High levels of ammonia in the blood (typical reference range, 11-35 umol/L). This is rare, except in the presence of liver failure.


Overproduction of ammonia

Protein load

  • gastrointestinal hemorrhage
  • gastric bypass
  • multiple myeloma
  • allogeneic stem cell transplantation
  • parenteral nutrition

Increased catabolism

  • starvation
  • seizures
  • vigorous exercise
  • burns
  • corticosteroids


  • urease-producing infection (e.g. Proteus and Klebsiella spp.)
  • congenital ureteric obstruction associated with infection

Reduced elimination

Liver failure (acute or chronic)

Drugs and toxins

  • valproate
  • carbamazepine
  • salicylates
  • rifampicin
  • hepatotoxic drugs (e.g. paracetamol, halothane) and toxins (e.g. mushrooms)

Metabolic errors

  • urea cycle disorders
  • organic acidemias
  • fatty acid oxidation disorders

CCC 700 6

Critical Care


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

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