Pediatric Drug AdministrationPediatric Drug Administration

Pediatric Drug AdministrationPediatric Drug Administration

Intramuscular DrugsIntravenous Drugs

Intermittent IV Drug Infusion Using a Volume Control SetDaily Maintenance Fluid Needs

5. Determine whether the ordered dosage is safe to administer.6. Explain the dosage inaccuracies that can occur with pediatric

drug formulas.

nomogram A quick reference graph for calculating pediatric doses.safe-dosage range Varying amounts of a drug that can be taken in a

single dose and still have therapeutic value.

G L O S S A R Ybody surface area (BSA) Calculated by using a graph that consists

of weight and height variables called a nomogram. It is expressedas meters squared (m2).

hypertonic solution Used to maintain daily fluid needs; are gener-ally a combination of saline, glucose, and potassium chloride.

O B J E C T I V E SUpon completion of this chapter, the student should be able to:

1. Convert pounds to kilograms.2. Use the two primary methods in calculating pediatric drug

dosages.3. Compare the ordered dosage with the recommended safe dosage.4. Identify the steps in calculating body surface area from a pediatric

nomogram and with the square root method.

O U T L I N EOverviewCalculating Pediatric Dosages

Body Weight Dosage CalculationsBody Surface Area (BSA) Dosage CalculationsClark’s RuleYoung’s RuleFried’s Rule

1 2

B J E C T I V E S

1428344225, Pharmaceutical Calculations for Pharmacy Technicians: A Worktext, by Jahangir Moini, MD, MPH - ©Thomson

CHAPTER 12 Pediatric Drug Administration 149

OVERVIEW

Administration of medications to children requires specialattention and care because of their size and the way theymetabolize drugs. Pharmacy technicians deal with prepara-tion or dispensing of medication for pediatric patients andhave full responsibility for providing a safe amount. Thepharmacy technician must calculate with absolute accuracy,compare the amount prescribed with safe dosages listed indrug literature, and must consult with the pharmacist ifthere is any doubt or concern about the product dosage.

Children of different ages respond to medications dif-ferently. For example, many organ systems in a newborn,an infant, or a toddler are varied. Metabolism of medica-tions in these groups compared with an adult dose will becompletely different. Therefore, variations for children areso significant that no foolproof formula exists to determinethe dosage of medications that a child should receive.

CALCULATING PEDIATRIC DOSAGES

Pharmacy technicians must be skillful in more advanced cal-culations for pediatric dosages. The two main methods cur-rently used for calculating safe pediatric dosages are bodyweight (such as mg / kg), and body surface area (BSA).The first method uses a specific number of milligrams, mi-crograms, or units for each kilogram of body weight. Usu-ally, drug data for pediatric dosage (mg / kg) are supplied bymanufacturers in a drug information insert. BSA, measuredin square meters (m2), is considered a more accurate methodthan body weight. BSA takes into consideration the rela-tionship between basal metabolic rate and surface area. BSAhas primarily been used to calculate the dosage of antineo-plastic agents. Manufacturers are beginning to include BSAparameters (mg / m2, mcg / m2, U / m2) in drug information.

Body Weight Dosage CalculationsStandard adult dosages are determined by the drug man-ufacturer. Dosage is usually recommended based on therequirements of an average-weight adult.

Dosages for newborns, infants, and children are basedon their unique and changing body differences. The pre-scribers must consider the weight, height, body surface,age, and condition of the child as contributing factors tosafe and effective drug dosages. The body weight methodis more common in pediatric situations. Remember thatboth the body weight and BSA methods are also used foradults, especially in critical care situations, and the calcu-lations are the same.

To calculate the amount of drug based on the child’sbody weight in kilograms, it is necessary to compare thechild’s ordered dosage to the recommended safe dosagefrom a reputable drug resource before administering the

medication. During calculation and verification for safepediatric dosages, follow these steps:

1. Convert the child’s weight from pounds to kilograms.2. Calculate the safe dosage in mg/kg or mcg/kg for a

child of this weight, as recommended by a reputabledrug reference: multiply mg / kg by the child’s weightin kg (e.g., 1 kg � 2.2 lb or 1 g � 1,000 mg).

3. Decide if the dosage is safe by comparing ordered andrecommended dosages.

4. Calculate one dose.5. Compare the prepared dosage to the ordered dosage

and the recommended dosage, and decide if thedosage is safe.

6. If the dosage seems unsafe, consult with the pharmacist.

Note: The dosage per kg may be mg / kg, g / kg, mEq / kg,U / kg, mU / kg, etc.

EXAMPLE:The physician orders morphine sulfate 1.8 mg IMstat. The child weighs 79 lb. Is this dosage safe?First convert pounds to kilograms.79 lb � 79 � 2.2 � 35.90 kg � 35.9 kgNext calculate the milligrams per kilogram asrecommend by a reputable drug source. Areputable drug source indicates that the usualIM/SC dosage may be initiated at 0.05mg/kg/dose.Decide if the dosage ordered is safe. For thischild’s weight, 1.8 mg is the recommendeddosage and 1.8 is the ordered dosage. Thisdosage is safe.Calculate the dose.

(Courtesy of Baxter Healthcare Corporation)

Ordered: morphine sulfate 1.8 mg IM statOn hand: morphine sulfate 5 mg / mLAdminister:

DH* Q =

1.8 mg5 mg

* 1 mL = 0.36 mL

ethods cur-ently used for calculating safe pediatric dosages are body

h ( h / k ) d body surface area (BSA)grams,

d b t bl d

h killf l i e advanced

ysician orders mghs 7h 7he chh h

nvert pounds to

The stat. TFirst c

rphine sulfate dosds thisI th9 lb.9 lb

lograms.h

A


150 CHAPTER 12 Pediatric Drug Administration

Or, apply the ratio and proportion method:5 mg : X mL : : 1.8 mg : 1 mL

5X � 1.8

X � 0.36 mLThis is a small child’s dose. Measure 0.36 mL ina 1 mL syringe. Route is IM. Needle may need tobe changed.

X =1.85

5 mg1 mL

=1.8 mgX mL

.1 .2 .3 .4 .5 .6 .7 .8 .9 1.0

mL

0.36 mL

Single-Dosage Ranges

Single-dosage drugs are intended to be given once or p.r.n.Dosage ordered by the body weight method is based onmg / kg / dose, calculated by multiplying the recom-mended mg by the patient’s kg weight for each dose. Somesingle-dosage medications indicate a minimum and maxi-mum range, or a safe-dosage range.

EXAMPLE 1:The physician orders Vistaril 20 mg IM q4–6h,p.r.n., nausea. The child weighs 44 lb. Is this asafe dosage?1. Convert lb to kg.

44 lb � 44 � 2.2 � 20 kg

(Label reproduced with permission of Pfizer, Inc.)

.1 .2 .3 .4 .5 .6 .7 .8 .9 1.0

mL

0.4 mL

Calculate recommended dosage. A reputabledrug resource indicates that the usual IMdosage is 0.5 mg to 1 mg / kg / dose every4 to 6 hours as needed.

Calculate the minimum and maximum safedosage range.Minimum per dose: 0.5 mg / kg / dose x 20mg � 10 mg / doseMaximum per dose: 1 mg / kg / dose x 20kg � 20 mg / dose

2. Decide if the ordered dosage is safe. Therecommended dosage is 10 mg to 20 mg,and the ordered dosage of 20 mg is withinthis range. Yes, the ordered dosage is safe.

3. Calculate one dose. Apply the three steps ofdosage calculation.Ordered: Vistaril 20 mg IM q4–6h p.r.n.,

nauseaOn hand: Vistaril 50 mg / mL

Or, apply the ratio and proportion method.

50X � 20

X � 0.5 mLThis is a small child’s dose. Measure it in a 1 mLsyringe. Route is IM. The needle may need to bechanged.

50X50

=2050

50 mg1 mL

=20 mgX mL

DH* Q

20 mg50 mg

* 1 mL =25

ML = 0.4 mL

2. Decide if the ordered dosage is safe. The

ugs are intendeby the body w

calculated be patient’s kg

be given oeight method is

multiplying theght for each

or p.r.nased onrecom-

e So

per dose: 0.5 mmg /

r dose: 1 m

Minimug � 10

Maxim

/ kg / dose x

k / d 2

gle dosage drordg /

d mg



STOP AND REVIEWSTOP AND REVIEW

Calculating Pediatric Dosages by Body Weight

1. Calculate one safe pediatric dose.a. Ordered: Keflex 125 mg p.o. q6h for a child who

weighs 44 lb. The recommended pediatric dosage ofKeflex (cephalexin) is 25–50 mg / kg / day in 4 equallydivided doses.Child’s weight: __________ kgRecommended minimum daily dosage for this child:__________ mg / dayRecommended minimum single dosage for this child:__________ mg / dayRecommended maximum daily dosage for this child:__________ mg / dayRecommended maximum single dosage for this child:__________ mg / dayIs the dosage ordered safe? __________

b. Keflex is available in a suspension of 125 mg per 5 mL.If the dosage ordered in question 1a is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do:____________________________________________________________________________________

c. Ordered: Chloromycetin 55 mg IV q12h for an 8-day-old newborn who weighs 2,200 g. The recommendeddosage of Chloromycetin (chloramphenicol) forneonates less than 2 kg is 25 mg / kg once daily; andfor neonates more than 2 kg and over 7 days of age therecommended dosage is 50 mg / kg / day divided q12h.Child’s weight: __________ kgRecommended daily dosage for this child:__________ mg / dayRecommended single dosage for this child:__________ mg / doseIs the ordered dosage safe?

d. Chloramphenicol is available as a solution for injec-tion of 1 g per 10 mL. If the dosage ordered in question1c is safe, give __________ mL. If it is not safe, ex-plain why and describe what you should do:____________________________________________________________________________________

e. Ordered: Suprax 120 mg p.o. q.d. for a child whoweighs 33 lb.The recommended dosage of Suprax (cefixime) forchildren under 50 kg is 8 mg / kg p.o. once daily or 4mg / kg q12h.Child’s weight: __________ kgRecommended single dosage for this child:__________ mg / doseIs the ordered dosage safe? __________

f. Suprax is available as a suspension of 100 mg per 5mL in a 50 mL bottle. If the dosage ordered in question1e is safe, give __________ mL. If it is not safe, ex-plain why and describe what you should do:____________________________________________________________________________________How many doses are available in the bottle ofSuprax? __________ dose(s)

2. The labels provided represent the drugs available toanswer questions 2a through 2j. Verify safe dosage,indicate the amount to give, and draw an arrow on theaccompanying measuring device. Explain unsafedosages and describe the appropriate action to take.a. Ordered: Nebcin 8 mg IM q6h for an infant who

weighs 5,000 g. The recommended pediatric dosage ofNebcin (tobramycin) is 2–2.5 mg / kg q8h or 1.5–1.9 mg / kg q6h.Infant’s weight: __________ kgRecommended minimum single dosage for this infant:__________ mg / doseRecommended maximum single dosage for this in-fant: __________ mg / doseIs the dosage ordered safe? __________

(Copyright Eli Lilly and Company. Used with permission.)

12 11

2

2 212

3mL

b. If the dosage ordered in question 2a is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do: _______________________________________________________________

(continues)



(continued)

c. Ordered: gentamicin 40 mg IV q8h for a prematureneonate who is 5 days old and weighs 1,800 g. Therecommended dosage of gentamicin for children is2–2.5 mg / kg q8h; for neonates, it is 2.5 mg / kg q8h;and for premature neonates less than 1 week of age,it is 2.5 mg / kg q12h.Neonate’s weight: __________ kgRecommended single dosage for this neonate:__________ mg / doseIs the dosage ordered safe? __________

.1 .2 .3 .4 .5 .6 .7 .8 .9 1.0

mL

(Courtesy of American Pharmaceutical Partners, Inc.)

d. If the dosage ordered in question 2c is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do: ______________________________________________________________

e. Ordered: Amoxil oral suspension 100 mg p.o. q8hfor a child who weighs 39 lb.Recommended dosage: See the label.Child’s weight: __________ kgRecommended minimum daily dosage for this child:__________ mg / dayRecommended minimum single dosage for this child:__________ mg / doseRecommended maximum daily dosage for this child:__________ mg / dayRecommended maximum single dosage for this child:__________ mg / doseIs the ordered dosage safe? __________

(Courtesy of GlaxoSmithKline)

1111 2 3 .4 .5 6 7 8 9 .0 mL



tsp

mL10987654321

f. If the dosage ordered in question 2e is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do: ________________________________________________________________

g. Ordered: Bactrim Pediatric Suspension 7.5 mL p.o.q12h for a child who weighs 15 kg and has a urinarytract infection. The recommended dosage of Bactrim(trimethoprim and sulfamethoxazole) for such infec-tions in children is based on the trimethoprim at 8 mg/ kg / day in 2 equal doses.Recommended daily trimethoprim dosage for thischild: __________ mg / dayRecommended single trimethoprim dosage for thischild: __________ mg / doseRecommended single dose for this child: __________mL / doseIs the ordered dose safe? __________

tsp

mL10987654321

(Courtesy of Roche Laboratories, Inc.)

h. If the dose ordered in question 2g is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do: ______________________________________________________________The dose ordered is equivalent to __________ tea-spoons.

(continues)



(continued)

i. Ordered: Terramycin 100 mg IM q8h for a 9-year-oldchild who weighs 55 lb. Recommended pediatricdosage: see the label.Child’s weight: __________ kgRecommended minimum daily dosage for this child:__________ mg / dayRecommended minimum single dosage for this child:__________ mg / doseRecommended maximum daily dosage for this child:__________ mg / dayRecommended maximum single dosage for this child:__________ mg / doseIs the ordered dosage safe? __________

j. If the dosage ordered in question 2i is safe, give__________ mL. If it is not safe, explain why and de-scribe what you should do: ______________________________________________________________

12 11

2

2 212

3mL

(Label reproduced with permission of Pfizer, Inc.)

Body Surface Area (BSA) Dosage CalculationsThe BSA is used frequently in calculating dosages for in-fants and children. A patient’s BSA is stated in square me-ters, or m2. Pharmacy technicians can calculate the BSA byusing a chart (nomogram) or formula calculation. Otherinformation is needed for the calculation such as thechild’s height, weight in kilograms, and age. Pediatricdosage in (square meters) is listed by the manufacturer orhospital pharmacy. The formula calculation is the most ac-curate. To determine BSA in square meters based on met-ric measurement of height and weight:

To calculate BSA in m2 based on household measurementof height and weight:

BSA (m2) = Bht (in) * wt (lb)

3131

BSA (m2) = Bht (cm) * wt (kg)

3600

EXAMPLE 1:Use the metric formula to determine the BSA for a child whose height is 85 cm and weight is13.9 kg:

� 0.573 m2 � 0.57 m2

B1181.53600

m2

BSA = B8.5 * 13.9

3600 m2

EXAMPLE 2:Calculate the BSA for a baby whose height is 24 in. and weight is 12.2 lb.

� 0.306 m2 � 0.31 m2

B292.83131

m2

BSA = B24 * 12.2

3131 m2

12

2 2 Lm

LLL

21



Nomogram

When the practitioners use a chart to estimate the BSA byplotting the height and weight and then connect the dotswith a straight line, it is called a nomogram (Figure 12-1).Use a nomogram for determining the BSA for a child whohas a normal height and weight. For a child who is un-derweight or overweight, the surface area is indicated by astraight line connecting the height and weight, intersect-ing the surface area (SA) column. This chart can be usedfor both children and adults for heights up to 240 cm (95in.) and weights up to 80 kg (180 lb).

West’s nomogram uses a calculation of the body sur-face area of infants and young children to determine the

WEST NOMOGRAM

2

3

4 0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.500.550.60

0.70

0.80

0.90

1.00

1.101.201.30

0.10

5

6

789

10

15

Wei

ght (

lb)

Sur

face

are

a (s

quar

e m

eter

s)

20

30

40

50

60

7080

90

For children ofnormal height

for weight

30 12

1314

15

1617181920

22

24

26

28

30

35

40

45

50

55

60

65

7075808590

40

50

60

70

80

90

100

110

120

130

140

150160170180190200

220

240

cm inHeight

80

70

60

50

40

30

25

20

15

109.08.07.0

6.0

5.0

4.0

3.0

2.0

1.0

2.5

1.5

180160140130120110100908070

60

50454035

30

25

20181614

12

1098

7

6

5

4

3

lb kgWeight

Nomogram

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.21.1

1.31.41.51.61.71.81.92.0

M2SA

3

2

1

Figure 12-1. Nomogram for calculating body surface area. (Note. From Nelson Textbook of Pediatrics (16th ed.), by R. E. Behrman, R. M. Kleigman, and H. B. Jenson, 2000, Philadelphia: Saunders. Reprinted with permission.)

pediatric dose. The nomogram is used as a quick referencefor pediatric doses. To use the nomogram, you will need astraightedge ruler. Place one end of the ruler on the pa-tient’s height (either centimeters or inches) and the otheredge on the weight (either kilograms or pounds). Draw aline to connect these two points; the meter-squared num-ber is where the line intersects on the line labeled meterssquared (m2). Write this number down.

For pediatric doses, you can use the following formula:

� Adult dose

Pediatric dose =Body surface area (BSA) of child in m2

1.7 m2 (average adult BSA)

0

0.80

0.9075190 801.4

408

101.201.3 80

60

60400

1 81.9



Clark’s RuleThe use of Clark’s rule to calculate pediatric dosages ismuch more accurate than other pediatric methods. It isbased on a child’s weight and uses 150 lb (70 kg) as the av-erage adult weight while assuming that a child’s dose isproportionately less. Calculate as follows:

� Adult dose

Pediatric dose =Child’s weight in pounds

150 pounds

Young’s RuleYoung’s rule is used for children who are older than 1 yearof age. Calculate as follows:

Pediatric dose =Child’s age in years * adult dose

Child’s age in years + 12


Determining Pediatric Dosages by Body Surface Area

1. Use the appropriate formula to determine the BSA.a. A child’s height is 88 cm and the weight is 13.2 kg.b. A child measures 94 cm in height and weighs 18 kg.c. A child measures 26 in. tall and weighs 21 lb.d. A child measures 65 cm tall and weighs 15 kg.e. A child measures 92 cm tall and weighs 24 kg.f. A teenager measures 135 cm tall and weighs 46 kg.

g. A child measures 43 in. tall and weighs 35 lb.

2. Find the BSA on the West nomogram (see Figure 12-1)for children with the following height and weight.a. 21 in. and 81 lb ____________ m2

b. 106 cm and 25 kg __________ m2

c. 41 in. and 32 lb ____________ m2

d. 80 cm and 11 kg ___________ m2

e. 140 cm and 30 kg __________ m2

f. 34 in. and 28 lb ____________ m2

g. 122 cm and 32 kg __________ m2

h. 38 in. and 31 lb ____________ m2

EXAMPLE:Find the dose of cortisone for a 45 lb infant(adult dose � 100 mg). 45

150* 100 mg = 30 mg

EXAMPLE:How much acetaminophen is the acceptabledosage for a 5-year-old child if the adult dosenormally equals 1,000 mg?5 (years) * 1000

5 (years) + 12=

500017

= 294 mg

Young’s rule is not valid for children who are older than 12years of age. If a child over 12 is still small enough in sizeto require a reduced dose, Clark’s rule should be used tocalculate the proper amount.

Fried’s RuleFried’s rule helps to estimate correct medication dosagesfor infants who are younger than 1 year of age. Calculateas follows:

Age in months

150* average adult dose = child’s dose

EXAMPLE:Find the dose of phenobarbital for an 11-month-old infant if the adult dose � 400 mg.11

150* 400 mg = 28 mg

Remember

• There are three steps used to calculate pediatric drugdosages:Step 1: Convert pounds to kilograms, then cross multiply

the ratio and round to the nearest whole number.Step 2: Calculate the drug dosage based on milligrams

per kilogram of body weight, and cross multiplythe ratio.

Step 3: Calculate how much medication the patient wouldthen receive based on the total amount allowedper day, divided into the proper amount ofadministrations per day.

INTRAMUSCULAR DRUGS

The amount of medication to be administered in pediatricpatients requires the pharmacy technician to consider theage and the size of the child. To be precise in calculatinginjection amounts, round the amount of the drug calcula-tion to the nearest hundredth. When a pharmacy techni-

ld i fld i f t if th d lt d 400

g50



cian calculates dosages for pediatric injections, he or shecan use the same method used for adults. The maximumvolume of “intramuscular injections” for infants is 0.5–1mL and for children more than 1 year old it is 1 mL. Forpreschoolers and elementary school-age children, theamount is 1–1.5 mL.

EXAMPLE 1:Ordered: Zinacef 50 mg / kg / day IM q6hOn hand: Zinacef 750 mg for injectionFind the amount to administer.According to the package insert, Zinacef may beadministered to pediatric patients above 3months of age at the rate of 50–100 mg / kg /day in divided doses every 6 to 8 hours.1 kg : 2.2 lb : : ? kg : 44 lb2.2 lb � ? kg � 1 kg � 44 lb? � 20 kg

INTRAVENOUS DRUGS

According to the size and age of children, the amount ofmedication to administer for intravenous drugs com-pared with adults is smaller. Volume control sets (Figure12-2) are most commonly used to administer hourlyfluids and intermittent IV medications to children. Thefluid chamber will hold 100 mL to 150 mL of fluid to be

Clamp

Injection port

Drug and fluidadministrationchamber

Drip chamber

Check valve

Clamp

Injection port

Capped needle

Figure 12-2. Volume control set.

Now, find the daily dosage.

1000 � 4 � 250 mg each doseAfter reconstitution, the Zinacef has a dosagestrength of 220 mg / mL. To find the amount toadminister for each dose:

250 mg *1 mL

220 mg= 250 *

1220

= 1.14 mL

50 mg1 kg

* 20 kg =501* 20 = 1000 mg

Clamp



infused in a specified time period as ordered, for examplefor 60 minutes or less. The medication is added to the IVfluid in the chamber for a prescribed dilution volume.The IV bag acts only as a reservoir to hold future fluid in-fusions and the nurse can fill the chamber for 1 to 2hours. If more fluid infusions are needed, then the nursecan add to the amount. Only small, ordered quantities offluid can be added, and the clamp above the chamber isfully closed.

Intermittent IV Drug Infusion Using a VolumeControl SetIn place of a continuous IV infusion, children receivingIVs may receive them via means of a saline or heparinlock. Medication is injected into the volume control setchamber, then an appropriate volume of IV fluid (to di-lute the drug) is added. Then the IV tubing is attached tothe child’s IV lock to infuse over a specified amount oftime. Once the chamber is empty and all the medicationis infused, a flush of IV fluid is used to make sure that allthe medication has cleared out of the tubing. Once thechamber empties, remember that some medication re-mains in the drip chamber, IV tubing, and the IV lock (allabove the height of the child’s vein). Peripheral or centralIV lines are not flushed with any standard amount offluid. Manufacturers of IV tubing all have slight differ-ences in their products, so the flush can vary from 15 mLto 50 mL, according to the tubing’s overall length and anyextra extensions added. It is necessary to verify hospitalpolicy as to the correct volume to flush central and pe-ripheral IV lines in children. For the examples in this text,15 mL is used as the volume to flush a peripheral IV lineunless otherwise specified.

In calculating the IV flow rate for the volume controlset, consider the total fluid volume of the medication, theIV fluid used for diluting, and the volume of IV flush fluid.Volume control sets are microdrip sets that use a drop fac-tor of 60 gtt / mL.

EXAMPLE:Ordered: Claforan 250 mg IV q6h in 50 mL

D5 1/4 NS to infuse in 30 minfollowed by a 15 mL flush. Child hasa saline lock.

On hand: See the label.

(Courtesy of Hoechst-Rousel Pharmaceuticals)

Instructions from the package insert for IV use:Add 10 mL diluent for a total volume of 11 mLwith a concentration of 180 mg / mL.Step 1 Calculate the total volume of the

intermittent IV flush: 50 mL � 15 mL �65 mL

Step 2 Calculate the flow rate of the IVmedication and the IV flush.Remember: The drop factor is 60 gtt / mL.

Step 3 Calculate the volume of the medicationto be administered.

Step 4 Add 1.4 mL Claforan 2 g to thechamber and fill with IV fluid to avolume of 50 mL. This provides theprescribed total volume of 50 mL in thechamber.

Step 5 Set the flow rate the 50 mL ofintermittent IV medication for 130 gtt /min. Follow with the 15 mL flush alsoset at 130 gtt / min. When complete,detach the IV tubing and follow thesaline lock policy.

DH* Q =

250 mg180 mg

* 1 mL = 1.39 mL = 1.4 mL

=65 mL1 min

*2 gtt1 mL

= 130 gtt�min

VT* C =

65 mL30 min

* 60 gtt�mL

EXAMPLE 2:Ordered: D5NS IV at 30 mL / hr for

continuous infusion and gentamicin30 mg IV q8h over 30 min

On hand: See the label.An infusion controller is in use with the volumecontrol set.

(Courtesy of American Pharmaceutical Partners, Inc.)

Step 1 Calculate the dilution volumerequired to administer the

t ofd. Manufacturers of IV tubing all have slight differ-

mLStep 5 Set the flow rate the 50 mL of

as cleared ous, remember chamber, IV

of the tubing. hat some medicbing, and the IV

nce theion re-ock

.4 mL Claformber and fill withme of 50 mL. Th

Step 4 Acvol

2 g toV fluid to aprovides the

medication r emn th



gentamicin at the prescribedcontinuous flow rate of 30 mL / hr.

Calculate Use ratio and proportion to verifyyour estimate.

60X � 900

X � 15 mL in 30 minTherefore, the IV fluid dilution volume required toadminister 30 mg of gentamicin in 30 minutes is15 mL to maintain the prescribed, continuousinfusion rate of 30 mL / hr.Step 2 Determine the volume of

gentamicin and IV fluid to add tothe volume control chamber.

Add 0.75 mL gentamicin and fillthe chamber with D5 NS to thetotal volume of 15 mL.

Step 3 Set the controller to 30 mL / hr inorder to deliver 15 mL ofintermittent IV gentamicin solutionin 30 minutes. Resume the regularIV, which will also flush out thetubing. The continuous flow ratewill remain at 30 mL / hr.

DH* Q =

30 mg40 mg

* 1 mL =34

mL = 0.75 mL

60X60

=90060

30 mL60 min

=X mL

30 min


Calculating Pediatric Intravenous Drug Administrations

1. Calculate the amount of IV fluid to be added to thevolume control chamber.a. Ordered: D5 0.33% NaCl IV at 66 mL / hr with Fortaz

720 mg IV q8h to be infused over 40 minby volume control set

On hand: Fortaz 1 g / 10 mLAdd __________ mL medication and __________ mLIV fluid to the chamber.

b. Ordered: D5W at 30 mL / hr for continuous infusionwith medication � 60 mg q6h to be in-fused over 20 min by volume control set

On hand: Medication � 60 mg / 2 mLAdd __________ mL medication and __________ mLIV fluid to the chamber.

c. Ordered: D5 0.45% NaCl IV at 48 mL / hr with Vi-bramycin 75 mg IV q12h to be infusedover 2 hr volume control set

On hand: Vibramycin 100 mg / 10 mLAdd __________ mL medication and __________ mLIV fluid to the chamber.

d. Ordered: 0.9% NaCl at 50 mL / hr for continuous in-fusion with Ancef 250 mg IV q8h to be in-fused over 30 min by volume control set

On hand: Ancef 125 mg / mLAdd __________ mL medication and __________ mLIV fluid to the chamber.

2. Calculate the IV flow rate to administer the following IVmedications by using a volume control set, anddetermine the amount of IV fluid and medication to beadded to the chamber. The ordered time includes theflush volume.a. Ordered: Antibiotic Z 15 mg IV b.i.d. in 25 mL 0.9%

NaCl over 20 min. Flush with 15 mL.On hand: Antibiotic Z 15 mg 3 mLFlow rate: __________ gtt / minAdd __________ mL medication and __________ mLIV fluid to the chamber.

b. Ordered: Antibiotic Y 60 mg IV q8h in 50 mL D5 1/3NS over 45 min. Flush with 15 mL.

On hand: Antibiotic Y 60 mg / 2 mLFlow rate: __________ gtt / minAdd __________ mL medication and __________ mLIV fluid to the chamber.

c. Ordered: Ancef 0.6 g IV q12h in 50 mL D5 NS over60 min or an infusion pump. Flush with 30 mL.

On hand: Ancef 1 g / 10 mLFlow rate: __________ mL / hrAdd __________ mL medication and __________ mLIV fluid to the chamber.

d. Ordered: Medication X 75 mg IV q6h in 60 mL D51/4 NS over 60 min. Flush with 15 mL.

On hand: Medication X 75 mg / 3 mLFlow rate: __________ gtt / minAdd __________ mL medication and __________ mLIV fluid to the chamber.

DAILY MAINTENANCE FLUID NEEDS

Pharmacy technicians should also be familiar with calcu-lating 24-hour maintenance IV fluids for pediatric pa-tients. They must use the following formula to calculate:

� 100 mL / kg / day for the first 10 kg of bodyweight

� 50 mL / kg / day for the next 10 kg of body weight� 20 mL / kg / day for each kg above 20 kg of body

weight

This formula uses the child’s weight in kilograms to esti-mate the 24-hour total fluid need, including oral intake.

mL / hr inorder to deliver 15 mL of

n solutio

At

H 40 mdd 0.75 mL genta chamber with D

4micin and fill

NS to the



EXAMPLE 1:Child who weighs 26 kg:100 mL / kg / day x 10 kg � 1,000 mL / day(for the first 10 kg)50 mL / kg / day x 10 kg � 500 mL / day (forthe next 10 kg)20 mL / kg / day x 6 kg � 120 mL / day (forthe next 6 kg)Total: 1,000 mL / day � 500 mL / day � 120mL / day � 1,620 mL / day, or per 24 hour1620 mL

24 hr= 67.5 mL � hr = 68 mL � hr

EXAMPLE 2:Child who weighs 14 kg:100 mL / kg / day x 10 kg � 1,000 mL / day(for the first 10 kg)

EXAMPLE 3:Child who weighs 8 kg:100 mL / kg / day x 8 kg � 800 mL / day orper 24 hours800 mL24 hr

= 33.3 mL � hr = 33 mL � hr

These types of IV solutions usually contain a combi-nation of saline, glucose, and potassium chloride and areknown as hypertonic solutions (Figure 12-3).

Sodium chloride is usually concentrated between0.225% and 0.9% (1/4 NS up to NS). Dextrose (glucose)for energy is usually concentrated between 5% and 12%for peripheral infusions. Plus, 20 mEq per liter of potas-sium chloride (20 mEq KCl / L) are added to continuouspediatric infusions.

Figure 12-3. IV Solution: D5W. (Courtesy of Baxter HealthcareCorporation)


Calculating Daily Maintenance Fluids for Pediatric Patients

1. Calculate the total volume and hourly IV flow rate for a3,500 g infant receiving maintenance fluids. Infuse__________ mL at __________ mL / hr.

2. Calculate the total volume and hourly IV flow rate for a13 kg child receiving maintenance IV fluids. Infuse__________ mL at __________ mL / hr.

3. Calculate the total volume and hourly IV flow rate for a77 lb child receiving maintenance fluids. Infuse__________ mL at __________ mL / hr.

4. Calculate the total volume and hourly IV flow rate for a25 kg child receiving maintenance IV fluids. Infuse__________ mL at __________ mL / hr.

5. Calculate the total volume and hourly IV flow rate for a17.6 lb newborn receiving maintenance IV fluids. Infuse__________ mL at __________ mL / hr.

6. Calculate the total volume and hourly IV flow rate for an8,800 g child receiving maintenance IV fluids. Infuse__________ mL at __________ mL / hr.

7. Calculate the child’s daily maintenance fluid needs forthe following weights.a. 68.2 lb � __________ mLb. 13.3 lb � __________ mLc. 12 kg � __________ mLd. 43 kg � __________ mL

50 mL / kg / day x 4 kg � 200 mL / day (forthe remaining 4 kg)Total: 1,000 mL / day � 200 mL / day � 1,200mL / day or 24 hours1200 mL

24 hr= 50 mL � hr

Sodium chloride is usually concentrated betweenose)

f IV solution sually contain comSTSTSTST REREVREVREVD OP AOP AND P AND WIEWWWWIEWIEWIEW

se ty

poration)



T E S T Y O U R K N O W L E D G ET E S T Y O U R K N O W L E D G E

For Questions 1 through 7, verify the safety of thefollowing pediatric dosages ordered. If the dosage issafe, calculate one dose and the IV volume to infuseone dose.

Ordered for a child weighing 15 kg:

D5 0.45% NaCl IV at 53 mL / h with ampicillin 275 mg IV q4hinfused over 40 min by volume control set

Recommended dosage: ampicillin 100–125 mg / kg / day in6 divided doses

On hand: ampicillin 1 g / 10 mL

1. Safe daily dosage range for this child: __________ mg/ day to __________ mg / daySafe single dosage range for this child: __________mg / dose to __________ mg / dose. Is the ordereddosage safe? __________. If safe, give __________ mL/ dose. If it is not safe, describe your next step. ________________________________________________

2. IV fluid volume to be infused in 40 min: __________mL. Add __________ mL ampicillin and __________mL D5 0.45% NaCl to the chamber.

Ordered for a child who weighs 55 lbs:

D5 NS at 60 mL / hr with penicillin G potassium 525,000 U q4hto be infused over 20 min by control set

Recommended dosage: penicillin G potassium100,000–250,000 U / kg / day in 6 divided doses q 4 hr.

On hand: penicillin G potassium 200,000 U / mL

3. Child’s weight: __________ kgSafe daily dosage for this child: __________ U / day to__________ U / daySafe single dosage for this child: __________ U / doseto __________ U / dose

4. Is the ordered dosage safe? __________. If safe, give__________ mL / dose. If it is not safe, describe yournext step. _______________________________________________________________________________

5. IV fluid volume to be infused in 20 min: __________mL. Add __________ mL penicillin G potassium and__________ mL D5 NS to the chamber.

Ordered for a child who weighs 22 kg:

D5 0.225% NaCl IV at 50 mL / hr with Amikin 165 mg IV q8hto be infused over 30 min by volume control set

Recommended dosage: Amikin 15–22.5 mg / kg / dayin 3 divided doses q 8 hr

On hand: Amikin 100 mg / 2 mL

6. Safe daily dosage range for this child: __________ mg/ day to __________ mg / day. Safe single dosagerange for this child: __________ mg / dose to__________ mg / dose. Is the ordered dosage safe?__________. If safe, give __________ mL / dose. Ifnot safe, describe your next step: ___________________________________________________________

7. IV fluid volume to be infused in 30 min: __________mL. Add __________ mL Amikin and __________mL D5 0.225% NaCl to the chamber.

For questions 8 through 15, use the BSA formulas tocalculate the BSA value.

8. Height: 4 ft Weight: 80 lb BSA: __________ m2

9. Height: 5 ft 6 in. Weight: 136 lb BSA: __________ m2

10. Height: 68 in. Weight: 170 lb BSA: __________ m2

11. Height: 64 in. Weight: 63 kg BSA: __________ m2

12. Height: 164 cm Weight: 58 kg BSA: __________ m2



15. Height: 85 cm Weight: 11.5 kg BSA: __________ m2

For questions 16 through 18, calculate the orderedmedication for each of the following IV bags toachieve the ordered concentration. On hand is KCl 2 mEq / mL.

16. Ordered: Add 30 mEq KCl per L of IV fluid.

On hand: 360 mL IV solution

Add: __________ mEq; __________ mL

(continues)



(continued)



Add: __________ mEq; __________ mL



Add: __________ mEq; __________ mL

To calculate the daily volume of pediatricmaintenance IV fluids to answer questions 19 through22, allow:

100 mL / kg / day for the first 10 kg of body weight

50 mL / kg / day for the next 10 kg of body weight

20 mL / kg / day for each kg of body weight above 20 kg

19. Calculate the total volume and hourly IV flow rate fora 78 lb child receiving maintenance fluids.

Infuse __________ mL at __________ mL / hr

20. Calculate the total volume IV flow rate for a 21 kgchild receiving maintenance fluids.

Infuse __________ mL at __________ mL / hr.

21. Calculate the total volume and hourly IV flow rate fora 2,400 g infant receiving maintenance fluids.

Infuse __________ mL at __________ mL / hr.

22. Calculate the total volume and hourly IV flow rate fora 33 lb child receiving maintenance fluids.

Infuse __________ mL at __________ mL / hr.

Calculate the volume for one dose of safe dosages.Refer to the BSA formulas or the West nomogram, asneeded, to answer questions 23 through 32.

23. A child is 140 cm tall and weighs 43.5 kg. Therecommended IV dosage of Adriamycin is 20 mg / m2.Use the BSA formula to calculate the safe IV dosage ofAdriamycin for this child. BSA: __________ m2

Safe dosage: __________ mg

24. Calculate the dose amount of Adriamycin for the childin Question 23.

On hand: Adriamycin 2 mg / mL

Give: __________ mL.

25. Use the BSA nomogram to determine the safe IMdosage of Oncaspar for a child who is 42 in. tall andweighs 45 lb. The recommended IM dosage is 2500 U / m2 / dose.

BSA: __________ m2. Safe dosage: __________ U.

26. Oncaspar is reconstructed to 750 U per 1 mL.Calculate one dose for the child in question 25. Give:__________ mL.

27. Should the Oncaspar in question 26 be given in oneinjection? __________

28. Ordered: Vincristine 2 mg direct IV stat for a childwho weighs 85 lb and is 50 in. tall. Recommendeddosage of vincristine for children: 1.5–2 mg / m2 � 1time / week; inject slowly over a period of 1 minute.

On hand: vincristine 1 mg / mL

BSA (per formula) of this child: __________ m2

Recommended dosage range for this child:__________ mg to __________ mg

Is the ordered dosage safe? __________. If safe, give__________ mL / min or __________ mL / 15 sec. Ifnot, what should you do? ____________________

____________________________________________

29. Use the BSA nomogram to calculate the safe oraldosage and amount to give of mercaptopurine for achild of normal proportions who weighs 25 lb.

Recommended dosage: 80 mg / m2 / day once dailyp.o.

On hand: mercaptopurine 50 mg / mL

BSA: __________ m2

Safe dosage: __________ mg

Give: __________ mL.



30. Use the BSA nomogram to calculate the safe IV dosageof sargramostim for a 1-year-old infant who is 25 in.tall and weighs 20 lb.

Recommended dosage: 250 mcg / m2 / day once dailyIV

BSA: __________ m2

Safe dosage: __________ mcg

31. Sargramostim is available in a solution strength of 500mcg / 10 mL. Calculate one dose for the child inquestion 30. Give: __________ mL.

32. Ordered: D5 0.45% NaCl IV at 66 mL / hr with Fortaz620 mg IV q8h to be infused over 40 min

Use a volume control set and flush with 15 mL.

On hand: Fortaz 0.5 g / 5 mL

Add __________ mL Fortaz and ______ mL D50.45% NaCl to the chamber.

CRITICAL THINKING

1. A pharmacy technician received an order to dispenseHalotex® (antifungal) for topical use for a 4-year-oldchild. Fortunately, the technician read the dosage andadministration section of the package insert. He findsa warning that Halotex should not be administered topatients less than 5 years of age. This patient shouldnot receive Halotex. What would be the proper step,that technician should take?


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