We are continuing on the theme of “normal” versus “abnormal” in medicine today. It turns out that there is clever medical lexicon to describe the insatiable urge to make all lab results and other findings normal in critical care medicine:

Euboxia is the state whereby all boxes on a pathology print-out are in the normal range.

Euboxia has been described in a recent journal article by Reade 2013: In pursuit of oxygen euboxia. The abstract is as follows:

“‘Euboxia’ (from the Greek ‘eu’ meaning good, normal or happy, and ‘box’ from the tradition of writing physiological variables in boxes) is a colloquial word used in many North American and other hospitals to describe the state of apparent perfection aimed at by residents by the time they present their patients on morning rounds. The term is used generally with irony or even sarcasm, as even the most junior medical student appreciates that while modern medicine can ‘fix’ just about any physiological variable (albeit at times only with measures such as mechanical ventilation and extracorporeal renal and cardiac support), our power to confer immortality remains elusive. Despite this clear disconnection between our ability to correct the parameters we can measure and our inability to correct the unmeasurable, much of the focus of critical care medicine throughout its history has been on restoring physiological variables to the ‘normal’ (by which is meant ‘normal in health’) range. This is now starting to change…”

The converse of euboxia is dysboxia.

The blogger Chris Nickson pointed out in that there are a variety of states in which it is undesirable to bring patients back to the normal range.

These include hypertension during acute stroke and normalization of blood pressure during acute penetrating trauma, both of which we have covered in recent posts on this blog.

A few examples of dysboxia that should not be immediately corrected include:

1. Elevated levels of carbon dioxide PaCO2 (hypercapnia) in acute respiratory distress syndrome. Permissive hypercapnia and acidosis are preferable to correction of PaCO2.

2. Correction of PaCO2 in diabetic ketoacidosis can be fatal.

3. Correction of anemia in critical illness does not improve outcomes; it can actually be harmful.

Click here for the complete list.

As Nickson writes: “Indeed, ‘normality’ is an elusive concept. ‘Normal’ people can have values that lie outside of the ‘normal’ range (for instance, if the reference interval is +/- 2 standard deviations from the mean ‘only’ 95% of the ‘normal’ population will fall within this range). Being outside of the ‘normal’ range might simply mean that, yes, you are part of a bell curve and that, yes, we humans are a diverse lot – it doesn’t necessarily mean you are sick. Furthermore, ‘normal’ values can lead us astray.”

I agree, and would add that many deviations from normal euboxia are in fact adaptations that help the organism cope with physiologic challenges.

Joe Alcock MD


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