Going back to extremes!

Seven years ago, thanks to a suggestion by Greg Kelly, we sought out the most extreme parameters clinicians have encountered in looking after their patients.

This is the league table we have assembled so far:

ParameterLevelDiagnosis
Albumin (lowest)3.6 g/LNicolas Vangrunderbeeck
Ammonia514 umol/LTorsten Behrens
Base excess (postive)50.3 mmol/LChronic Type 2 respiratory failure due to Cystic FibrosisJoanna Hickey
Bilirubin1113 umol/lDrug-induced hepatitis (anabolic steroids)Jurij Hanžel
Blood pressure345/245 mmHgDuring weightlifting (P. Palatini et al, 1989: https://www.ncbi.nlm.nih.gov/m/pubmed/2632751/)Michael Helbo Bøndergaard
Carbon dioxide (PaCO2) (while alert and able to communicate)164 mmHgType 2 Respiratory FailureKautilya Jaiswal
Cardiac arrest to ROSC (longest time)6 h 52 minEnvironmental hypothermia treated with cardiac bypassMads Gilbert
CD4 count (lowest)2 cells/uLAIDSAnne
CoagulopathyINR >10
PT >100
APTT >200
Fib <0.4
D Dimer >128
Venom-induced consumptive coagulopathy (VICC) due to Eastern Brown Snake biteLuke Render
Creatinine3006 umol/Lobstructive uropathyRik Bell
Creatinine Kinase (CK)130,000 U/LRhabdomyolysisRobbie Ley Greaves
CRP970.8 mg/LMatthieu Komorowski
Diuresis over 24 hours24 L (peak rate 1525 mL/h)Caffeine overdose (500 mg)Ian Humble
Ethanol level (in conscious patient)0.76 g/dLAlcohol intoxicationNeil Hughes
Fastest door to operation time25 minutes from triage to appendix outAppendicitisCasey Parker
Fastest door-to-needle & reperfusion time for stroke13 minutes & 21 minutesStrokeBridget Bishop
Fastest door-to-needle time for coronary catherisation6 minutesSTEMITracy Morton
Fluid gain between hemodialysis sessions21 LRenal failureKT
Frusemide dose1 g q8h IV for 3 days, with 11-12 L fluid lossAtheer
Glucose (highest)121 mmol/LHHS/ HONKGuru
Haemoglobin263 g/LClarkson disease Pieter Roel Tuinman
HCO3 (highest)67.5 mmol/LChronic Type 2 respiratory failureJakob Mathiszig-Lee
Hemoglobin in chronic anemia13 g/LMenorrhagiaHammer Doc
Highest PaCO2 (awake patient)19.6 kPa / 147 mmHgChronic Type 2 respiratory failureJakob Mathiszig-Lee
Hypertension>300 mmHg (non-invasive)Post-op hypertensionTony Lourensen
Insulin infusion (highest dose)1000 units/ h (?duration)Calcium channel overdoseJakob Mathiszig-Lee
Ketamine infusion (highest)500mg/h for 3 hrssedated unintubated psychotic patientMinh Le Cong
Lactate, hyperlactemia (highest)unrecordable, repeated with patient improvement as 30 mmol/LShaun
pH (lowest in any diagnosis, and survived)6.27DKA, cardiac arrestJonathan Ilicki, Zaiti Kamarzaman
pH (lowest in DKA, and survived)6.27DKA, cardiac arrestJonathan Ilicki, Zaiti Kamarzaman
Potassium (hypokalaemia)1.2 mmol/LHypokalaemiaAdrian Clarke, Aimee Semmens
Sedation with no effect(1) 80mg IV midazolam, 80 mg IV haloperidol (2) 120 mg diazepam, 100 mg haloperidol(1) Agitated patient (2) IVDU(1) Duncan (2) Toby
Sodium, hypernatremia212 mmol/LGastroenteritisJames Fordyce
Sodium, hyponatremia98 mmol/LBeer drinker's potomania / water intoxicationMatthieu G / Sascha Saharov
Temperature, lowest (in survivor)13.7 CHypothermiaMads Gilbert
Triglycerides3,586mg/dlPancreatitis and hyperlipidaemiaChandra Roy
Troponin I443.50 ng/mLSTEMIVince Di Guilio
TSH234.579 uIU/mLMyxoedema comaJacob Pluid
Urea135 mmol/LDiarrhoea and vomiting, chronic alcohol abuse, Acute kidney injuryDavid Mackintosh
White blood count415 x 10E9/LShane O'Donovan

If you think you have something worthy of addition to this league table,  send evidence of your pathophysiological phenomenon to chris @ lifeinthefastlane.com (nothing patient identifiable!), and we will amend the list (eventually!).

extremes

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

2 Comments

  1. We should revise the category: pH (lowest in any diagnosis, and survived)

    Instead, we should have: pH (excluding DKA, and survived).

  2. Procalcitonin 668 – Strep pneumo bacterimia and septic shock. Survivedz

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