title: Acute lower limb ischemia is a frequent complication of severe diabetic hyperosmolarity.
abstract: OBJECTIVE
  To describe the outcome of intensive care unit (ICU) patients admitted with a hyperglycaemic hyperosmolar non-ketotic syndrome (HHNS), with a specific analysis of precipitating conditions and complications including lower limb ischemia.
  
  
  METHODS
  Retrospective review of patients admitted in a university-hospital ICU for HHNS.
  
  
  RESULTS
  Seventeen consecutive patients (9F/8M, age: 75 years [57-81] (median [25-75% percentiles], Glasgow Coma score: 13 [12-14]) were admitted for HHNS over an 8-year period (1998-2005). On admission, the blood glucose level was 40.0 mmol/l [26.3-60.8], the corrected serum sodium concentration 167 mmol/l [158-174], and the calculated plasma osmolarity 384 mosmol/l [365-405]. All the patients presented with renal failure due to severe dehydration. An infection was identified as the precipitating factor in 8/17 cases. Three (18%) patients died in the ICU. Non-survivors were significantly older than survivors (P=0.02). Using univariate analysis, no other parameter measured on admission was related to mortality. Four patients (24%) presented with lower limb ischemia. They had a significantly more elevated blood urea nitrogen (P=0.03), creatinine phosphokinase level (P=0.04), and leukocyte count (P=0.02). The bilateral, symmetrical, and distal extremity involvement suggested diminished blood flow due to hyperviscosity, hypotension, vasoconstrictors, or cholesterol emboli rather than a proximal arterial obstruction as causative mechanisms. No patient was treated surgically. Ischemia reversed with fluid loading and resulted in toe dry digital necrosis.
  
  
  CONCLUSIONS
  HHNS is a rare but life-threatening cause of ICU admission. There is a high incidence of lower limb ischemia in HHNS patients, which may be related to dehydration and blood hyperviscosity.
authors.affiliation: Service de réanimation médicale et toxicologique, APHP, hôpital Lariboisière, université Paris-VII, 2 rue Ambroise-Paré, 75010 Paris, France. bruno-megarbane@wanadoo.fr
authors.forename: B
authors.initials: B
authors.lastname: Megarbane
authors.forename: C
authors.initials: C
authors.lastname: Marsanne
authors.forename: T
authors.initials: T
authors.lastname: Meas
authors.forename: V
authors.initials: V
authors.lastname: Médeau
authors.forename: P J
authors.initials: PJ
authors.lastname: Guillausseau
authors.forename: F J
authors.initials: FJ
authors.lastname: Baud
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D017719:Diabetic Foot / Q000453:epidemiology* / Q000473:pathology; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D007511:Ischemia / Q000453:epidemiology*; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D012189:Retrospective Studies; D012959:Socioeconomic Factors