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:
| Parameter | Level | Diagnosis | Submitted by |
|---|---|---|---|
| Ammonia | 514 umol/L | Torsten Behrens | |
| Base excess (postive) | 40.6 mmol/L | Chronic Type 2 respiratory failure | Jakob Mathiszig-Lee |
| 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 |
| 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 | |
| Haemoglobin | 263 g/L | Clarkson disease | Pieter Roel Tuinman |
| Hemoglobin in chronic anemia | 13 g/L | Menorrhagia | Hammer Doc |
| Highest dose insulin infusion | 1000 units/ h (?duration) | Calcium channel overdose | Jakob Mathiszig-Lee |
| Highest glucose | 121 mmol/L | HHS/ HONK | Guru |
| Highest HCO3 | 67.5 mmol/L | Chronic Type 2 respiratory failure | Jakob Mathiszig-Lee |
| 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 |
| Ketamine infusion | 500mg/h for 3 hrs | sedated unintubated psychotic patient | Minh Le Cong |
| Lactate, hyperlactemia | unrecordable, repeated with patient improvement as 30 mmol/L | Shaun | |
| longest time from cardiac arrest to ROSC | 6 h 52 min | Environmental hypothermia treated with cardiac bypass | Mads Gilbert |
| 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 |
Haemodialysis patient with 21 litre fluid gain between sessions!
Sounds like a productive day at the pub.
Sounds like a visit to the Guinness brewery!
C
“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 😉
CRP 950!!!
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
Glc of 121mmol in HONK pt … Pt survived.. Endocrinologist was not not very surprised
Glucose 118.5 in the NSW fellowship course VAQ 2012.2 question 6 (Na only corrects to 149 though)
Troponin I of 180.0 ng/ml. before cath lab.
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.
Diabetic found on floor (this year) broke a couple of records for me:
Temp 26.5, pH 6.64, HCO3 2
Survived
Bicarb of 0 (and pH 6.93) in a pt with multiple other unexplained electrolyte abnormalities….survived.
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.
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
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.
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).
.
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.
BUN of 181
ETOH of 663 (woke up a few hours after this level was drawn and pulled out ETT)
is that ETOH in mg/dL? Cause if it is the pride of my department is upheld. Our drunks are drunker than your drunks.
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!
pH 6.33 – lactate unrecordable on first ABG, next one with pH of 6.5 was 30mmol/L.
Survived, discharged on ICU day 2.
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.
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…
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.
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!
If only suspected appendicitis ED cAses were all like that…lot less money and time spent on that WCC, or CT or even USS.
BUN 240 with uremic frost (yes I have a photo).
Almost forgot – here’s the photo. http://www.facebook.com/photo.php?fbid=2466408583366&set=a.1151179783468.22743.1346832693&type=3&theater
Wow – never seen it, til now.
Chris
Ammonia level of 514! in a patient found unresponsive at home. Last seen 5 days prior. Do not know the final outcome.
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!
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!
ETOH of 548 and ambulatory, talking, and semi-coherent. When he went into DT’s, it was stupendous.
Sodium 98mmol/l from beer potomania (quite frequent in Belgium…). Patient asymptomatic.
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
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….
drowning? cold?
C
No – had underlying disorder contributing, was warm, with K > 13 (cytoprotective I suppose)…
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.
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”
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.
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!
Hematocrit 80%
Hb 25 g/dl
Highest WCC 55.4 x 10^9/L. Lived.
Do you mean highest infectious WCC? > 200 or higher not unheard of with acute leukaemias….
Hb of 2.2
Like straw when venepunctured
Most dilated oesophagus – 9cm causing tracheal compression and jugular venous distension
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…
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.
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.
epigastric pain for a week—lipase 11693
K+ 25.9mmol/L (Na 131, HCO3 16, Ur 28.2, Cr 266) – didn’t seem all that unwell to me.
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.
I’ve seen CD4 of zero (“nil”) in at least 2 HIV patients
Lowest EF- 0%. Completely stunned myocardium.
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
Urea 135.0 mmol/L (Creatinine only 1920 umol/L).
Vomiting and diarrhoea for a week in an alcoholic. Mildly confused, not obtunded.
Free Thyroxine 49.7 TSH <0.01 – Thyroxic Crisis
Newborn, 3 days old, sodium level = 101. Alive and healthy.