We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis.
We reviewed all current ...literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients.
Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases.
Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of “life over limb,” and may be safely performed with acceptable outcomes.
A collection of N-acyl and N-carbamoyl succinimides were prepared by acylation of succinimide with acyl chlorides or by ethylene dichloride (EDC) coupling of carboxylic acids. The x-ray crystal ...structures of N-benzoyl and N-p-nitrobenzoyl succinimides were determined. The N-acyl succinimides were effective in acylating primary amines, a secondary amine, and an aromatic amine.
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Reaction of K10α2‐P2W17O61 or K10α1‐P2W17O61 or Bu4NOsCl4N in a water/methanol mixture, and subsequent precipitation with (Bu4N)Br provided α2‐P2W17O61{OsVIN}7− and α1‐P2W17O61{OsVIN}7− Dawson ...structures as tetrabutylammonium salts. Reactions of (Bu4N)4α‐H3PW11O39 with either ReCl3(N2Ph2)(PPh3)2 or Bu4NReCl4N are alternatives to the synthesis of (Bu4N)4α‐PW11O39{ReVIN}. 183W and 15N NMR, EPR, IR, and UV‐visible spectroscopies and cyclic voltammetry have been used to characterize these compounds and the corresponding (Bu4N)4α‐PW11O39{OsVIN} Keggin derivative.
Spectroscopic characterization of nitrido derivatives provides insight into the electronic structure of polyoxotungstates. The full assignment of the 183W NMR spectra of PW11O39{OsN}4− and α2‐P2W17O61{OsN}7− is presented, and EPR spectra of PW11O39{ReN}4− are discussed and simulated (see figure).
Iron(II) complexes of meso-tetra-p-tolylporphyrin (TTP), tetramethyldibenzotetraaza14annulene (tmtaa), and trans-1,2-bis(salicylidene)cyclohexanediamine (saldach) catalyzed the cyclopropanation of ...styrene with aryldiazomethanes. When p-tolyldiazomethane was used as the carbene source, trans-cyclopropanes were the major products. Trans/cis ratios of up to 17:1 were obtained. However, using mesityldiazomethane resulted in a reversal of stereoselectivity, giving cis-cyclopropanes as the major product (cis/trans ratios of up to 2.9:1). The stereoselectivity of iron(II) porphyrin-catalyzed cyclopropanation reactions was enhanced by performing the reactions at low temperature or by using bulky porphyrin ligands. Using trimethylsilyldiazomethane as the carbene source, trimethylsilylcyclopropanes were produced in excellent yields with (TTP)Fe. On treatment of (TTP)Fe with diazoreagents, carbene complexes were observed spectroscopically. These complexes transferred their carbene ligand to styrene to produce cyclopropanes stoichiometrically.
A new synthetic methodology has been developed for the synthesis of N-alkyl and N-aryl arenesulfinamides. The methodology involved reacting arenesulfinic acids (R = -Me, -H, -Cl) with ...1,1'-carbonyldiimidazole (CDI) to form the reactive intermediate, an arenesulfinylimidazole. This intermediate was then reacted with both primary and secondary amines to yield the corresponding N-alkyl sulfinamides in yields up to 90%. While the overall yields ranged from 52% to 90%, the level of diastereoselection with racemic or enantiomerically enriched amines only reached a level of 54:46 favoring the major diastereomer as determined by analysis of the 500 MHz
1
H NMR spectra. A series of aniline derivatives were also investigated as coupling partners and were found to form the N-aryl arenesulfinamide in good yield.
A series of N-substituted phthalimides have been prepared in an effort to explore synthetic variants of the Nefkens’ reagent. Three N-acylphthalimides R=–CH3, –CH2CH3, and –C(CH3)3 were prepared and ...employed for the protection of a series of representative amines. In addition, an N-methanesulfonylphthalimide and N-(diethylphosphoryl)phthalimide were also prepared. It was determined that among the phthalimides that were prepared N-propanoylphthalimide was the most effective reagent for the protection reaction.
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•A new putative reagent tirmethylacetic p-toluenesulfinic anhydride has been prepared.•The reagent has been used to synthesize sulfinate esters.•Sulfones were prepared from ...Baylis-Hillman derived alcohols.•The reagent has been used to prepare a N-p-toluenesulfinylamide.
A reagent combination of toluenesulfinic acid and trimethylacetyl chloride affords a putative trimethylacetic p-toluenesulfinic anhydride. This reagent has been used to prepare a series of sulfinate esters from primary and secondary alcohols. In addition, the reagent was used to convert Baylis-Hillman substrates into allylic sulfones. Attempts to use the reagent to convert amines to sulfinamides were unsuccessful. In contrast, the use of 2-pyrrolidinone afforded N-p-toluenesulfinyl pyrrolidinone in 64% yield. The use of a chiral 4-benzyl-1,3-oxazolidinone or 4-benzyl-1,3-oxazolidine-2-thione led to the isolation of S-p-tolyl p-toluenethiosulfonate.
Catalytic systems derived from Os(TTP)2 or Fe(TTP) (TTP = 5,10,15,20-tetra-p-tolylporphyrinato) are extremely efficient at converting styrenes and diazo reagents to cyclopropanes in high yields and ...high stereoselectivity. A number of mechanistic studies have been undertaken to elucidate the catalytic pathway. A mono(carbene) complex, (TTP)OsCHCO2Et, has been isolated but is not the catalytically active species. An electron-withdrawing ligand trans to the carbene in (TTP)OsCHCO2Et activates the carbon fragment toward transfer to an olefin. Labeling studies with (TTP)OsCHX and N2CHY and substrate reactivity profiles are consistent with a trans-osmium(II) bis(carbene) species as the active catalyst.
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