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Veterinary Technician’s Guide to Practical Math for Manor College Externship Students Nov. 2013 Developed by Christina M. Lunski, CVT 1 Table of Contents Weight Conversions…………………………………………… pages 3-5 More Conversions………………………………………………pages 6-7 Reading Drug Labels………………………………………… pages 8-12 Calculating Total Fluid Needs (TFN)…………..…………… pages 13-14 Dose Calculations……………………………………………… pages 15-18 Defining CRI’s………………………………………………… pages 19-20 Step by Step Examples of CRI’s……………………………… pages 21-23 CRI Calculations……………………………………………… pages 24-25 Case Study of “Mimi”: Putting it all together………………. pages 26-29 2 Weight Conversions: Make the following weight conversions. Remember to round to 2 decimal places. oz = ounce lb = pound kg = kilogram Example: 17 lb 6 oz = __________ kg Math: Step one: Convert ounces to pounds. 6 oz x 1 lb = 0.375 lb 16 oz Step two: Add initial pounds and ounces that were converted to pounds. 17 lb + 0.375 lb = 17.375 lb Step three: Convert pounds to kilograms. 17.375 lb x kg = 7.897 kg = 7.9 kg 2.2 lb Example: 5280 mcg = __________lb 5280 mcg x 1 mg = 5.28 mg x 1 g = 0.00528 g x 1 kg = 0.00000528 kg x 2.2 lb = 0.00001162 lb 1000 mcg 1000 mg 1000 g 1 kg 3 Weight Conversions: Make the following weight conversions. Remember to round to 2 decimal places. 1. 26 lb = __________ kg 19. 124 lb = _________ kg 2. 7 lb = __________ kg 20. 97 lb 14 oz = _________ kg 3. 2 kg = __________ lb 21. 78 lb = _________ kg 4. 49 lb = __________ kg 22. 56 kg = _________ lb 5. 33 lb = __________ kg 23. 11 lb 4 oz = _________ kg 6. 6 lb 15 oz = __________ kg 24. 56 lb 3 oz = _________ kg 7. 24 lb 12 oz = __________ kg 25. 79 lb = 8. 50 kg = __________ lb 26. 104 kg = _________ lb 9. 41 lb 13 oz = __________ kg 27. 132 lb = __________ kg 10. 12 lb 4 oz = __________ kg 28. 85 lb = _________ kg 11. 14 kg = __________ lb 29. 94 kg = __________ lb 12. 97 lb = __________ kg 30. 74 lb 7 oz = _________ kg 13. 34 kg = __________ lb 31. 61 kg = __________ lb 14. 42 lb 11 oz = __________ kg 32. 83 lb = __________ kg __________ kg 15. 16 lb 5 oz = __________ kg 33. 75 lb = __________ kg 16. 63 kg = __________ lb 34. 6 kg = __________ lb 17. 21 lb 6 oz =__________ kg 35. 41 kg = __________ lb 18. 84 lb = 36. 32 kg = __________ lb __________ kg 4 37. 9 kg = __________ lb 44. 58 lb = __________ kg 38. 116 lb 9 oz = __________ kg 45. 63 kg = __________ lb 39. 7 lb = 46. 81 kg = __________ lb __________ kg 40. 6 lb 7 oz =__________ kg 47. 43 lb 14 oz = __________ kg 41. 37 lb 14 oz = __________ kg 48. 29 kg = __________ lb 42. 7 kg = __________ lb 49. 17 lb = __________ kg 43. 16 kg = __________ lb 50. 15 kg = __________ lb 5 More Conversions: Make the following conversions. Remember to round units to 2 decimal places. ml = milliliter L = liter oz = ounce (fluid) mcg = microgram mg = milligram g = gram lb = pound kg = kilogram tsp = teaspoon tbsp = tablespoon 1. 7 L = __________ml 15. 12 oz = __________lb 2. 500 mg = __________g 16. 215 mcg = __________mg 3. 3150 mg = __________g 17. 142 lb = 4. 9 g = __________mg 18. 34 g = __________mcg 5. 4000 ml = __________L 19. 7 lb = __________kg 6. 7 kg = ___________g 20. 300 ml = __________oz 7. 0.5 kg = ___________g 21. 15 g = _________mcg 8. 1500 mg = __________g 22. 5 ml = __________tsp 9. 0.5 g = ___________mg 23. 5.5 L = __________ml 10. 450 ml = ___________L 24. 43 kg = __________lb 11. 1000 mcg = _________mg 25. 30 ml = __________oz 12. 1.9 L = __________ml 26. 1000 ml = __________L 13. 0.5 L = __________ml 27. 1 kg = __________g 14. 250 ml = __________L __________kg 28. 3900 mcg = _________mg 6 29. 1 tsp = __________ml 40. 1000 g = __________mg 30. 4123 ml = __________L 41. 8 oz = __________ml 31. 740 mg = __________mcg 42. 1 oz = __________ml 32. 4.2 g = __________mg 43. 500 mcg = 33. 6 kg = __________g 44. 12 L = __________ml 34. 20 ml = __________L 45. 42 kg = __________lb 35. 17 kg = __________mg 46. 80 ml = __________L 36. 7 lb 9 oz = __________kg 47. 1 mg = _________mcg 37. 6.8 L = 48. 2.2 lb = __________kg 38. 4321 ml = __________L 49. 1 tbsp = __________ml 39. 39 g = 50. 6 tsp = __________ml __________mcg __________g _________ml 7 Reading Drug Labels: Drug labels provide a variety of information such as the drug name (generic or brand/trade name), the drug’s expiration date, the concentration of the drug, the route of administration, and the quantity of the drug. The following are some photographs of various drug vials. The coinciding questions will ask you to pull information from the drug vials in order to answer the questions. All of the vials contain their entire contents and have not yet been opened. Only use the label’s individual information to obtain your answers. 1. What is the generic name of this drug? 2. What is the name of the compounding pharmacy in which this drug was produced? 3. What is the concentration of this drug in mg/ml? 4. What is the name of this injectable antibiotic? 5. Per the drug label, by which route(s) can this drug be given? 6. How many grams are in a single vial of this drug? 7. How many milligrams are in a single vial of this drug? 8. If you were instructed to give ½ of a gram of this drug to a patient, how many milligrams would you draw up in a syringe? 8 9. What is the name of this commonly used broad spectrum antibiotic? 10. How many milligrams are contained in a single vial of this drug? 11. Per the drug label, by which route(s) can this antibiotic be given? 12. What two drugs make up this common antibiotic that has the trade name unasyn? 13. How many milligrams does this vial contain? 14. How many total grams of this drug are in the vial? 15. Per the drug label, by which route(s) can this drug be given? 16. Give the month and the year in which this drug expires. 9 17. The generic name of this drug is dolasetron. What is the brand name of this drug? 18. How many total milliliters are in this vial? 19. How many milligrams are in 5 milliliters of this drug? 20. How many milligrams are in 1 milliliter of this drug? 21. What is the name of this drug that is commonly used to treat hypocalcemia?? 22. What is the concentration of this drug in mg/ml? 23. What percent concentration is this drug? 24.How many total milliliters of this drug are in this vial? 25. How many total milligrams of this drug are in this vial? 10 26. What is the name of this injectable drug that is commonly used as an antiarrhythmic and a local anesthetic? 27. What percent solution is this drug? 28. How many milligrams are in 5 milliliters of this drug? 29. How many milligrams are in 1 milliliter of this drug? 30. If you are instructed to pull up 30 mgs of this drug, how many milliliters will you draw up in a syringe? 31. What is the name of this commonly used intravenous anesthetic? 32. How many milligrams of this drug are in 20 milliliters? 33. How many milligrams are in 1 milliliter of this drug? 11 34. What is the name of this injectable solution that is used to treat hypomagnesemia and is commonly given via a CRI? 35. What percent concentration is this solution? 36. How many milligrams are in 1 milliliter of this solution? 37. How many total milliliters are in a new single bottle of this solution? 38. By which route(s) can this drug be given? 39. Its generic name is mannitol, but ManniJect is one of its trade names. This osmotic diuretic has how many milligrams in 1 milliliter? 40. If you were instructed to give a patient 2 grams of this solution, how many milliliters would you draw up in a syringe? 12 Calculating Total Fluid Needs (TFN) For each question calculate the total fluid needs (TFN) in ml/hr and convert into drops/second. List each component of the TFN in your answer. Drip Rates: 10 drop/ml (blood set) = ml/hr = drop/min 6 15 drop/ml (macro drip set) = ml/hr = drop/min 4 60 drop/ml (micro drip set) = ml/hr = drop/min 1 Example: Your patient weighs 10 kgs, is 15 % dehydrated, and has a 100 ml fluid loss from diarrhea. Math: Replacement fluids (RF) = 0.15 x 10 x 1000 ml/kg = 1500 ml Ongoing Losses (OGL) = 100 ml Maintenance Fluids (MF) = 60 ml/kg/day x 10 kg = 600 ml Total Fluid Needs (TFN): 1500 ml + 100 ml + 600 ml = 2200 ml/24 hr 2200 ml = 91.67 ml/hr x 15 drop/ml = 1375 drop/hr = 22.92 drop /min = 0.38 drop/sec 24 hr 60 min/hr 60 sec/min 0.38 drop/sec = 1 drop/3 sec 13 1. Your patient weighs 20 kg, is 5 % dehydrated, and vomited 50 ml fluid. Calculate the replacement fluids (RF), the ongoing losses (OGL), the maintenance fluids (MF), the total fluid needs (TFN), and the fluid rate in drop/sec. 2. Your patient weighs 54 kg, is 7 % dehydrated, and has a 100 ml fluid loss from diarrhea. Calculate the RF, OGL, MF, TFN, and fluid rate in drop/sec. 3. Your patient is 31 kg, is 8 % dehydrated, and has vomited 75 ml of fluid. Calculate the RF, OGL, MF, TFN, and fluid rate in drop/sec. 14 Dose Calculations: Dose calculations are commonly written in mgs/kg or mg/lb. Calculate the following doses in mgs and mls. Remember to round drug doses in mg or ml to 2 decimal places. 1. A 39 kg post-operative splenectomy labrador retriever named “Joey” needs a dose of buprenex (buprenorphine) IV for pain management. The dose is 0.01 mg/kg IV. The concentration of buprenex is 0.5 mg/ml. How many mgs of buprenex will you give to “Joey”? How many mls of buprenex will you give “Joey”? 2. “Lucy”, a 12 year old 16 kg beagle needs a dose of the antibiotic cefazolin IV to treat her infected bite wound. The dose is 22 mg/kg IV. The concentration is 100 mg/ml. How many mgs of cefazolin will you give to “Lucy”? How many mls will you give to “Lucy”? 3. A 4 kg persian named “Smokey” presents with an upper respiratory infection and requires hospitalization. The doctor orders the antibiotic ampicillin IV for “Smokey”. The dose is 22 mg/kg IV. The concentration is 100 mg/ml. How many mgs will “Smokey” receive? How many mls will “Smokey” receive? 4. A 2 lb terrier puppy named “Princess” presents with hives and a swollen muzzle after receiving her first (killed) rabies vaccine earlier in the day at her rDVM (referring veterinarian). The doctor orders an injection of diphenhydramine (Benadryl 50mg/ml) to be given at a dose of 2 mg/kg IM to counteract her vaccine reaction. How many mgs will you give to “Princess”? How many mls will you give to “Princess”? Into which muscle will you inject the diphenhydramine? 5. A 4 kg 14 year old DSH named “Kitty” is hospitalized with pyelonephritis (a bacterial infection of the kidneys). A culture and sensitivity of her urine has already been completed and the DST (drug-susceptibility testing) returned showing multiple drug resistances, but it is sensitive to the broad spectrum antibiotic baytril (enrofloxacin). The recommended dose is 5 mg/kg IV. The concentration of baytril is 22.7 mg/ml. How many mgs will “Kitty” receive? How many mls will you give to “Kitty”? What toxicity has been reported in feline patients receiving therapeutic doses of baytril? What primary symptom does this cause? 15 6. “Fetch”, a 20 kg border collie is hospitalized for dehydration and diarrhea. He is to receive the anti-diarrheal and antibiotic metronidazole (flagyl) IV. His dose is 10 mg/kg IV. The concentration is 5 mg/ml. How many mgs will “Fletch” need? How many mls? A fecal float is done and it shows giardia (a protozoal infection). Lucky for “Fetch” metronidazole is also the drug of choice to treat giardia. Is giardia zoonotic? 7. A 2 kg yorkie named “Tiny” presents to the hospital postictal. You check a BG (blood glucose). It is 32 g/dl. The doctor instructs you to give “Tiny” a dextrose bolus at a dose of 0.5 g/kg (1000 mg/g) IV to treat his hypoglycemia. The dextrose is a 50 % solution (500 mg/ml). How many grams will “Tiny” receive? How many mgs? How many mls? 8. “Lucky” is a 10 year old greyhound weighing 31 kgs that presents with a femur fracture. He is very painful and needs a dose of methadone IV for pain management. The dose is 0.2 mg/kg IV. The concentration is 10 mg/ml. How many mgs of methadone will you give “Lucky”? How many mls? 9. “Freckles” is hospitalized for pneumonia. She is a 17 kg cocker spaniel. Her treatment orders include the bronchodilator aminophylline IV. Her dose is 7.5 mg/kg IV. The concentration of aminophylline is 25 mg/ml. How many mgs will “Freckles” receive? How many mls? 10. Dolasetron (anzemet) is an antiemetic. The concentration is 20 mg/ml. A nauseous 7 week old 4 kg pit bull puppy named “Spot” needs a dose at 0.6 mg/kg IV. How many mgs will “Spot” be given? How many mls? 11. “Balto” is a 6 year old 35 kg intact husky mix. He presents through the ER after likely being HBC (hit by car) with anisocoria and nystagmus, both signs of head trauma. The doctor instructs you to give 1 g/kg mannitol IV to decrease intracranial pressure. Mannitol is a 20 % solution. How many grams will “Balto” receive? How many mgs? How many mls? Is mannitol a hypertonic fluid, an isotonic fluid, or a hypotonic fluid? 12. A 7 kg DLH named “Berry” needs the antibiotic unasyn (ampicillin and sulbactam) IV to treat a recent bite wound that has now abscessed. The dose is 22 mg/kg IV. The concentration is 30 mg/ml. How many mgs will “Barry” receive? How many mls? 16 13. A 10 kg spaniel mix named “Flynn” presents with acute vomiting. Abdominal radiographs are done and there is no obstruction observed. The doctor instructs you to give 1 mg/kg cerenia (maropitant citrate) SQ. Cerenia is an anti-emetic. The concentration is 10 mg/ml. How many mgs will you give to “Flynn”? How many mls? 14. “Joe” is a 16 week old 9 kg boxer that presents with hives from an allergic reaction to a bee sting. In addition to an injection of diphenhydramine (Benadryl) IM, the doctor instructs you to give a dose of the steroid Dex SP (dexamethasone sodium phosphate) IM. The dose is 1 mg/kg IM. The concentration is 4 mg/ml. How many mgs will “Joe” receive? How many mls? 15. A 2 year old 52 kg Irish wolfhound named “Woody” is being treated for rodenticide toxicity with vitamin K injections SQ. The dose is 2 mg/kg. The concentration is 10 mg/ml. How many mgs of vitamin K will you give to “Woody”? How many mls? What are three potential clinical signs for confirmed rodenticide toxicity? 16. A post-operative 8 year old 47 kg golden retriever named “Maggie” is hooked up to a continuous ECG. She was having intermittent VPC’s, but has now gone into V-tach with a sustained heart rate of 240. You notify the doctor who instructs you to pull up a 2 mg/kg dose of lidocaine. The doctor instructs you to start by giving “Maggie” ½ of the initial 2 mg/kg dose IV slowly. Lidocaine is a 2 % solution. How many mgs will you initially draw up? How many mls? How many mgs will you administer to “Maggie”? How many mls? 17. A 29 kg Chesapeake Bay retriever presents with cluster seizures. The doctor instructs you to give a 0.5 mg/kg dose of the sedative valium (diazepam) IV. The concentration of valium is 5 mg/ml. How many mgs will you give to your patient? How many mls? 18. A 5 year old 23 kg English bulldog is hospitalized and his treatment orders include a once daily injection of protonix (pantoprazole) at a dose of 1 mg/kg IV to decrease his gastric acid secretions and to control his gastroesophageal reflux (GERD). The concentration is 4 mg/ml. How many mgs will you give to your patient? How many mls? 17 19. An 11 kg beagle named “Butch” has gastrointestinal (GI) ulcerations and is to be treated with 0.5 mg/kg famotidine (pepcid) IV. The concentration is 10 mg/ml. How many mgs will you give to “Butch”? How many mls? 20. A 30 kg standard poodle named “Angel” is recovering from GDV (gastric dilatation volvulus) surgery. Her pain management regimen includes hydromorphone (dilaudid with a concentration of 2 mg/ml) at a dose of 0.1 mg/kg IV every four hours. How many mgs will “Angel” receive at each dose? How many mls? 18 Defining Constant Rate Infusions (CRI’s): A CRI is a constant rate infusion of a medication. It is the delivery of a drug IV at a continuous rate over a predetermined amount of time. Multiple medications have a higher efficacy rate when a constant level is able to be achieved and maintained in serum concentrations. CRI’s are commonly used to treat seizures, to control glucose levels, to increase GI motility, to minimize and treat cardiac arrhythmias, to control pain, to supplement electrolytes, to maintain blood pressure, and to also treat a multitude of other medical ailments. All CRI’s require an indwelling intravenous catheter and a method of delivery. Some CRI’s require sampling lines because certain drugs can be irritating to the blood vessels. CRI’s allow for better precision in medication delivery. There are also fewer side effects due to the slower rate/concentration of the drug. Drugs with very short half-lives must be administered via CRI to achieve the desired pharmacologic effects and to maintain steady serum concentrations. Other drugs are given via CRI to decrease daily total doses and to increase efficacy. To calculate a CRI, you need the following information: Weight of the patient Dose of medication Concentration of medication Rate of administration Volume of diluent CRI doses come in different forms: mg/kg/day (milligram/kilogram/day) mg/kg/hr (milligram/kilogram/hour) mcg/kg/min (microgram/kilogram/minute) mmol/kg/hr (millimole/kilogram/hour) mEq/kg/day (milliequivalent/kilogram/day) 19 When making up a CRI, why is it important to remove fluids equal to the amount of the additive? Patient: 10 kg Lidocaine CRI: 40 mcg/kg/min at 10 ml/hr in 100 ml 0.9 % NaCl (the 100 mls is the total volume, total volumes can range from a small number requiring a syringe pump or a larger number requiring a fluid pump and a fluid bag) Concentration of lidocaine: 2 % solution. (0.04 mg)(10 kg) x 60 min x 1 hr x 100 ml (total volume) = 240000 mcgs = 240 mgs = 12 ml 1 min 1 hr 10 ml 1 1000 mg 20 mg/ml If the 12 mls are not removed, then the total volume is 112 ml at 10 ml/hr and the bag will last for 11.2 hours. The dose also will no longer be 40 mcg/kg/min, it will be 35.7 mcg/kg/min as shown below. 240 mgs = 21.43 mg/hr 11.2 hr 1 hr = 60 min 21.43 mg = 0.36 mg/min 60 min 0.36 mg/min = 0.04 mg/kg/min = 35.7 mcg/kg/min 10 kg The same applies for dextrose supplementation: If you have a 1 L bag and want to make it a 5 % solution: % desired x mls in bag = 5 % x 1000 ml = 100 ml of dextrose Concentration (50 % dextrose) available 50 % If you do not remove the equivalent of 100 mls of diluent then the dose will be incorrect, as shown below. 5 % desired x 1100 ml (now in bag) Concentration (50% dextrose) available = 100 ml (50 %) x X % x 1100 ml = 100 ml x (50 %) 50 % (x)(1100) = 50 ml x%= 50 1100 ml x = 0.045 x (100) x = 4.5 % 20 Step by Step examples of CRI’s: Example 1: A lidocaine CRI is ordered for a 19 kg dog at a rate of 40 mcg/kg/min at 4 ml/h. How will you prepare the IVF (intravenous fluids)? Lidocaine is a 2 % solution. The patient is expected to be on the CRI for 10 hours. Weight of patient: 19 kg Dose of medication: 40 mcg/kg/min Concentration of medication: 2% (20 mg/ml) Rate of administration: 4 ml/hr Volume of fluids: 40 ml (4 ml/h x 10 hr) Math: 19 kg x 40 mcg/min = 760 mcg x 60 min = kg min hr 456,000 mcg x 1 mg = 456 mgs x 1 ml 1000 mcg 20 mg = 22.8 ml of lidocaine 40 ml total volume of fluids - 22.8 ml of lidocaine = 17.2 ml of diluent 21 Example 2: A post-op GDV German shepherd weighing 40 kg is ordered to have a reglan (metoclopramide) CRI at 1 mg/kg/24 hr. You have a 1 L bag of P-lyte and the fluid rate is 160 ml/hr. The concentration of reglan is 5 mg/ml. How many mgs will you add to the bag? How many mls? Math: First, figure out how many mgs are needed in 24 hrs. Then, how many mgs are needed in a single hour. 40 kg x 1 mg/24 hr = 40 mg x 1 day = 1.67 mg x 1 hr = 1.67 mg/hr 1 kg 1 day 24 hr hr mg Next, figure out how many hours your bag will last. 1000 ml x 1 L = 6.25 hr 1 160 ml/hr Last, calculate your mgs and mls. 1.67 mg/hr x 6.25 hr = 10.44 mg 1 mg 10.44 mg = 2.09 ml 5 mg/ml 22 Example 3: A post-op linear foreign body 5 kg 2 year old DSH needs a fentanyl CRI for pain management at a rate of 3 mcg/kg/hr at 3 ml/hr. The plan is start the fentanyl CRI for her first 12 hours post-op. You have a syringe pump and a 60 ml syringe. The total fluid volume is to equal 36 ml. The concentration of fentanyl is 50 mcg/ml (0.05 mg/ml). How many mgs of fentanyl will you put in the syringe? How many mls of fentanyl? How many mls of diluent? Math: 5 kg x 3 mcg/hr = 15 mcg x 12 hr = 180 mcg x 1 mg = 80.1 mg x 1 ml = 1 kg hr mcg 1 1000 mcg ml 0.05 mg 3.6 ml fentanyl (80.1 mgs) Total fluid volume: 36 ml – 3.6 ml fentanyl = 32.4 ml diluent 23 CRI Calculations: Complete the following CRI calculations. Weights in kilograms need to be rounded to 2 decimal places. Drug doses in milliliters and milligrams need to be rounded to 2 decimal places. Always use correct units. Use zeroes as place markers. 1. “Max” is a 29 kg collie who needs a reglan (metoclopramide) CRI to increase his GI motility. The CRI dose is 2 mg/kg/day. The concentration of reglan is 5 mg/ml. You have a 1 L bag of P-lyte. The fluid rate is 4 ml/kg/hr. What will your fluid rate be in ml/hr? How many hours will 1 L of P-lyte last? How many mgs will be added to his fluids? How many mls? 2. “Oreo” is a 49 kg great dane who needs a reglan CRI at a dose of 1 mg/kg/24hr. The concentration of reglan is 5 mg/ml. He has a fluid rate of 150 ml/hr. There are 750 ml of P-lyte left in his fluid bag. How many hours will the remainder of his bag last? How many mgs of reglan will you add to his fluids? How many mls? 3. “Cody” is a 14 kg cocker spaniel who needs a lasix (furosemide) CRI for decreased urine output and peripheral edema. The starting dose is 0.25 mg/kg/hr. The CRI should last for 10 hours and his fluid rate is 2.5 ml/hr. This CRI will be made up in a syringe pump due to the low volume and the low rate of infusion. The concentration of lasix is 50 mg/ml. Calculate the dose of lasix in mgs and mls. How much diluent (mls) is needed for this CRI? 4. “Littlefoot” a 2 kg DMH needs the pressor dopamine to treat her hypotension. The dose is 5 mcg/kg/min to start. The concentration of dopamine is 40 mg/ml. The rate is 5 ml/hr. How many mgs of dopamine will “Littlefoot” need if the CRI is made up for 24 hours? How many mls? How many mls of diluent will you need? 5. “Rover” a 24 kg boxer is hypoglycemic. His BG has dropped to 67 mg/dl. The doctor has instructed you to start him on 5% dextrose supplementation (dextrose CRI). Dextrose comes in a 50 % solution. There are 760 mls of P-lyte left in his bag. How many mgs of dextrose will you add to his IV fluids? How many mls will you add to his IV fluids? Don’t forget to remove the equivalent in mls from his IV fluids prior to adding dextrose for precise dosing. 24 6. “Charlie” a 10 kg beagle needs a nitroprusside (a vasodilator) CRI at 5 mcg/kg/min at 5 ml/hr in a total volume of 50 ml. The concentration of nitroprusside is 50 mg/2 ml. How long will the CRI last? How many mgs of nitroprusside will you add to the diluent? How many mls? 7. “Jinx”, a 5 year old 37 kg American bulldog mix is in need of a MLK (morphine, lidocaine, ketamine) CRI for pain management post-operatively. All three of these medications will be added into the same 250 ml bag of fluids. The morphine CRI will be set up at 0.12 mg/kg/hr at 20 ml/hr. The concentration of morphine is 15 mg/ml. How many mgs will be added to the fluids? How many mls? The ketamine CRI will be set at 0.12 mg/kg/hr. The concentration of ketamine is 100 mg/ml. How many mgs will you add to the bag? How many mls? The lidocaine CRI is 40 mcg/kg/min. The concentration of lidocaine is a 2% solution. How many mgs will you add to the bag? How many mls? How many hours will the bag last? What is the total volume of additives? Remember to remove the equivalent in mls of diluent prior to adding medications. 8. “Bouncer” is a 13 year old, 9 kg DSH being treated for diabetic ketoacidosis (DKA). She is in need of an insulin CRI at 1.1 u/kg/24 hr. The beginning rate is 10 ml/hr. How many units of regular insulin will you add to a 240 ml bag of 0.9% NaCl (10 ml have been removed from the bag to accommodate the rate of 10 ml/hr for 24 hr). 9. “Corey”, an 8 year old 4 kg maltese is in v-tach (ventricular tachycardia) and is not converting to a normal sinus rhythm (NSR) on his own. The doctor has you bolus 1 mg/kg lidocaine IV slow. Lidocaine is a 2 % solution. How many mg will you bolus? How many mls? The lidociane bolus converted the ECG into NSR, although only briefly. The doctor orders a 40 mcg/kg/min lidociane CRI at a rate of 10 ml/hr. The CRI will be made up in a 100 ml bag of 0.9 % NaCl. How many hours will the bag last? How many mgs will you add to the bag? How many mls? Remember to remove the equivalent in mls from the 100 ml bag of 0.9 % NaCl for precise dosing. 10. “Gus” is a 16 year old 8 kg DSH that presents with signs of head trauma. “Gus” needs a dose of mannitol at 0.5 g/kg IV to decrease his intracranial pressure. Mannitol is a 20 % solution. How many grams will “Gus” receive? How many mgs? How many mls? What will the fluid rate be in ml/hr if the entire dose of mannitol is to be given over 20 minutes? 25 Case Study of “Mimi”: Putting it all together….. 1. “Mimi” is a 4 year old 2 kg terrier mix that presents with a history of PLE (protein losing enteropathy), hypocalcemia, hypoglycemia, hypoproteinemia, pleural effusion, right cranial lung lobe consolidation, right medial lung lobe torsion, and a leukocytosis (neutrophilia with left shift). A 20 guage intravenou catheter (IVC) is placed in each of her cephalic vessels and a 22 g sampling line is placed in her right lateral saphenous vessel to better facilitate future serial sampling. A 10 ml/kg P-lye bolus is ordered to begin to correct her dehydration. The bolus is to go over 20 minutes. How many mls will “Mimi” receive? What will her fluid rate be in ml/hr? 2. “Mimi” has an ionized Calcium of 0.79 mg/dL and needs a Calcium gluconate CRI at 7.5 mg/kg/hr at a rate of 1 ml/hr. Calcium gluconate is a 10 % solution. Her CRI should last for 10 hours and you have a total fluid volume of 10 mls. Ca+ gluconate is a 10 % solution. How many mgs will you need for the CRI? How many mls? 3. Due to “Mimi’s” low protein levels she is to receive a 20 ml dose of FFP (fresh frozen plasma) over 4 hours. What will her rate be for her FFP transfusion in ml/hr? 4. A thoracotomy is indicated for “Mimi’s” right medial lung lobe torsion. The surgical bay is being set up. Meanwhile, a fentanyl CRI is ordered for pain management. The doctor orders a 2 mcg/kg bolus IV prior to beginning the fentanyl CRI. The concentration of fentanyl is 0.05 mg/ml (50 mcg/ml). How many mcgs will you bolus “Mimi”? How many mgs? How many mls? Post fentanyl bolus you need to begin “Mimi” on her fentanyl CRI at a dose of 3 mcg/kg/hr at a rate of 3 ml/hr. The total fluid volume is 30 mls. How many mcgs of fentanyl will you need? How many mgs? How many mls? 5. The surgical bay is ready and it is time to anesthetize “Mimi”. You pull up a total dose of 6 mg/kg of propofol. The concentration of propofol is 10 mg/ml. You are going to start by injecting “Mimi” IV with 1/3 of her total propofol dose (a total of 2 mg/kg). How many mg is this total? How many mls? 6. “Mimi” is then anesthetized, intubated with a 4 Fr endotracheal tube, started on isofluorane (iso) at 2 %, prepped for surgery, and transported into the surgical bay. A dose of unasyn (an 26 antibiotic) is given at a dose of 22 mg/kg IV. The concentration of unasyn is 30 mg/ml. How many mgs is this? How many mls? 7. A lateral intercostal thoracotomy is done at the 5th intercostal space. “Mimi” tolerates anesthesia well and has a smooth recovery, although she still seems painful and additional pain medication is indicated. A lidocaine bolus is first ordered at a dose of 1 mg/kg IV. The concentration of lidocaine is a 2 % solution. How many mgs is the bolus? How many mls? A CRI is then ordered at 25 mcg/kg/min at a rate of 2.5 ml/hr. The total fluid volume is 25 mls. How many mgs of lidocaine do you need for the CRI? How many mls? 8. An indwelling 6 Fr foley urinary catheter is placed to monitor her urine production postoperatively and to also assist in keeping her comfortable. Her FFP transfusion is complete and she now auscults with bilateral crackles. A dose of Lasix is ordered at 1 mg/kg IV. The concentration of Lasix is 50 mg/ml. How many mgs is this? How many mls? The Lasix (a diuretic) assisted with her urine production and later “Mimi” auscults clear bilaterally. 9. “Mimi’s” glucose levels then drop to 43 mg/dl and the doctor calls for a 0.5 g/kg dextrose bolus IV and then to start 5 % dextrose supplementation in her crystalloids. How many grams will “Mimi” be bolused of dextrose? How many mgs? How many mls? She has 410 mls of P-lyte left in her bag. Dextrose is a 50 % solution. How many mls will you add to her bag? Do not forget to remove the equivalent in mls from her crystalloids prior to adding the dextrose supplementation to ensure precise dosing. 10. The night goes well for “Mimi”. Her chest tube is pulled first thing the following morning since there has been zero production of neither fluid nor air. Her ionized calcium (iCa) is better at 1.13 mg/dL, so you begin to wean her off of her supplementation. Her new CRI dose for calcium gluconate is 5 mg/kg/hr at 1 ml/hr with a total fluid volume of 24 mls. Calcium gluconate is a 10 % solution. How many mgs of calcium gluconate do you need? How many mls? 11. As the day continues, “Mimi” continues to make progress. She has begun eating small amounts of canned chicken when hand fed and drinking water when offered. Her protein levels are slowly improving. Her fentanyl CRI is due to be weaned overnight to 2 mcg/kg/hr at a rate of 2 ml/hr and a total fluid volume of 24 mls. The concentration of fentanyl is 0.05 mg/ml (50 mcg/ml). How many mgs of fentanyl will you need for the CRI? How many mls? 27 12. “Mimi’s” treatment orders include a dose of dex sp (dexamethasone sodium phosphate), a steroid for her presumed GI disease pending her biopsy results. The concentration of dex sp is 4 mg/ml. Her dose is 0.1 mg/kg IV once daily. How many mgs will you give “Mimi”? How many mls? 13. Her iCa continues to improve and her calcium gluconate CRI is lowered to a rate of 2 mg/kg/hr. You will recheck her iCA levels in eight hours, so you only need to make up the CRI for 8 hours. The rate will be 2 ml/hr. Calcium gluconate is a 10 % solution. How many mgs will you need for the CRI? How many mls? How many mls of diluent? 14. Day three and we transition “Mimi” to oral calcium supplementation via TUMS. Her dose is 250 mgs PO (by mouth), but we only have 500 mg tablets. How many tablets will “Mimi” receive? 15. “Mimi’s” blood sugars are beginning to regulate on their own and her dextrose supplementation can be decreased to 2.5 %. She has 200 ml left in her bag of P-lyte and she has a fluid rate of 5 ml/hr. The concentration of dextrose is a 50 % solution. How many mls of dextrose will you add to her bag? Do not forget to remove the equivalent in mls from her crystalloids prior to adding dextrose supplementation to ensure precise dosing. 16. Due to Mimi’s poor gastric motility, a reglan CRI has been added to her treatment orders. The reglan CRI will be at 2 mg/kg/day. She needs a new 500 ml bag of P-lyte, since we are simultaneously discontinuing her dextrose supplementation. She is eating reliably and maintaining her blood glucose on her own. The concentration of reglan is 5 mg/ml. Her fluid rate is 5 ml/hr. How many mgs of reglan will you add to “Mimi’s” bag? How many mls? 17. Her fentanyl and lidocaine CRI’s are both discontinued since she feels more comfortable and she is transitioned to buprenex at a dose of 0.01 mg/kg IV every 4-6 hours for continued pain management. The concentration of buprenex is 0.5 mg/ml. How many mgs will “Mimi” receive? How many mls? 18. “Mimi” continues to improve and we transition her from injectable medications to oral medications. You are to give her 1 mg/kg famotidine (pepcid) suspension by mouth. “Mimi” 28 weighs 2 kg. The concentration of the famotidine oral suspension is 10 mg/ml. How many mgs will you give “Mimi”? How many mls? 19. “Mimi” needs 15 mgs metronidazole oral suspension. The concentration of the metronidazole oral suspension is 50 mg/ml. How many mls will you give “Mimi”? 20. “Mimi’s” reglan CRI is discontinued. She is now due for oral reglan. Her dose is 0.4 mg/kg by mouth (PO). The concentration is 5 mg/5ml (1 mg/ml). How many mgs will you give “Mimi”? How many mls? 21. The calcium gluconate CRI is discontinued. “Mimi” continues to receive TUMS as an oral supplement, but calcitrol has also been added into her treatment plan. Her dose of calcitrol is 15 ng/kg PO. The concentration of calcitrol is 30 ng/ml. How many nanograms will you give “Mimi”? How many mls? 22. “Mimi” also needs the antibiotic clavamox to treat her pneumonia. The concentration of clavamox drops is 62.5 mg/ml. She is to receive 0.5 ml PO every twelve hours. How many mgs will she receive at each dose? 23. “Mimi” is ready to be discharged and is being sent home with oral cerenia (maropitant citrate) to be used as needed (prn) for nausea. The dose is 2 mg/kg once daily PO for up to four days in a row. The tablet size available is 16 mg. How many tablets will “Mimi” receive in a single dose? 24. “Mimi” is discharged but becomes anorexic at home that same evening. A script is filled for the appetite stimulant mirtazapine. It comes in an oral suspension. The concentration is 4 mg/ml. The dose is 0.6 mg/kg PO. How many mgs will “Mimi” receive? How many mls? 25. The doctor wants to script out 7 doses of mirtazapine. How many mls will you send home with “Mimi”? 29