TABLE OF CRITICAL LIMITS

C
Adults1 Children2
ritical limits define boundaries of tion,7 Dr. Kost and Kristin N. Hale
CLINICAL CHEMISTRY LOW LIMIT HIGH LIMIT CLINICAL CHEMISTRY LOW LIMIT HIGH LIMIT
life-threatening values of labora- investigate trends in critical values
tory test results. Critical results Test Units Mean (SD) Range Mean (SD) Range Test Units Mean (SD) Range Mean (SD) Range practices including improving preana-
or values are those that fall out- Glucose mmol/L 2.6 (0.4) 1.7-3.9 26.9 (8.0) 6.1-55.5 Glucose mmol/L 2.6 (0.5) 1.7-3.3 24.7 (8.9) 13.9-55.5 lytical processing; streamlining urgent
side high and low critical limits. Urgent mg/dL 46 (7) 30-70 484 (144) 110-1000 notification; assuring effective critical
clinician notification of critical results Potassium mmol/L 2.8 (0.3) 2.5-3.6 6.2 (0.4) 5.0-8.0 Potassium mmol/L 2.8 (0.3) 2.0-3.5 6.4 (0.5) 5.0-8.0 limits; assessing decision levels; and
is the labs responsibility. The system 8.0 (hemolyzed) using visual logistics. Special consider-
of critical value reporting was first ations for pediatrics is addressed since
Calcium mmol/L 1.65 (0.17) 1.25-2.15 3.22 (0.22) 2.62-3.49 Calcium mmol/L 1.62 (0.17) 1.25-1.87 3.17 (0.22) 2.74-3.74
implemented in a hospital by George newborns/neonatals must adapt to the
mg/dL 6.6 (0.7) 5.0-8.6 12.9 (0.9) 10.5-14.0
D. Lundberg, MD, and first published extrauterine environment with its strik-
in MLO in 1972. These tables are based Sodium mmol/L 120 (5) 110-137 158 (6) 145-170 Sodium mmol/L 121 (5) 110-130 156 (5) 150-170 ing physiological changes. Identifying
on three national surveys by Gerald J. CO2 content mmol/L 11 (2) 5-20 40 (3) 35-50 CO2 content mmol/L 11 (2) 6-18 39 (3) 33-45 existing personal adverse events clus-
Kost, MD, PhD, MS, F(ACB), of the Magnesium mmol/L 0.41 (0.16) 0.21-0.74 2.02 (0.82) 1.03-5.02 Magnesium mmol/L 0.45 (0.04) 0.41-0.49 1.77 (0.45) 1.23-3.00 tered by time/location could be used to
University of California-Davis Health mg/dL 1.0 (0.4) 0.5-1.8 4.9 (2.0) 2.5-12.2 predictapatientsfutureadverseevents.
System. Adapted with permission from Customizing critical values is possible
Phosphorus mmol/L 0.39 (0.10) 0.26-0.65 2.87 (0.48) 2.26-3.23 Phosphorus mmol/L 0.42 (0.16) 0.16-0.65 2.87 (0.39) 2.26-3.23
his articles,1-4 the tables summarize for some unmet needs like comparing
mg/dL 1.2 (0.3) 0.8-2.0 8.9 (1.5) 7.0-10.0
critical limits used by 92 responding critical values lists to national norms
U.S. medical centers, including 20 Bilirubin mol/L 257 (86) 86-513 Bilirubin mol/L 257 (68) 86-342 and clarifying protocols for repeat
trauma centers, and 39 childrens hospi- mg/dL 15 (5) 5-30 critical values testing. Also, site-neutral
tals. Mean and standard deviation (SD) Chloride mmol/L 75 (8) 60-90 126 (12) 115-156 Chloride mmol/L 77 (8) 70-90 121 (5) 115-130 policies encourage timely reporting,
data are presented. The frequency with Osmolality mmol/kg 250 (13) 230-280 326 (18) 295-375 Osmolality mmol/kg 253 (12) 240-270 318 (10) 300-330 recording, and integrating critical
which critical limits were listed can be values into a patients closed-loop
Urea nitrogen mmol/L 37.1 (21.1) 14.3-107.1 Urea nitrogen mmol/L 19.6 (11.4) 3.9-53.6
found in the original articles. EMR. The authors detail Canadian and
mg/dL 104 (59) 40-300
As a rule of thumb, themean low U.S. regulatory and accrediting bodies
and mean high figures may be con- Uric acid mol/L 773 (119) 595-892 Uric acid mol/L 714 (119) 595-892 where critical values practices and
sidered the critical limits for each test mg/dL 13 (2) 10-15 treatment are a professional concern.
listed. Each institution should establish CSF glucose mmol/L 2.1 (0.6) 1.1-2.8 24.3 (11.4) 13.9-38.9 CSF glucose mmol/L 1.7 (0.7) 1.1-2.8 In other parts of the world, surveys
its own set of critical limits and clinician mg/dL 37 (10) 20-50 438 (206) 250-700 reveal inconsistent, infrequent, or no
notification policy. use of critical values reporting, which
Creatinine mol/L 654 (380) 177-1326 Creatinine mol/L 336 (212) 221-884
Dr. Kost conducted an indepen- could have detrimental effects on select
mg/dL 7.4 (4.3) 2.0-15.0
dent national survey of U.S. medical patient groups. In Europe, the most
centers and childrens hospitals to Ionized calcium4 mmol/L 0.82 (0.14) 0.50-1.07 1.55 (0.19) 1.30-2.00 Ionized calcium4 mmol/L 0.85 (0.13) 0.60-1.08 1.53 (0.11) 1.35-1.75 acceptedstandardforaccreditationand
determine ionized calcium critical mg/dL 3.29 (0.56) 2.00-4.29 6.21 (0.76) 5.21-8.02 certification of clinical laboratories is
limits.4 His extensive overview of Lactate mmol/L 3.4 (1.3) 2.3-5.0 Lactate mmol/L 4.1 (1.2) 2.4-5.5 ISO EN 15189:2007, which includes
critical limits and patient outcomes mg/dL 30.6 (11.7) 20.7-45.0 immediate notification of critical values
appeared in the March 1993 issue of Albumin g/L 17 (5) 10-25 68 (10) 60-80 as a special requisite. National stan-
MLO.3 Readers are also encouraged dards of care must be considered and
Ammonia mol/L 109 (50) 35-200
to review general practice guidelines.5 compared in order to harmonize critical
The Joint Commission identifies Protein g/L 34 (5) 30-40 95 (6) 90-100 values practices throughout the world.
critical values in current National CSF protein mg/L 1875 (854) 1000-3000 The authorslist eight conclusions and
Patient Safety Goals (NPSG). One HEMATOLOGY HEMATOLOGY recommendations for critical values
goal is: Report critical results of tests practices. They believe coordinated
Hematocrit L/L 0.18 (0.05) 0.12-0.30 0.61 (0.06) 0.54-0.80 Hematocrit L/L 0.20 (0.06) 0.10-0.30 0.62 (0.05) 0.54-0.70
and diagnostic procedures on a timely and energetic professional leaders with
basis (Rationale for NPSG.02.03.01).6 Hemoglobin g/L 66 (17) 40-120 199 (27) 170-300 Hemoglobin g/L 69 (13) 50-100 208 (29) 170-250 a clear understanding of the future of
Critical results of tests and diagnos- Platelets 109/L 37 (18) 10-100 910 (147) 555-1000 Platelets 109/L 53 (25) 20-100 916 (220) 600-1500 standard care will ensure consistent
tic procedures fall significantly outside WBC count 109/L 2.0 (0.7) 1.0-4.0 37.0 (20.7) 10.0-100.0 WBC count 109/L 2.1 (0.9) 0.5-3.5 42.9 (25.1) 15.0-100.0 critical values practices, and enhance
the normal range and may indicate a PT s 27 (9) 14-40 PT s 21 (6) 15-35 patient care worldwide.
life-threatening situation.The objective
PTT s 68 (33) 32-150 PTT s 62 (21) 40-100
is to provide the responsible licensed References
caregiver these results within an estab- Fibrinogen g/L 0.88 (0.17) 0.50-1.00 7.75 (2.63) 5.00-10.00 Fibrinogen g/L 0.77 (0.30) 0.20-12.0
lished time frame so that the patient can Bleeding time min 14.0 (4.0) 9.5-20.0 1. Kost GJ. Critical limits for urgent clinician
notification at U.S. medical centers. JAMA.
be promptly treated. BLOOD GASES AND pH BLOOD GASES AND pH 1990;263:704-707.
Elements of Performance for
pCO2 mm Hg 19 (3) 9-25 67 (6) 50-80 pCO2 mm Hg 21 (6) 15-40 66 (23) 50-150 2. Kost GJ. Critical limits for emergency clinician
NPSG.02.03.01: notification at United States childrens hospitals.
1. Develop written procedures for pH 7.21 (0.06) 7.00-7.35 7.59 (0.03) 7.50-7.65 pH 7.21 (0.05) 7.10-7.30 7.59 (0.04) 7.50-7.70 Pediatrics. 1991;88, 597-603.
managing the critical results of tests/ pO2 mm Hg 43 (6) 30-55 pO2 mm Hg 45 (7) 30-55 124 (25) 100-150 3. Kost GJ. Using critical limits to improve patient
diagnotic procedures that address the kPa 5.7 (0.8) 4.0-7.3 outcome. MLO. 1993;25(3):22-27.
following: the definition of critical NEWBORN2 LOW LIMIT HIGH LIMIT 4. Kost GJ. The significance of ionized calcium in
results of tests/diagnostic procedures; cardiac and critical care. Availability and criti-
by whom and to whom critical results Test Facility Units Mean (SD) Range Mean (SD) Range cal limits at U.S. medical centers and childrens
hospitals.ArchPatholLabMed.1993;117:890-896.
of tests/diagnostic procedures are 1. Adult table modified with permission by JAMA, Vol. 263, pp. 704-707, 1990. CSF, cerebrospinal fluid; WBC, white blood cell; PT, prothrombin time; PTT, partial Glucose CH mmol/L 1.8 (0.4) 1.1-2.8 18.2 (3.6) 16.7-27.8
thromboplastin time. Qualitative critical results for adults1 include the following: For blood bank and immunologyincompatible crossmatch, tests positive 5. Empancipator K. Critical values: ASCP practice
reported; the acceptable length of time for syphilis (RPR or VDRL). For microbiology and parasitologyPositive results from Gram stain or in culture from blood, cerebrospinal fluid, or body cavity Potassium CH mmol/L 2.8 (0.4) 2.5-3.7 7.8 (0.5) 6.5-8.0 parameter. Am J Clin Pathol. 1997;108:247-253.
between availability and reporting fluid; positive India ink preparation; positive rapid antigen detection by agglutination tests for Cryptococcus, group B streptococci, Haemophilius influenzae
b, or Neisseria meningitidis, positive results from acid-fast bacillus stain or culture; Salmonella, Shigella, or Campylobacter on stool culture; presence of Modified CH mmol/L 2.8 (0.4) 2.5-3.7 6.5 (See Ref. 3) 6. Joint Commission National Patient Safety Goals
of critical results of tests/diagnostic malarial parasites. For clinical microscopy and urinalysiselevated white blood cell count in CSF; presence of malignant cells, blasts, or microorganisms potassium for the Laboratory and Hospital, Laboratory
procedures. in CSF or body fluids; combination of strongly positive test results for glucose and for ketones in urine; presence of pathologic crystals (urate, cysteine, Goals. Available at http://www.jointcommission.
2. Implement the procedures for leucine, or tyrosine) on urinalysis. For hematologyListed frequently are the presence of blasts on blood smear; new diagnosis or findings of leukemia; Bilirubin CH mol/L 222 (86) 86-308 org/assets/1/6/NPSG_Chapter_Jan2012_HAP.
presence of sickle cells (or aplastic crisis). Listed occasionally are plasma cells, band cells, atypical lymphocytes, and abnormal reticulocyte count. pdf. A
ccessed June 28, 2012.
managing the critical results of tests/
Hemoglobin USMC g/L 95 (35) 50-150 223 (23) 210-250
diagnostic procedures. 2. Children and newborn tables modified with permission by Pediatrics, Vol. 88, pp. 597-603, 1991. CSF, cerebrospinal fluid; WBC, white blood cell; PT, prothrombin 7. Kost G, Hale KN. Global trends in critical values
time; PTT, partial thromboplastin time; CH, Childrens Hospital; USMC, U.S. Medical Centers. Qualitative critical results for children2 include the following: For practices and their hamonization. Clin Chem Lab
3. Evaluate the timeliness of report- hematologypresence of blasts in the blood smear; new diagnosis or findings of leukemia; presence of drepanocytes (sickle cells); atypical lymphocytes, Hematocrit USMC L/L 0.33 (0.08) 0.24-0.45 0.71 (0.04) 0.65-0.75 Med. 2011;49(2):167-176.
ing the critical results of tests/diagnostic or abnormal reticulocyte count; abnormal erythrocyte indices (mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin
procedures. concentration). For clinical microscopy and urinalysiselevated white blood cells in cCSF; presence of malignant cells, blasts, or microorganisms in CSF pO2 USMC mm Hg 37 (7) 30-50 92 (12) 70-100
or body fluids; combination of strongly positive test results for glucose and for ketones in urine. For microbiology and parasitologypositive results from
In Global trends in critical val- Gram stain or culture from blood, CSF, or body cavity fluid; presence of malarial parasites.
ues practices and their harmoniza-

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