Benefitting from their magnetic properties, the beads located close to the glottic entrance could be removed by placing a steel Magill forceps close to the objects and using magnetic pull rather than grasping. The beads in the stomach were removed en bloc due to their magnetic properties using an endoscopic retrieval basket. Small beads can be difficult to remove, however, in this case it was possible to utilize their magnetic properties during the removal process.

Bead

10.4103/sja.sja_867_20

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Citations (6)