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:
| Parameter | Level | Diagnosis | Submitted by |
|---|---|---|---|
| Albumin (lowest) | 3.6 g/L | Nicolas Vangrunderbeeck | |
| Ammonia | 514 umol/L | Torsten Behrens | |
| Base excess (postive) | 50.3 mmol/L | Chronic Type 2 respiratory failure due to Cystic Fibrosis | Joanna Hickey |
| Bilirubin | 1113 umol/l | Drug-induced hepatitis (anabolic steroids) | Jurij Hanžel |
| Blood pressure | 345/245 mmHg | During 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 mmHg | Type 2 Respiratory Failure | Kautilya Jaiswal |
| Cardiac arrest to ROSC (longest time) | 6 h 52 min | Environmental hypothermia treated with cardiac bypass | Mads Gilbert |
| CD4 count (lowest) | 2 cells/uL | AIDS | Anne |
| Coagulopathy | INR >10 PT >100 APTT >200 Fib <0.4 D Dimer >128 | Venom-induced consumptive coagulopathy (VICC) due to Eastern Brown Snake bite | Luke Render |
| Creatinine | 3006 umol/L | obstructive uropathy | Rik Bell |
| Creatinine Kinase (CK) | 130,000 U/L | Rhabdomyolysis | Robbie Ley Greaves |
| CRP | 970.8 mg/L | Matthieu Komorowski | |
| Diuresis over 24 hours | 24 L (peak rate 1525 mL/h) | Caffeine overdose (500 mg) | Ian Humble |
| Ethanol level (in conscious patient) | 0.76 g/dL | Alcohol intoxication | Neil Hughes |
| Fastest door to operation time | 25 minutes from triage to appendix out | Appendicitis | Casey Parker |
| Fastest door-to-needle & reperfusion time for stroke | 13 minutes & 21 minutes | Stroke | Bridget Bishop |
| Fastest door-to-needle time for coronary catherisation | 6 minutes | STEMI | Tracy Morton |
| Fluid gain between hemodialysis sessions | 21 L | Renal failure | KT |
| Frusemide dose | 1 g q8h IV for 3 days, with 11-12 L fluid loss | Atheer | |
| Glucose (highest) | 121 mmol/L | HHS/ HONK | Guru |
| Haemoglobin | 263 g/L | Clarkson disease | Pieter Roel Tuinman |
| HCO3 (highest) | 67.5 mmol/L | Chronic Type 2 respiratory failure | Jakob Mathiszig-Lee |
| Hemoglobin in chronic anemia | 13 g/L | Menorrhagia | Hammer Doc |
| Highest PaCO2 (awake patient) | 19.6 kPa / 147 mmHg | Chronic Type 2 respiratory failure | Jakob Mathiszig-Lee |
| Hypertension | >300 mmHg (non-invasive) | Post-op hypertension | Tony Lourensen |
| Insulin infusion (highest dose) | 1000 units/ h (?duration) | Calcium channel overdose | Jakob Mathiszig-Lee |
| Ketamine infusion (highest) | 500mg/h for 3 hrs | sedated unintubated psychotic patient | Minh Le Cong |
| Lactate, hyperlactemia (highest) | unrecordable, repeated with patient improvement as 30 mmol/L | Shaun | |
| pH (lowest in any diagnosis, and survived) | 6.27 | DKA, cardiac arrest | Jonathan Ilicki, Zaiti Kamarzaman |
| pH (lowest in DKA, and survived) | 6.27 | DKA, cardiac arrest | Jonathan Ilicki, Zaiti Kamarzaman |
| Potassium (hypokalaemia) | 1.2 mmol/L | Hypokalaemia | Adrian 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, hypernatremia | 212 mmol/L | Gastroenteritis | James Fordyce |
| Sodium, hyponatremia | 98 mmol/L | Beer drinker's potomania / water intoxication | Matthieu G / Sascha Saharov |
| Temperature, lowest (in survivor) | 13.7 C | Hypothermia | Mads Gilbert |
| Triglycerides | 3,586mg/dl | Pancreatitis and hyperlipidaemia | Chandra Roy |
| Troponin I | 443.50 ng/mL | STEMI | Vince Di Guilio |
| TSH | 234.579 uIU/mL | Myxoedema coma | Jacob Pluid |
| Urea | 135 mmol/L | Diarrhoea and vomiting, chronic alcohol abuse, Acute kidney injury | David Mackintosh |
| White blood count | 415 x 10E9/L | Shane 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!).
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a 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 three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
6 Comments
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We should revise the category: pH (lowest in any diagnosis, and survived)
Instead, we should have: pH (excluding DKA, and survived).
Procalcitonin 668 – Strep pneumo bacterimia and septic shock. Survivedz
Lowest sodium – 97 (repeated 3 times on different analysers to confirm)
Presented “off legs” – alcohol excess and malnutrition. Not orientated to time/place but alert + conversant
Creatinine Kinase of 468692 U/L. This was in a a young man with rhabdomyolysis and anuric renal failure. By some bizarre coincidence, the current record has been submitted by someone who shares my first and last name (Robbie Greaves)!
pCO2 200mmHg in a patient with an asthmatic exacerbation, pH 6.7.
Pt survived and doing well.
Jaime. This is insanity. Great work at fixing them!