Module 3 Cascabel

Module 3 Practice of Pharmacy Clinical Pharmacy, Hospital Pharmacy, Pharmaceutical Calculations Kathreen Mae D. Cascabel BSPharmacy

Clinical Pharmacy 

A practice in which the pharmacist utilizes his professional judgment in the application of pharmaceutical sciences to foster the safe and appropriate use of drugs, in or by patients, while working with members of the health care team (Francke 1969)



Health science specialty whose responsibility is to assure the safe and appropriate use of drugs in patients through the application of specialized knowledge and functions in health care

Pharmaceutical Care o o o o

The responsible provision of drug therapy for the purpose of achieving definite outcomes that improves a patient’s QOL (Helper and Strand 1990) A patient-centered practice in which the practitioner assumes responsibility for a patient’s drug related needs and is held accountable for this commitment (Cipolle 1998) Identify, resolve, prevent potential and actual drug related problems Knowledge and skills required: Diseases, drug therapy, non-drug therapy, lab and diagnostic testing

Outcomes - Cure of disease - Elimination or Reduction of symptoms - Arrest of disease process - Prevention of disease or symptoms

Evidence-Based Medicine (EBM) o

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

EBM integrated components Clinical expertise  clinician’s cumulated experience, education and clinical skills Patient values  personal and unique concerns, expectations, and values Best evidence  clinically relevant research with sound methodology Hierarchy of Evidence Systematic reviews Randomized Clinical Trials Non-randomized Clinical Trials Observational Studies Expert Options

Phases of Product Development Pre-clinical Animal studies Phase 1 Healthy humans Phase 2 Patients with disease Phase 3 Large scale Phase 4 Post-marketing surveillance

Drug Information Sources Primary Most current information Secondary For quick and selective screening of 1° sources Tertiary Easy access; may be outdated

Safety Effectiveness

Journal articles Abstracting and Indexing Services Textbooks

Study Designs

Type Samples based on

Case Control/ Retrospective Observational Presence (cases) or absence (controls) of a disease

Advantage

Inexpensive

D/A

Recall bias

Cohort/ Prospective Observational Presence or absence of risk factors (monitor for disease development) Less recall bias

Time-consuming, expensive

Cross-sectional/ Prevalence Studies Survey Disease prevalence and prevalence factors

Randomized Controlled Clinical Trial Experimental (gold st.) Compares 2 or more tx or tx and placebo

Decreased bias and confounding Blinded or Double blinded Costly and timeintensive, ethical considerations

Therapeutic Guidelines o o

Provide clear and concise, independent and evidence-based recommendations about patient management that have been developed by experts Objective: Reduce chance of error by establishing standard protocol for how care is carried out

Therapeutic Drug Monitoring o

Encompasses the measurement of serum drug levels and the application of clinical pharmacokinetics to improve patient care

Applications  Time to maximal response  Need for loading dose  Dosage alterations  Choosing a formulation Drugs requiring TDM  Intensity of pharmacologic effect is proportional to the drug concentration at the site of action  Drugs have an established therapeutic plasma range  Relationship between plasma drug concentration & clinical effect rather than relation between dose & effect  Drug toxicity and disease presentation are difficult to distinguish from clinical assessment alone Therapeutic Range – the range of drug conc within which the drug exhibits max efficacy and min toxicity in px majority Commonly Monitored Drugs:  Aminoglycosides: gentamicin, tobramycin, netilmicin, amikacin, vancomycin  Cardioselective agents: digoxin, procainamide, lidocaine, disopyramide, flecainide

Review of a Prescription

Drug-Related Problems 1. Medication Errors Any preventable event that may lead to inappropriate medication use or cause harm to the patient while the medication is in the control of a health care professional, patient or consumer A

Have the capacity to cause error

B

Did not reach the patient

C

Reached the patient

D

Increased patient monitoring

E

Treatment or intervention

F

Initial or prolonged hospitalization

G

Permanent harm

H

Near-death

I

Death

2. Adverse Drug Events a. Patient Factors (ADRs, patient’s reaction to drug) b. Drug Factors (D-D, D-F, D-Dis interactions, other incompatibilities) ADE ADR

- any injury resuling from medical intervention - response that is noxious or unintended

Pregnancy Categories Category

Human Studies

Animal Studies

Effect

A

✓ X X

✓ ✓ ✓

SAFE

B C D X

✓

✓

Examples

SAFE

Amoxicillin, Paracetamol

UNSAFE

Rifampicin, Theophylline

Benefits outweigh risks

Phenytoin, Tetracycline

TERATOGENIC

Isotretinoin, Thalidomide

Patient Case General Patient Information Chief Complaint HPI PMH SH FH Medication History ROS Physical Examination Lab and Diagnostic Test Px Problem List and Plans

Date and time of admission, patient name, age, race, gender Reason for seeking medical care Narrative that described the current medical problem Current and previous problems unrelated to present illness Use of tobacco & illicit drugs, occupation, marital status, sexual history, living condition Medical histories of first degree relatives Demography, diet, social habits, current and past Rx and non-Rx drugs, allergies, ADRs All patient complaints not included in the HPI VS, systemic exam (HEENT, skin, ear, chest, abdomen, genitalia, neurologic)

Pharmaceutical Care Plan 1. Assessment 2. Plan 3. Monitoring

- review of the medical conditions and symptoms to determine the need for drug therapy - decision of an appropriate drug therapy based on assessment - review of outcomes of therapy to determine if patient is obtaining desired outcomes

Drug Utilization Review (DUR) o o

Ongoing study of the frequency of the use and cost of drugs Prospective DUR (before dispensing) or Retrospective DUR (after dispensing), Concurrent DUR (IDEAL)

Advantages:  Identify drug-drug interaction  Prevent duplication  Prevent under/overdose  Improve quality of care  Encourage physicians to use formulary/generic drugs

Pharmacoeconomic Methodologies Cost-Effectiveness Cost-Minimization Cost-Utility Cost-Benefit Cost of Illness

Lowest cost for a given level of effectiveness Comparison of drugs that are generically equivalent Incorporates a measure of QOL into outcomes being measured Uses monetary value in comparing costs and consequences All direct and indirect cost attributable to a certain disease

Ethics Autonomy Nonmaleficence Beneficence Confidentiality

Respect px as individual Do no harm Act in the best interest of the patient Respects px privacy and autonomy

Common Laboratory Tests Hematologic Test

Increase

RBC/Erythrocytes

Hematocrit

Reticulocyte

Polycythemia Dehydration Vomiting

Hemolytic Anemia Blood loss

Hemoglobin

Decrease Macrocytic Anemia (B9 & B12) Microcytic Anemia (IDA & thalassemia) IDA Aplastic Anemia Bone Marrow Supp IDA, blood loss

ESR

Inflammation Rheumatic Fever Infection

Polycythemia Sickle cell anemia Corticosteroids

aPTT

Heparin (Intrinsic)

Hypercoagulation

PT

Warfarin (Extrinsic 2, 7, 9, 10)

INR

Warfarin

WBC

Infection (leukocytosis)

Marrow suppress (leukopenia)

Neutrophils PMN’s

Infection Neutrophilic leukocytosis

Overwhelming infections

Basophils/Mast Cells

Chronic myelogenous leukemia

Eosinophils

Acute allergic reactions Parasitic infections

Monocytes

TB Subacute bacterial endocarditis

Lymphocytes

Viral infections

Immunodeficiency

Platelet

Thrombocytopenia

Marrow suppression Chemotherapy

Renal Test

Increase

Decrease

BUN

Renal failure

Hepatic failure

Creatinine

Renal failure

------------------

Creatinine clearance

------------------

Renal failure

Serum Enzymes Test Creatinine Kinase (CK) CK MB CK MM CK BB

Increase Myocardial Infarction Rhabdomyolysis

Lactate Dehydrogenase LDH 1 and 2 LDH 3 LDH 4 and 5

Acute injury of cardiac muscles Liver dysfunction Lung disease, Hemolytic anemia

Alkaline Phosphatase

Biliary obstruction Paget’s disease HyperPTH, Osteomalacia

Alanine Aminotransferase (ALT)

Decrease

Clofibrate and Fluoride

Liver disease

B6 deficiency

Serum Glutamic-Oxaloacetic Transaminase (SGOT)

Myocardial Infarction Liver disease

B6 deficiency

Cardiac Troponins

Myocardial Infarction

Rhabdomyolysis

Serum Glutamic-Pyruvic Transaminase (SGPT)

Aspartate Aminotransterase (AST)

Electrolytes Test

Increase

Decrease

Sodium

Hypertension Hypernatremia (imp. excretion)

Hyponatremia (renal failure)

Potassium

Renal dysfunction Acidosis Cellular breakdown

Diuretic use, alkalosis, vomiting, diarrhea, steroids, Amph B, Li

Chloride

Acute renal failure Hyperparathyroidism Dehydration

Chronic renal failure Adrenal Insufficiency Diuretic use (Thiazide & Loop)

Minerals Test

Increase Hyperparathyroidism Paget’s disease Thiazides

Calcium

Decrease PTH or Vit. D deficiency Loop diuretics

Magnesium

Hepatitis Addison’s disease

Malabsorption Hyperaldosteronism

Phosphate

Renal dysfunction, Hypoparathyroidism Increased Vit. D intake

Malnutrition Hyperparathyroidism Insufficient Vit. D intake

Others Test

Increase

Acid Phosphatase

Prostate CA

Gamma glutamyl transpeptidase (GGT)

Liver disease

Proteins Albumin Globulin Glucose Normal DM (Fasting) Hypoglycemia Male Hypoglycemia Female

Liver disease

Glycosylated Hemoglobin (HbA1C) Cholesterol LDL HDL Tryglycerides Bilirubin Direct Indirect Uric acid

Decrease

Diabetes Corticosteroid use

Insulin, ethanol, propranolol, hypoglycemic

Uncontrolled DM

Hemolytic anemia

Atherosclerosis (LDL)

Atherosclerosis (HDL)

Hemolysis Biliary obstruction Liver necrosis Gout Rapid cellular destruction

Wilson’s disease Malabsorption syndromes

Significance Thyroid function test Liver function test Cardiac enzymes Lipids Clotting time CBC Stool exams, FOBT Urine exams Sputum exams

Establish level of thyroid function and response to suppressant or replacement therapy Designed to give information about the state of a patient's liver Used to diagnose Myocardial Infarction Hyperlipidemia and risk assessment for CAD Used to prevent blood loss. Normal clotting time 2 – 6 minutes hgb, hct, RBC, WBC count, MCV, MCH, mean corpuscular hgb concentration Diagnosis of certain conditions affecting the digestive tract Checks different components of urine, a waste product made by the kidneys Bacteria or fungi that are infecting the lungs or breathing passages

Hospital Pharmacy o Practice of pharmacy in a hospital o Department wherein the procurement, storage, compounding, manufacturing, packaging, controlling, assaying, dispensing, distribution and monitoring of medications take place o Min: 6 beds o CEO = hospital director

Primary Secondary Tertiary Quaternary

- emergency - no departments; level 1 + surgery; intermediate care - departmental; intense care - teaching & training; subspecialties

Long term HC facility Resident treatment facility Clinic/Infirmary Ambulatory surgery Birthing home

- for recovering - safe, hygienic, living arrangements for residents - ambulatory

HOSPITAL FUNCTIONS Patient Care Education Research Public Health

HOSPITAL – organized structure which pools together all the health professionals, facilities, and supplies into a coordinated system for delivering health care

Type of Service  General  Special

Length of Stay  Short term <30 days  Long term ≥30 days

Ownership  Governmental  Non-governmental o Profit-oriented o Non-profit oriented

Bed Capacity 1. 2. 3. 4. 5. 6. 7.

Under 50 50-99 100-199 200-299 300-399 400-499 500 and over

SUPPORTING SERVICES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Nursing Dietary Central Supply Medical Record Blood Bank Pathology Radiology Anesthesia Medical Social Service

MEDICAL STAFF/DOCTORS Main types: 1. Open staff 2. Closed staff

- Courtesy/on call - Exclusive/active/attending

Specific Types: 1. Honorary 2. Consulting 3. Active/Attending 4. Associate 5. Resident 6. Courtesy

- retired - specialists - regular patient care (closed staff) - junior of active - specialized training - not affiliated; with privilege to admit

HOSPITAL PHARMACIST’S RESPONSIBILITIES Policies and Procedure Competence Training and Education Documentation Interdisciplinary interaction

DIVISIONS Administrative Services

Plan, coordinate, supervise departmental activities Develop policies Make schedule of staff Coordinate administrative needs of the P&TC

Education and Training

Coordinate activities of programs of pharmacy students Hospital-wide education program Training

Pharmaceutical Research

New formulations Improve existing formulations Cooperate in research

In-Patient Services

Provide medication for in-patients Inspection and Control Cooperative with Research division

Out Patient Services

Compound and dispense out-patient Rx Inspection/Control Maintain Rx records Provide DRUG CONSULTATION

Drug Information Services

Provide drug info on drugs and drug therapy to hospital staff Maintain drug information center Hospital pharmacy newsletter, literature files

Departmental Services

Control and Dispense IV Fluids Control and Dispense Regulated Drugs Coordinate and Control all drug delivery and distribution system

Purchase and Inventory Control

Maintain Drug Inventory Purchase of Drugs Receive, store, and distribute drugs Interview MedReps

Central Supply Services

Coordinate the distribution of medical supplies and irrigating fluids

Assay and QC

Perform Analyses Develop and revise assay procedure Assist in Research

Manuf and Packaging

Manufacture, Drug packaging Product Development Unit dose program

Sterile Products

Produce small volume parenterals Manufacture sterile ophthalmic, irrigating solutions, etc Perform Aseptic Dilution

Radiopharmaceutical Services

Procurement, storage, and dispensing of radioisotopes Involves proper handling and control

IV Admixture

Centralize the preparation of IV admixture Review each IV admixture for incompatibilities Work with IV Therapy Nurses

PHARMACY AND THERAPEUTICS COMMITTEE Objective: Achieve optimal patient care and safety through rational drug therapy Primary Purposes: 1. Policy development 2. Education Organization: Physicians (1 chairperson), Pharmacists (1 secretary), Nurses, Administrators, QA coordinators Functions and Scope: 1. Evaluators and advisors for all matters pertaining to drug use 2. Develop formulary 3. Programs to ensure safe and effective drug therapy, and 4. Cost effective drug therapy 5. Educational programs on matters to drug use 6. QA activities related to distribution, admin, use of meds 7. Monitor and evaluate ADRs 8. Drug use evaluation programs and studies 9. Advice pharma department in implementing effective distribution and control 10. Disseminate information on its actions and approved recommendations to all HC staff

FORMULARY SYSTEM o

A method whereby the medical staff of an institution, working through the PTC, evaluates, appraises, and selects from among the numerous available drug entities and drug products those that are considered useful in px care.

FORMULARY o

A continually revised compilation of pharmaceuticals reflecting the current clinical judgment of the medical staff Part I. Information on Hospital Policies and Procedures Concerning Drugs 1. Drug categories 2. PTC description 3. Regulations (prescribing, dispensing, administering) 4. Operating procedures 5. How to use the formulary Part II. Drug Product Listing 1. By generic name 2. Within therapeutic class 3. Combination Minimum information:  Generic  Synonyms and brands  DF, strengths, packagings, sizes stocked  Formulation  Additional information (adult and pedia dose, cautions, controlled substances symbol) Part III. Special Information 1. List of Hospital-approved abbreviations 2. Rules in calculating pediatric doses 3. Dosing guides for renal impairment 4. Dialyzable poisons, etc.

PURCHASING AND INVENTORY CONTROL 𝑻𝒖𝒓𝒏𝒐𝒗𝒆𝒓 𝒓𝒂𝒕𝒆 =

𝒄𝒐𝒔𝒕 𝒐𝒇 𝒈𝒐𝒐𝒅 𝒔𝒐𝒍𝒅 𝒂𝒗𝒆𝒓𝒂𝒈𝒆 𝒐𝒇 𝒃𝒆𝒈𝒊𝒏𝒏𝒊𝒏𝒈 𝒂𝒏𝒅 𝒆𝒏𝒅𝒊𝒏𝒈 𝒊𝒏𝒗𝒆𝒏𝒕𝒐𝒓𝒚

Satisfactory turnover rate: 4 times a year Low turnover  Sock duplication, Large purchases of slow moving items, Dead inventory High turnover  Small volume purchasing

DISPENSING (In Patient) 1. 2. 3. 4. 5.

Charge plate Envelope System Drug Basket Method Mobile Dispensing Unit Mechanical Dispensing

PRESCRIPTIONS

Violative Prescriptions  generic name is not written;  generic name is not legible, brand name is legible  brand name is indicated and instructions added, such as 'No Substitution' Impossible Prescriptions  only generic name is written but illegible  generic does not correspond with the brand  both generic and brand are not legible  product not registered with BFAD Erroneous Prescriptions  brand name precedes the generic name  generic name is the one in parenthesis  brand name is not in parenthesis  more than one drug product is prescribed in one prescription form

Drug Utilization Review (DUR) o o

Ongoing study of the frequency of the use and cost of drugs Prospective DUR (before dispensing) or Retrospective DUR (after dispensing), Concurrent DUR (IDEAL)

Advantages:  Identify drug-drug interaction  Prevent duplication  Prevent under/overdose  Improve quality of care  Encourage physicians to use formulary/generic drugs

DRUG DISTRIBUTION SYSTEMS Advantages

Disadvantages Error Inventory Pilferage Deterioration hazards

Floor Stock System Free Floor Stock Charge Floor Stock

 Readily available  Transcription  Personnel

   

Individual Prescription Order (IPO)

 RPh reviews Rx  Healthcare interaction  Inventory control

 Delay

 Time for direct px care  Eliminates potential ADE  Errors  Paper duplication

 Time-consuming  Costly

Combination of I and II -

GOVERNMENT HOSPITALS

Unit Dose Dispensing (UDDDS) Centralized Decentralized Combined 1 & 2 Partial

DRUGS FOR EMERGENCY BOX Aminophylline

Mannitol

Amphetamine

Nalorphine HCl

Amylnitrite inhalation

Neostigmine methylsulfate

Atropine sulfate

Norepinephrine injection

Caffeine Na Benzoate

Pentobarbital

Calcium gluconate

Pentylenetetrazol injection

Chloroprophenpyrimadine maleate/Chlorphenamine

Phenobarbital

Digoxin

Phenylephrine

Diphenylhydantoin Na/Phenytoin

Phytonadione injection

Epinephrine

Picrotoxin injection

Heparin

Procainamide

Hydrocortisone

Protamine sulfate

Isoproterenol

Saline for injection

Magnesium sulfate injection

Sodium molar acetate solution

Metaraminol bitartate

Water for injection

COMPOUNDING IV FLUIDS o

for fluid replacement, electrolyte balance restoration and supplementary nutrition, and as vehicles for administration of other drug substances and TPN LVP – 100-1000 ml SVP – 25-50 ml

o o

IV ADMIXTURE o o o

When one or more sterile products are added to an IV fluid for administration Aseptic technique, laminar flowhood, air filtered through HEPA (High Efficiency Particulate Air) HEPA filters remove 99.97% of all particles larger than 0.3 um  Horizontal or vertical flow  Dioctylphthalate (DOP) test to determine proper functioning

TOTAL PARENTERAL NUTRITION/ Hyperalimentation o o o o

IV administration of calories, N, and other nutrients to achieve tissue synthesis and anabolism Dudrick – technique via subclavian vein into superior vena cava For patients unable to digest, refuse to eat, cannot be fed orally Normal Caloric Requirement: 2500 calories/day for adults

Formulation of TPN: 1. Protein 2. Carbohydrates 3. Lipid 4. Electrolytes 5. Trace elements 6. Vitamins 7. Fluids Container: Silicon based bags, superseded by PVC and ethylvinyl acetate Storage and Packaging: 2-6°C, do not store at room temp in excess of 12-24 hours required for administration. Polystyrene containers.

Pharmaceutical Calculations

A. Metric System Weight 1 kilogram (kg) 1 hektogram (hg) 1 dekagram (dag) 1 gram (g) 1 decigram (dg) 1 centigram (cg) 1 milligram (mg) 1 microgram (µg) 1 nanogram (ng)

= = = = = = = = =

1,000 g 100 g 10 g 1g 0.1 g 0.01 g 0.001 g 0.000001 g 0.000000001 g

Volume 1 kiloliter (kL) 1 hektoliter (hL) 1 dekaliter (daL) 1 liter (L) 1 deciliter (dL) 1 centiliter (cL) 1 milliliter (mL) 1 microliter (µL) 1 nanoliter (nL)

= = = = = = = = =

1000 L 100 L 10 L 1L 0.1 L 0.01 L 0.001 L 0.000001 L 0.000000001 L

Length 1 kilometer (km) 1 hektometer (hm) 1 dekameter (dam) 1 meter (m) 1 decimeter (dm) 1 centimeter (cm) 1 millimeter (mm) 1 micrometer (µm) 1 nanometer (nm)

= = = = = = = = =

1000 m 100 m 10 m 1m 0.1 m 0.01 m 0.001 m 0.000001 m 0.000000001 m

B. Common System: Apothecary and Avoirdupois Systems Apothecary: Fluid Measures 1 fluidrachm (f ʓ) 1 fluidounce (foz) 1 pint (pt or O) 1 quart (qt) 1 gallon (gal or C)

= = = = =

60 minims (ᶆ) 8 f ʓ = 480 ᶆ 16 foz 2 pt = 32 foz 4 qt = 8 pt

Avoirdupois: Weight Measures 1 ounce (oz) 1 pound (lb)

= = = =

437.5 gr 16 ounces 7000 grains 454 grams

Apothecary: Weight Measures 1 scruple (э) 1 drachm ( ʓ) 1 ounce (oz) 1 pound (lb)

= = = = =

20 grains (gr) 3 scruples = 60 gr 8 drachms = 480 gr 12 ounces = 5760 gr 12 ounces = 373 g

Household Measures 1 teaspoonful 1 dessertspoonful 1 tablespoonful 1 glassful

= = = =

5 mL 10 mL 15 mL 240 mL

= 1/6 f ʓ = ½ foz = 8 foz

= 1 1/3 f = 4fʓ

CONVERSION Volume 1 mL 1ᶆ 1 fʓ 1f 1 pt 1 gal (US) 1 f (water)

= = = = = = = =

Weights 16.23 minims (ᶆ) 0.06 mL 3.69 mL 29.57 mL 473 mL 3785 mL 128 foz 455 gr

Length 1 meter (m) 1 inch (in)

= =

ROMAN NUMERALS ss = ½ I or I = 1 V or v = 5 X or x = 10 L or l = 50 C or c = 100 D or d = 500 M or m = 1000

1g 1 kg 1 gr 1 oz (avoir.) 1 ʓ (apoth.) 1 lb (avoir.) 1 lb (apoth.)

= = = = = = = = =

15.432 gr 2.2 lb (avoir.) 0.065 g (65 mg) 28.35 g 437.5 gr 31.1 g 480 gr 454 g 373.2 g

Approximate Equivalents 39.37 in 2.54 cm

1 tsp 1 tbsp 1 mL Tumbler Teacup Wineglass

= = = = = =

Prefix atto femto pico nano micro milli centi deci deka hecto kilo mega giga tera peta exa

Symbol a f p n µ or mc m c d ds h k M G T P E

5 mL 15 mL 20 drops 240 mL 120 mL 60 mL

Power of Ten 10-18 10-15 10-12 10-9 10-6 10-3 10-2 10-1 101 102 103 106 109 1012 1015 1018

FORMULAS TO REMEMBER PERCENTAGE ERROR % 𝐸𝑟𝑟𝑜𝑟

=

𝐸𝑟𝑟𝑜𝑟/𝑆𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 𝑄𝑢𝑎𝑛𝑡𝑖𝑡𝑦 𝐷𝑒𝑠𝑖𝑟𝑒𝑑

𝑆𝑚𝑎𝑙𝑙𝑒𝑠𝑡 𝑄𝑢𝑎𝑛𝑡𝑖𝑡𝑦

=

𝑥

100%

𝑚𝑎𝑥 𝑝𝑜𝑡𝑒𝑛𝑡𝑖𝑎𝑙 𝑒𝑟𝑟𝑜𝑟 𝑜𝑟 𝑠𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 𝑥 100 𝑃𝑒𝑟𝑚𝑖𝑠𝑠𝑖𝑏𝑙𝑒 𝑒𝑟𝑟𝑜𝑟

CALCULATION OF DOSES/POSOLOGY Children | Based on Body Weight 𝑨𝒈𝒆 𝑨𝒈𝒆 + 𝟏𝟐

Young's Rule, based on age

×

𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

𝑨𝒈𝒆 𝒂𝒕 𝒏𝒆𝒙𝒕 𝒃𝒊𝒓𝒕𝒉𝒅𝒂𝒚 (𝒚𝒆𝒂𝒓𝒔) 𝟐𝟒

Cowling's Rule

𝒎𝒐𝒏𝒕𝒉𝒔 𝟏𝟓𝟎

Fried's Rule for Infants

𝒍𝒃𝒔 𝟏𝟓𝟎

Clark's Rule

×

×

Children | Based on Body Surface Area 𝑩𝑺𝑨 (𝒎𝟐 ) 𝟏. 𝟕𝟑 𝒎𝟐

𝑥

𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

𝐵𝑆𝐴 𝑜𝑓 𝑐𝑕𝑖𝑙𝑑 (𝑚2 ) 𝑥 𝐷𝑜𝑠𝑒 𝑝𝑒𝑟 𝑚2

ADULT DOSE 𝑩𝑺𝑨 (𝒎𝟐 ) 𝟏. 𝟕𝟑 𝒎𝟐 𝑖𝑛 × 𝑙𝑏 𝐵𝑆𝐴 = √ 3131

𝑥

𝑈𝑠𝑢𝑎𝑙 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

𝑐𝑚 × 𝑘𝑔 𝐵𝑆𝐴 = √ 3600

×

𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒

DENSITY, SPECIFIC GRAVITY AND SPECIFIC VOLUME 𝒎𝒂𝒔𝒔 (𝒈) 𝒗𝒐𝒍𝒖𝒎𝒆 (𝑳)

Density

Specific Gravity

𝒘𝒕𝒔𝒖𝒃𝒔 𝒘𝒕𝒔𝒕𝒅

(same volumes)

Specific Volume

𝑽𝒔𝒕𝒅 𝑽𝒔𝒖𝒃𝒔

(same volumes)

DILUTION AND CONCENTRATION 𝑪 𝟏 𝑽𝟏 = 𝑪 𝟐 𝑽𝟐 Alligation Medial – “weighted average” | % strength ng whole solution pag hinalo ang solutions na iba-ibang % Alligation Alternate – number of parts ng each component mag hinalo to achieve a desired strength

ISOTONIC SOLUTIONS 𝑁𝑎𝐶𝑙 𝑒𝑞𝑢𝑖𝑣 1. 2. 3. 4.

=

𝑀𝑊 𝑜𝑓 𝑁𝑎𝐶𝑙 (58.5) 𝑖 𝑓𝑎𝑐𝑡𝑜𝑟 𝑜𝑓 𝑁𝑎𝐶𝑙 (1.8)

×

𝑖 𝑓𝑎𝑐𝑡𝑜𝑟 𝑜𝑓 𝑡ℎ𝑒 𝑠𝑢𝑏𝑠 𝑀𝑊 𝑜𝑓 𝑠𝑢𝑏𝑠

Ilan ang meron (equivalent). Ilan ang dapat meron (NaCl). Ilan ang idagdag para maabot ang dapat meron (subtraction). Optional. Divide

PROOF STRENGTH Proof spirit Proof strength of alcohol Proof gallon

– an aqueous solution containing 50% (v/v) of absolute alcohol – expressed by taking 50% alcohol, or proof spirit, as 100 proof – frequently used to measure, or evaluate, alcohols of given quantities and strengths

% ×𝟐

Proof Strength

Proof Gallons

𝑾𝑮

𝒙 𝟓𝟎

%

𝑾𝑮

𝒙 𝑷𝒓𝒐𝒐𝒇 𝟏𝟎𝟎

Molarity (M)

𝒈𝒔𝒐𝒍𝒖𝒕𝒆 𝑴𝑾 × 𝑳𝒔𝒐𝒍′𝒏

Normality (N)

𝒈𝒔𝒐𝒍𝒖𝒕𝒆 𝑴𝑾 × 𝑳𝒔𝒐𝒍′𝒏 𝒇

𝒈𝒔𝒐𝒍𝒖𝒕𝒆 𝑴𝑾 × 𝒌𝒈𝒔𝒐𝒍𝒗𝒆𝒏𝒕

Molality

𝒘𝒕(𝒎𝒈) 𝑭 𝑴𝑾

Milliequivalent (mEq)

𝑴𝑾 𝑭 × 𝟏𝟎𝟎𝟎

Moles (m)

𝒈 𝑴𝑾

Millimoles (mmol)

𝒎𝒈 𝑴𝑾

𝒘𝒕(𝒎𝒈) 𝑭 𝑴𝑾

mOsmol

𝑔𝑡𝑡/𝑚𝑖𝑛

RATE OF INFUSION

Jeliffe Equation

𝑎𝑚𝑡 𝑜𝑓 𝑓𝑙𝑢𝑖𝑑 𝑥 𝑔𝑡𝑡𝑠/𝑚𝐿 (𝐼𝑉 𝑠𝑒𝑡) 𝑕𝑟𝑠 𝑡𝑜 𝑎𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑒𝑟 𝑥 𝑚𝑖𝑛𝑠/𝑕𝑟

𝑘𝑔 𝑚2

BMI

Cockroft and Gault

=

(𝟏𝟒𝟎 − 𝐴𝑔𝑒)(𝑘𝑔) 𝟕𝟐 (𝑆𝐶𝑟 𝑖𝑛 𝑚𝑔/𝑑𝐿 )

𝐶𝑟𝐶𝑙𝑭 = 𝐶𝑟𝐶𝑙𝑀

×

𝟎. 𝟖𝟓

𝟗𝟖 − [(𝟎. 𝟖)(𝐴𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠 − 𝟐𝟎) 𝑆𝐶𝑟 𝑖𝑛 𝑚𝑔/𝑑𝐿 )

𝐶𝑟𝐶𝑙𝑭 = 𝐶𝑟𝐶𝑙𝑀

×

𝟎. 𝟗𝟎

𝐶𝑟𝐶𝑙𝑴 =

𝐶𝑟𝐶𝑙𝑴 =

𝑙𝑏𝑠 × 704.5 𝑖𝑛