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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Medical Specialty | Emergency Medicine | Going to Extremes

Going to Extremes

by Chris Nickson, Last updated June 2, 2016

A while ago one of my ICU mates in Melbourne, Dr Greg Kelly, suggested we could use a blogpost to crowdsource the most extreme medical extremes that LITFLers have encountered. I was reminded of this suggestion recently when we admitted a patient with a blood glucose of 81 mmol/L and a corrected sodium somewhere around the 200 mmol/L mark (!).

Here are some of Greg’s suggestions:

1. Lowest pH in a patient who lived
2. Most propofol to get someone to stop moving (who subsequently moved again) – 800mg is Greg’s max
3. Highest CRP (564)
4. Lowest sodium (who survived) and lowest from beer potomania alone (104 mmol/L – ended up with central pontine myelinolysis though)
5. Lowest bicarb (I’ve seen 3 mmol/L, a friend has seen 1 mmol/L), lowest CO2 from patient hyperventilation alone (8 mmHg)

So now it’s over to you LITFLers. Have you seen extremes even more out there than Greg’s? Feel free to suggest other examples if you thing you’ve got an extreme that’s hard to beat… A bit of clinical context would be great (remember nothing that is patient identifiable though).

Bring it on!

Addendum 11 August 2012

So far we have some amazing comments – with some fantastic pathological records being set

… now we need some evidence! Send any evidence of these pathophysiological feats to chris @ lifeinthefastlane.com – and we will add to the official Hall of Fame

Here is the league table based on submissions so far:

ParameterLevelDiagnosisSubmitted by
Ammonia514 umol/LTorsten Behrens
Base excess (postive)40.6 mmol/LChronic Type 2 respiratory failureJakob Mathiszig-Lee
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
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 minutes
StrokeBridget 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
Haemoglobin263 g/LClarkson diseasePieter Roel Tuinman
Hemoglobin in chronic anemia13 g/LMenorrhagiaHammer Doc
Highest dose insulin infusion1000 units/ h (?duration)Calcium channel overdoseJakob Mathiszig-Lee
Highest glucose121 mmol/LHHS/ HONKGuru
Highest HCO367.5 mmol/LChronic Type 2 respiratory failureJakob Mathiszig-Lee
Highest PaCO2 (awake patient)19.6 kPa / 147 mmHgChronic Type 2 respiratory failureJakob Mathiszig-Lee
Hypertension>300 mmHg (non-invasive)Post-op hypertensionTony Lourensen
Ketamine infusion500mg/h for 3 hrssedated unintubated psychotic patientMinh Le Cong
Lactate, hyperlactemiaunrecordable, repeated with patient improvement as 30 mmol/LShaun
longest time from cardiac arrest to ROSC6 h 52 minEnvironmental hypothermia treated with cardiac bypassMads Gilbert
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

 

 

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Filed Under: Emergency Medicine, Intensive Care Tagged With: extremes, greg kelly, Investigations, Physiology

About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has 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 since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. 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 Lifeinthefastlane.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.

Reader Interactions

Comments

  1. KT says

    August 10, 2012 at 8:07 am

    Haemodialysis patient with 21 litre fluid gain between sessions!

    Reply
    • Jeremy Webb says

      August 10, 2012 at 9:10 am

      Sounds like a productive day at the pub.

      Reply
      • Chris Nickson says

        August 10, 2012 at 5:40 pm

        Sounds like a visit to the Guinness brewery!
        C

        Reply
      • KT says

        August 12, 2012 at 5:12 pm

        “I do follow my fluid restriction nurse!”

        BiPAP, CCU bed and telemetry (reading bigeminy), admit with daily HD until dry, discharge, readmit 2 days later..with fluid overload! Only 18L this time.

        Some of these ureas are fantastic… One of our pts has been missing for a couple of weeks now, I’ll have to see if they can top it 😉

        Reply
  2. Nicky says

    August 10, 2012 at 9:00 am

    CRP 950!!!

    Reply
  3. David Thorisson says

    August 10, 2012 at 9:32 am

    Once gave 72mg benzodiazepam IV (over ca 1,5h) to an agitated patient with previous history of alcohol abuse (though abstinent for at least 5 years). Had no effect at all, wasn’t even tired.

    Propofol knocked him out immediately

    Reply
  4. Guru says

    August 10, 2012 at 10:03 am

    Glc of 121mmol in HONK pt … Pt survived.. Endocrinologist was not not very surprised

    Reply
  5. Hamish says

    August 10, 2012 at 10:14 am

    Glucose 118.5 in the NSW fellowship course VAQ 2012.2 question 6 (Na only corrects to 149 though)

    Reply
  6. Wanderer says

    August 10, 2012 at 11:12 am

    Troponin I of 180.0 ng/ml. before cath lab.

    Reply
  7. anne says

    August 10, 2012 at 12:05 pm

    Not as dramatic or acute as the metabolic ones above but how about a CD4 count of 2 in an HIV positive patient? Not uncommon in the days before ARV rollout here in SA.

    Reply
  8. Jon says

    August 10, 2012 at 12:59 pm

    Diabetic found on floor (this year) broke a couple of records for me:
    Temp 26.5, pH 6.64, HCO3 2
    Survived

    Reply
  9. Jared says

    August 10, 2012 at 2:12 pm

    Bicarb of 0 (and pH 6.93) in a pt with multiple other unexplained electrolyte abnormalities….survived.

    Reply
  10. Todd Raine says

    August 10, 2012 at 2:30 pm

    I see that my pH of 6.69 has already been eclipsed, so I shall move on…

    Ethanol level 134 mmol/L… pt not only conscious but decided to leave the ED – walked out in 3″ heels without a slip. Left me speechless.

    Also once gave 34 mg of Midaz, and an unremembered amount of fentanyl, to a 14 yo female who had dislocated her ankle playing soccer (lying on her back, toes pointed at the floor). Upon reduction, she fell immediately into a deep slumber and was unrousable for 6 hours.

    Reply
  11. minh le cong says

    August 10, 2012 at 2:47 pm

    This is the current retrieval world record for a sedated unintubated psychotic patient on ketamine infusion
    500mg/hr max. for approx 3 hrs during aeromedical retrieval
    duration of infusion total = 20 hrs includes pre flight hospital admission phase
    Full recovery with complete amnesia for whole event
    DC from ED with drug induced psychosis Dx

    Reply
  12. Duncan says

    August 10, 2012 at 4:02 pm

    I once used up all the midazolam and haloperidol in the four resus bay wall plastic bins on an agitated patient (probably both personality and anticholergic driven) – total would have been over 80mg of each IV. Remained physically restrained by 5 security guards and in view of the overwhelmed department then used propofol (at unremarkable doses) titrated to a GCS of >9 with airway maintained. The consultant in the morning seemed amused and was making noises about a gram of phenobarb then waking him up, but sure enough when I came back on duty the following night he was back on the propofol infusion with the same plan after multiple shift changes and some ongoing optimism.

    We had to wake him up that night after he aspirated despite his clinically safe airway. He was fine from an aspiration point of view (coughed it all up, briefly tachycardic and relatively hypoxic but all promptly resolved), but unfortunately we were then compelled to keep him unsedated, so he had physical restraints and spend the rest of the night talking garbage and occasionally shouting.

    It was enough to make ICU reconsider their earlier refusals.

    Reply
  13. Rogue Medic says

    August 10, 2012 at 4:25 pm

    Minh,

    I always claim that I can’t remember. 😉

    I have not given huge amounts of medication, because I generally do not have much to give. However, on an interfacility transport of a patient on fentanyl, lorazepam, and dexmedetomidine (Precedex), I did give some large doses. I am not allowed to transport dexmedetomidine (not in my scope of practice) I do not remember what that dose was, but the patient had been receiving 7 mg/hour lorazepam and 250 mcg/hour fentanyl with the dexmedetomidine. Once that was stopped, I had to increase the lorazepam to 18 mg/hour and the fentanyl to 1,100 mcg/hour to keep this SAH patient from becoming too agitated. Sending a nurse might have been better for the patient, but the receiving doctor told me that they do not use dexmedetomidine at the destination hospital (a major university medical center). When I left, they were decreasing the doses, because they were “too high.” The agitated SAH patient did not seem to agree with that approach. I do not know what the long term outcome was, but I am not optimistic (not that bleeding brains ordinarily inspire optimism). No signs of chest rigidity during transport, which would have made things really interesting, since I do not carry paralytics. I did not quite need 21 liters of fluid replacement afterward.

    I did have a patient with bounding radial pulses and an auscultated and palpated blood pressure of 38 systolic. my partner confirmed this. Low blood sugar (I don’t remember how low, but probably 10 to 20 mg/dL). Gave dextrose and he was “all better.” OK, he was still drunk, with all of the comorbidities that his lifestyle could provide, but his blood pressure and blood sugar were “all better.”

    I am curious about lowest blood pressures with different pulse points (pedal, radial, brachial, carotid, et cetera).

    .

    Reply
  14. James Fordyce says

    August 10, 2012 at 4:26 pm

    Sodium 208. Young child, developmental delay, gastro, melbourne heatwave, looked flat as a tack. We didn’t believe it, rechecked, got 212. Never found out the outcome.

    Reply
  15. ChiefMasterChief says

    August 10, 2012 at 4:43 pm

    BUN of 181
    ETOH of 663 (woke up a few hours after this level was drawn and pulled out ETT)

    Reply
    • Amanda Lavis says

      August 10, 2012 at 6:30 pm

      is that ETOH in mg/dL? Cause if it is the pride of my department is upheld. Our drunks are drunker than your drunks.

      Reply
  16. John Cronin says

    August 10, 2012 at 5:59 pm

    During a procedural sedation I was involved in a few years back, we gave the patient 180mg propofol with absolutely no effect. He was fairly chubby but still we were surprised. We then realised the cannula through which we were giving it had tissued!! Used a different cannula and we sedated him with a modest dose. Then monitored him for a few hours for delayed effects of the extravasted white stuff but patient was fine…EEK!

    Reply
  17. Shaun says

    August 10, 2012 at 6:07 pm

    pH 6.33 – lactate unrecordable on first ABG, next one with pH of 6.5 was 30mmol/L.

    Survived, discharged on ICU day 2.

    Reply
  18. Amanda Lavis says

    August 10, 2012 at 6:25 pm

    Ethanol level 0.7g/dL (thats 154 in US currency). I had guessed 0.69 and won some money. BAL bingo is an addiction and a scourge in the workplace.

    Reply
  19. Neil Hughes says

    August 10, 2012 at 6:32 pm

    One from Lanarkshire – ETOH of 760, but of slurred speech but otherwise wondering what the fuss was about. Sadly not to usual around these parts…

    Reply
  20. Archie says

    August 10, 2012 at 7:47 pm

    Troponin of 330 on arrival to ED…around 400 post cath lab.
    Gravestones on ECG
    Survived.

    …then returned 2 weeks later with a massive GI bleed due to warfarin for LV aneurysm. Hb on arrival 52.

    Reply
  21. caseyparker207 says

    August 10, 2012 at 10:20 pm

    On a positive note.

    Triage to appendix out – 25 minutes! Love working in a small hospital.

    I was asked for directions to ED on my way out as I finished my elective list. Patient looked sore. Surgeon was walking next to me.
    We pulled her into a bay, classic Hx he confirmed McBurnies as I did a urine: negative UA and HCG. Sans orderly – we pushed her to theatre, consent en route. Arrived as they nurses were just setting up for the next morning’s list.
    Skinny – 3 cm incision, anterior pustulent appy out in minutes! Recovery took longer than the preop processs.
    Of course I got in trouble for not recording her on the ED log…. paperwork slows us!

    Reply
    • minh le cong says

      August 11, 2012 at 11:44 am

      If only suspected appendicitis ED cAses were all like that…lot less money and time spent on that WCC, or CT or even USS.

      Reply
  22. Joe Lex says

    August 10, 2012 at 10:31 pm

    BUN 240 with uremic frost (yes I have a photo).

    Reply
    • Joe Lex says

      August 12, 2012 at 1:40 am

      Almost forgot – here’s the photo. http://www.facebook.com/photo.php?fbid=2466408583366&set=a.1151179783468.22743.1346832693&type=3&theater

      Reply
      • Chris Nickson says

        August 12, 2012 at 8:50 am

        Wow – never seen it, til now.
        Chris

        Reply
  23. Torsten Behrens says

    August 10, 2012 at 10:53 pm

    Ammonia level of 514! in a patient found unresponsive at home. Last seen 5 days prior. Do not know the final outcome.

    Reply
  24. David Hall says

    August 10, 2012 at 11:26 pm

    Sodium of 100 in a 94 year old with SIADH and pneumonia and on diuretics. We were all curious to see if it would drop to double figures but stubbornly stayed at 100 for 4 days until climbing back to her baseline of 115. At which point she woke up and later went back to live in her own home!

    Reply
  25. Hammer Doc says

    August 11, 2012 at 12:06 am

    Chronic anemia with hemoglobin of 13 g/L (1.3 g/dL) in a young female patient with menorrhagia and somehow had compensated over many years to be able to walk into the ED with this value…. the venipuncture looked like Kool-Aid!

    Reply
  26. lisa says

    August 11, 2012 at 12:46 am

    ETOH of 548 and ambulatory, talking, and semi-coherent. When he went into DT’s, it was stupendous.

    Reply
  27. Matthieu G says

    August 11, 2012 at 12:53 am

    Sodium 98mmol/l from beer potomania (quite frequent in Belgium…). Patient asymptomatic.

    Reply
  28. medexaminer says

    August 11, 2012 at 3:40 am

    Once saw a patient with a BMI of 4,600 listed on the computer EMR. (Someone had accidentally entered the height as 6 inches instead of 6 feet.)
    -Daily Medical Examiner

    Reply
  29. Greg Kelly says

    August 11, 2012 at 8:17 am

    CPR with good neurological outcome – 2.5 hours. Involved one of our brilliant retrieval registrars commencing resus, intubating, art line, central line and cross town trip in ambulance (with nurse on her first retrieval trip for company). Child arrived with pH of >7 (just) and some response to stimulation so was put on ECMO….

    Reply
    • Chris Nickson says

      August 12, 2012 at 9:23 am

      drowning? cold?
      C

      Reply
      • Greg Kelly says

        August 12, 2012 at 12:44 pm

        No – had underlying disorder contributing, was warm, with K > 13 (cytoprotective I suppose)…

        Reply
  30. toby says

    August 11, 2012 at 9:34 am

    Druggy in ICU that got a bit excited after she was extubated. The reg gave her 100 mg of haloperidol and 120 mg of valium and she was still spitting on the nurses.

    Reply
  31. Atheer says

    August 11, 2012 at 2:12 pm

    My patient received 1gm of iv furosemide q8h which was meant to be only 1g over 8 hours only. This was done when I was doing Med Reg and one friday afternoon I charted the frusemide but then came back on Monday to find my patient in great shape after losing ~11-12 liters of fluid over the weekend and best ever creatinin level
    I call that “furosemide holiday”

    Reply
  32. Tony Lourensen says

    August 11, 2012 at 8:12 pm

    Sustained systolic BP beyond the capacity of the sphygmo (>300mmHg) in post op pt on ward. Multiple measurements on multiple sphygmos. Lots of IV antihypertensives later, no bleed, no stroke.

    Reply
  33. Andy Neill says

    August 11, 2012 at 10:51 pm

    Na of 104. Walked in. Not even confused! Mix of new diuretic, vomiting SIADH. Na was normal a month prior. Will get some evidence for you!

    Reply
  34. Mattia Quarta says

    August 12, 2012 at 2:52 am

    Hematocrit 80%
    Hb 25 g/dl

    Reply
  35. Michelle L says

    August 12, 2012 at 6:44 pm

    Highest WCC 55.4 x 10^9/L. Lived.

    Reply
    • Greg Kelly says

      August 13, 2012 at 8:54 am

      Do you mean highest infectious WCC? > 200 or higher not unheard of with acute leukaemias….

      Reply
  36. Tim Leeuwenburg says

    August 13, 2012 at 6:19 pm

    Hb of 2.2

    Like straw when venepunctured

    Reply
  37. Dave says

    August 13, 2012 at 8:46 pm

    Most dilated oesophagus – 9cm causing tracheal compression and jugular venous distension

    Reply
  38. Ben Smedley says

    August 13, 2012 at 10:05 pm

    I recently had a lady who walked in, talking, with a presenting complaint of diarrhoea but looked impressively blue. Her SATS were so low I verified with an ABG and her arterial p02 was 4.1 kPa (30mmHg)… Eventual “diagnosis” of infective exacerbation of pulmonary fibrosis…

    Reply
    • Greg Kelly says

      August 14, 2012 at 7:48 am

      That definitely gets the record for “lowest arterial saturations in someone who walked in off the street complaining of something other than not being able to breathe….” Holy s…moke.

      Reply
  39. Mattia Quarta says

    August 14, 2012 at 3:45 am

    Hematocrit 80%
    Hb 25 g/dl

    Sorry I didn’t give much of an explanation. This values belonged to a “blueberry” lady with a complex congenital cyanotic heart disease that had a partial surgical correction when she was a child. She came to the ED because she was feeling a little more short of breath than usual. As a matter of fact she wasn’t even that distressed: kept reading a novel during phlebotomy. 

    Reply
  40. smashweasel says

    August 16, 2012 at 12:36 am

    epigastric pain for a week—lipase 11693

    Reply
  41. Bricey says

    August 18, 2012 at 4:47 pm

    K+ 25.9mmol/L (Na 131, HCO3 16, Ur 28.2, Cr 266) – didn’t seem all that unwell to me.

    Reply
  42. Jerry Smilack says

    March 5, 2013 at 5:04 am

    Chris:

    I just discovered your “Going to Extremes.” You may be interested in a project that my co-editors and I put together in book form in 1997, and just now placed on a web site (listed above).

    Please feel free to provide items that you have assembled, and we can consider them for inclusion on our web site.

    Reply
  43. Seth Trueger says

    March 5, 2013 at 11:50 am

    I’ve seen CD4 of zero (“nil”) in at least 2 HIV patients

    Reply
  44. Segun Olusanya says

    March 5, 2013 at 10:19 pm

    Lowest EF- 0%. Completely stunned myocardium.

    Reply
  45. not a doc says

    May 24, 2017 at 4:08 am

    my mother was recently admitted with the lowest sodium level of all time, 96.

    .6 days later she’s up to 126. no coma, no seizures. super delirious though

    Reply
  46. Dave Mackintosh says

    January 13, 2018 at 9:58 am

    Urea 135.0 mmol/L (Creatinine only 1920 umol/L).
    Vomiting and diarrhoea for a week in an alcoholic. Mildly confused, not obtunded.

    Reply
  47. Fred English says

    May 17, 2018 at 5:33 pm

    Free Thyroxine 49.7 TSH <0.01 – Thyroxic Crisis

    Reply
  48. J says

    July 1, 2018 at 5:51 am

    Newborn, 3 days old, sodium level = 101. Alive and healthy.

    Reply

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