
CORRESPONDENCE 



Year : 2006  Volume
: 38
 Issue : 6  Page : 435437 

Teaching undergraduate students appropriate dose calculations in relation to intravenous infusion
DM Parmar, SP Jadav
Department of Pharmacology, M.P. Shah Medical college, Jamnagar361008, India
Correspondence Address: D M Parmar Department of Pharmacology, M.P. Shah Medical college, Jamnagar361008 India
Source of Support: None, Conflict of Interest: None  Check 
DOI: 10.4103/02537613.28216
How to cite this article: Parmar D M, Jadav S P. Teaching undergraduate students appropriate dose calculations in relation to intravenous infusion. Indian J Pharmacol 2006;38:4357 
How to cite this URL: Parmar D M, Jadav S P. Teaching undergraduate students appropriate dose calculations in relation to intravenous infusion. Indian J Pharmacol [serial online] 2006 [cited 2019 Oct 20];38:4357. Available from: http://www.ijponline.com/text.asp?2006/38/6/435/28216 
Medical emergencies such as cerebral malaria, diabetic coma, cardiogenic shock and many more require immediate treatment with parenteral drug administration. Intravenous (i.v.) infusion is one of the commonly preferred routes for this purpose. As one of the goals of undergraduate training is to train students in managing patients,[1] it is mandatory that the students acquire a sound knowledge of certain basic steps of intravenous drug infusion. These include dose calculation ( viz., based on body weight and body surface area) and clinical skills ( viz. , proper collection of drugs from ampoule/vial, introduction of drug into suitable diluting fluid, i.v. drip setting, etc.). One of the ways to achieve such a goal is by including many exercises on calculation of infusion rates in the undergraduate pharmacology practicals curriculum.
As dose calculation is an important initial step in such clinical procedures, we have emphasized it in relation to different aspects such as the following:
Total dose: The infusion rate will not differ in case of total dose administration (e.g., infusion rate of quinine will remain the same for a 30, 50 or a 70 kg patient since it is given in the dose of 10 mg/kg in 500 ml of 10% dextrose solution which is to be administered over 4 h). In contrast to this, the infusion rate will differ when drugs are to be given at the specified rates (e.g., infusion rate of aminophylline will differ for a 30, 50 or a 70 kg patient since it is to be given in the dose of 1 mg/kg/hr in 500 ml of normal saline).
Weight (mg/kg): The weightbased dose calculation (mg/kg) is more popular despite certain disadvantages, viz., one needs to know the different doses according to body weight (mg/kg) as well as according to the age of the patient.[2]
Body surface area: Body surface area (BSA) is another method which is considered as a more accurate basis for dose calculation since total body water, extracellular fluid volume and metabolic activity are better paralleled by it. The BSA of an individual can be calculated from the formula of Dubois [BSA (m^{ 2}) = Body weight (kg)^{ 0.425} X Height (cm)^{ 0.725} X 0.007184] or obtained from chartform/sliderule nomograms based on body weight and height. Dose recommendations in terms of BSA are available only for a limited number of drugs (e.g., anticancer drugs) as this method is more cumbersome in clinical practice.[3]
Time: The dose of some drugs is calculated per minute and per hour (e.g., dopamine 5 mcg/kg/min and insulin 0.1 U/kg/h). The infusion rates differ for different time duration in case of anticancer drugs like paclitaxel (see below).
Average adult body weight: The dose can also be calculated by using the average adult body weight (6070 kg) basis from the formula: [Individual dose = Body weight (kg)/70 × average adult dose].[3]
Diluting fluid: Selection of a suitable diluting fluid is necessary for i.v., infusion. For example, 10% dextrose solution is being used for quinine infusion, which prevents hypoglycemia due to hyperinsulinemia caused by the powerful stimulatory effect of quinine on pancreatic beta cells,[4] whereas dopamine infusion is given with 5% dextrose (acidic pH) solution for its compatibility and stability with the latter (i.e., 5% dextrose).[5]
Some problems that may be encountered during dose calculation are listed below.
» 1. Following the same steps of dose calculation for different drugs   
To calculate the rate of quinine infusion is simple since quinine is to be given in 500 ml of 10% dextrose solution, to be administered over 4 h (i.e., we have to administer 500 ml of 10% dextrose solution with the required dose of quinine over 4 h).
But students can make mistakes if they follow this step of rate calculation for calculating the infusion rate of other drugs that are to be administered by their specified infusion rates (e.g., aminophylline: 1 mg/kg/h). Therefore, the students should be taught these aspects as well since many drugs come under this category (e.g., dopamine, insulin and oxytocin). [Please refer comparison given on page 1]
Thus, it is obvious that such an infusion rate for aminophylline (133167 drops/min) is not practically feasible.
The correct calculation for the rate of aminophylline infusion is given below.
Ų Exercise:
You have decided to give i.v. infusion of aminophylline for a child (10 years old, 30 kg) suffering from acute bronchial asthma (Dose: 1 mg/kg/hr). Set an i.v. drip for this patient.
Ų Answer:
A. Calculate the required dose of Inj. aminophylline:
i.e. 30 mg of Inj. aminophylline (1 mg/kg)
B. Selection of fluid:
i.e. Normal saline
C. Aminophylline is available as 2.5% W/V in 10 ml ampoule, i.e. 250 mg/10 ml.
Introduce all 10 ml of Inj. aminophylline into 500 ml of normal saline solution.
Now we have 250 mg in 500 ml of normal saline solution, i.e. 30 mg will be present in 30/250 × 500 = 60 ml, which is to be administered in 1 h.
So, the desired rate of administration will be:
60 ml to be given in 1h (60 min),
i.e. 60/60 = 1 ml/min
Thus, in 1 min, 1 ml is to be given
1 ml = 1620 drops in normal i.v. set
So, the rate of aminophylline administration will be 1620 drops/min.
OR
Introduce all 10 ml of Inj. aminophylline into 500 ml of normal saline solution.
i.e. 500 ml of normal saline solution contains 250 mg of aminophylline
So, 1 ml will have 1/500 × 200 = 0.5 mg of aminophylline.
For 0.5 mg of aminophylline, 1 ml is required
So, 30 mg will be present in 30/0.5 × 1 = 60 ml, which is to be administered in 1 h.
So, the desired rate of administration will be:
60 ml to be given in 1 h (60 min)
i.e. 60/60 = 1 ml/min
Thus, in 1 min, 1 ml is to be given
1 ml = 1620 drops in normal i.v. set
So, the rate of aminophylline administration will be 1620 drops/min.
» 2. Dose calculation by different methods   
Problem:
Calculate the required dose for aminophylline infusion for a child suffering from acute bronchial asthma (12 years old, 37 kg, BSA 1.25 m^{ 2} Dose: 1 mg/kg/h).
Solution:
A. mg/kg basis:
i.e. 37mg/h
B. Average adult body weight (6070 kg) basis:
Formula: [Individual dose = Body weight (kg)/70 × average adult dose]
i.e. 37/70 × 70 = 37 mg/hr
C. BSAbased rule:
Formula: [Individual dose = BSA (m^{ 2})/1.7 × average adult dose]
i.e. 1.25/1.7 × 70 = 51 mg/hr
D. Salisbury rule (proposed for children):[6]
 Less than 30 kg: (Weight × 2) percentage of the adult dose of a drug
 More than 30 kg: (Weight + 30) percentage of the adult dose of a drug
According to this, (37 + 30) percentage of the adult dose of a drug
i.e. 67 % of 70 mg of aminophylline,
i.e. 47 mg/h
This shows that there is no difference in doses calculated by mg/kg and average adult body weightbased rules, but there is a definite difference when both are compared with the BSAbased rule. The dose calculated by the Salisbury rule is closer to the BSAbased value.
Metabolism of theophylline (aminophylline) is often faster in children, after the first year of life,than in adults; and there is a marked interindividual variation in the rate of its elimination (average halflife is about 3.5 h in young children as compared to 89 h in adults).[3],[4] Considering these pharmacokinetic parameters as well as the narrow safety margin of aminophylline, the more accurate BSAbased rule may be preferred for dose calculation, keeping in mind its limited application in a clinical setup.
» 3. Dose calculation in relation to time duration   
Paclitaxel (an anticancer drug) is to be given in different schedules [ Schedule 1: 175 mg/m^{ 2} over 3 h (infusion rate: 58 mg/m^{ 2} per hour, plasma clearance: 212 ml/min per m^{ 2}) and Schedule 2: 175 mg/m^{ 2} over 24 hours (infusion rate: 7 mg/m^{ 2} per hour, plasma clearance: 393 ml/min per m^{ 2})].[4] A practical problem may arise if one calculates the dose of paclitaxel for schedule 2 from schedule 1. The dose and infusion rate will become 1400 mg/m^{ 2} and 58 mg/m^{ 2} respectively, which appear very different from the actual schedule 2 for 24 h. As clearance of paclitaxel is saturable and decreases with an increasing dose or dose rate,[4] such probable mistakes will definitely affect the clinical response.
To conclude, during undergraduate pharmacology practicals, different aspects, such as total dose, weight (mg/kg and average adult body weight basis), BSA, time duration and diluting solution, as well as likely practical problems that may arise during dose calculation, should be highlighted by demonstrating different exercises on the calculation of infusion rates.
» References   
1.  Pattnaik KP, Mohapatra S, Mohanty M, Mohpatra BN, Patel D, Mukherji D. Clinical orientation of undergraduate pharmacology practicals: An intervention study. Indian J Pharmacol 2006;38:2002. 
2.  British National Formulary. London. British Medical Association, 1995; 11. 
3.  Tripathi KD. Essential of medical pharmacology. 5th ed. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.; 2003. 
4.  Undem BJ, Lichtenstein LM. Drugs used in the treatment of asthma. In: Hardman JG, Limbird LE, Gilman AG. editors. Goodman and Gilman's The pharmacological basis of therapeutics. 10th ed. New York: McGrawHill; 2001. 
5.  Dollery C. Therapeutic drugs. 2nd ed. Edinburgh: Churchill Livingstone; 1999. 
6.  Lack JA, StuartTaylor ME. Calculation of drug dosage and body surface area of children. Br J Anaesth 1997;78:6015. [PUBMED] [FULLTEXT] 
Tables
[Table  1]
This article has been cited by  1 
Internsę knowledge of clinical pharmacology and therapeutics after undergraduate and ongoing internship training in Nigeria: A pilot study 

 Oshikoya, K.A., Senbanjo, I.O., Amole, O.O.   BMC Medical Education. 2009; 9(1): art no 50   [Pubmed]   2 
Ability of medical students to calculate drug doses in children after their paediatric attachment 

 Oshikoya, K.A., Senbanjo, I.O., Soipe, A.   Pharmacy Practice. 2008; 6(4): 191196   [Pubmed]  


