DRIP TRICKS

Medication Calculations
In Critical Care, often medications are ordered as IV continuous drips These medications are potent and requires constant monitoring to assess for desired effect and potential side effects

Medications may be ordered in:

mg/hr: Lasix and Aminophylline units/hr: Heparin and Insulin mcg/min: Nitroglycerin mcg/kg/min: Dopamine and Dobutamine mg/min: Lidocaine

Units of Measure
1000 g = 1 mg 1000 mg = 1g 1000 g = 1 kg 1 kg = 2.205 lbs. 1000 mL = 1 L 1 mL = 1 cc = 1 cm3

To convert from one multiple to the other, move the decimal point 3 places in the direction indicated

kg 3g 3

mg 3 g

Drip Formulas
mg/ml mg of medicine mL of solution

mg/hr

mg of medicine mL of solution

x infusion rate (ml/hr)

mg/min

mg of medicine mL of solution

x infusion rate 60 (ml/hr)

mg/kg/min

mg of medicine mL of solution

x infusion rate 60 pt.s weight in kg (ml/hr)

Drip Formulas
g/ml mg of medicine x 1000 mL of solution

g/hr

mg of medicine x 1000 x infusion rate mL of solution (ml/hr)

g/min

mg of medicine x 1000 x infusion rate 60 mL of solution (ml/hr)

g/kg/mi mg of medicine x 1000 x infusion rate 60 pt.s weight in n mL of solution kg (ml/hr)

Drip Formulas
Rate in gtts/min volume to be given x # of gtts/ml of IV set 60 hrs to be given

Rate in mL/hr

g/kg/min to be given x 60 x pt.s weight in kg drip concentration in g/mL

Rate in mL/hr

mg/kg/min to be given x 60 x pt.s weight in kg drip concentration in mg/mL

Calculating Drops Per Minute

gtts/min = volume to be infused X gtts/mL of administration set total time in minutes

Infuse 500 cc of PNSS over 3 hours. Using a 15 gtts/mL administration set what drip rate would you use? gtts/min = 500 mL X 15 gtts/mL = 41.66 gtts/min 180 minutes

Calculating Solution Concentration

mg in solution divided by mL in solution

To prepare your lidocaine infusion you have mixed 2 grams of lidocaine into 500 mL of D5W. How much lidocaine is in 1 mL of this solution?
2000 mg = 4 mg/mL 500 mL

Calculating Solution Concentration

To prepare your dopamine infusion you have mixed 800 mg of dopamine into 500 mL of D5W. How much dopamine is in 1 mL of this solution? 800 mg = 1.6 mg g/mL 500 mL *1.6 mg X 1000 = 1600

Calculating mg/min OR Calculating g/min

gtts/min = volume on hand X drip factor X desired dose

dosage on hand

Administer 2 mg per minute of lidocaine to a patient. To prepare the infusion you mix 2 grams of lidocaine in an IV bag containing 500 mL of D5W. You will use a microdrop administration set (60 gtts/mL). Calculate the infusion rate.

Calculating g/kg/min
gtts/min = desired dose X weight (kg) X drip factor solution concentration Administer 5 mcg/kg/min of dopamine to a patient weighing 85 kg. To prepare the infusion you mix 800 mg of dopamine in 500 mL of D5W (1600 mcg/mL). You will use a mIcrodrop administration set (60 gtts/mL). Calculate the infusion rate. gtts/min = 5 mcg X 85 kg X 60 gtts/mL = 15.94

Calculating g/kg/min
Using the same information from the above patient calculate the same infusion using a macrodrop administration set (15 gtts/mL). gtts/min = 5 mcg X 85 kg X 15 gtts/mL = 3.98 gtts/min 1600 g

Drip Trick #1: C Factor x pump rate = g/kg/min

Theres standard drip mixture hanging, and youre having to titrate often. To simplify the calculation of g/kg/min each time you change the infusion rate, calculate a constant (C factor or Magic Number) Each time you change the infusion rate, multiple the new rate by the C factor to determine the g/kg/min you are now giving C = mg of med X 1000 kg mL of solution 60 pts wgt in

Drip Trick #1: C Factor x pump rate = g/kg/min

you have Dopamine 800mg mixed in 500mL and your patient weighs 70kg. C = 800 X 1000 C = 0.38 C Factor x 0.38 0.38 0.38 x x x Pump Rate 10 mL/hr 15 mL/hr 25 mL/hr = g/kg/min = 3.8 g/kg/min = 5.7 g/kg/min = 9.5 g/kg/min 500 60 70

Drip Trick #2: pump rate = g/kg/min

If you mix the drip according to the patients weight, the infusion rate dialed into the pump (the mL/hr) will equal the dose in g/kg/min
the mg of med = 60 x pt wt in kg x mL of solution you want to mix in you need 1000

Drip Trick #2: pump rate = g/kg/min

For a patient weighing 70kg, you want to know how many mg of Dopamine to mix in 500mL of solution, so that the mL/hr infusion rate equals the g/kg/min mg of Dopamine = 60 x 70kg x 500mL 2100mg 1000 So if you mix: 2100 mg of Dopamine =

in 500mL

Drip Trick #2: pump rate = g/kg/min

If you want a more dilute mixture, cut the mg in half (2100mg/2 = 1050) So that when you mix: 1050 mg of Dopamine

in 500mL
An infusion rate of 5mL/hr delivers 2.5 g/kg/min

10mL/hr delivers 5 g/kg/min

20mL/hr delivers 10 g/kg/min

Common Drips

Aminophylline
Bronchodilator, bronchial smooth muscle relaxant, for treatment of acute asthma or bronchospasm associated with chronic bronchitis or emphysema AE: Irritability, restlessness, tremor, insomnia, headache, dizziness, drug-related seizures, tachycardia, palpitations, extrasystoles, hypotension, nausea, vomiting, anorexia, abdominal pain, diarrhea, tachypnea, respiratory arrest

Aminophylline
Prep: 25mg/mL in 10mL vial IVP: 5mg/kg loading dose slowly over 30 minutes (no faster than 20mg/min) Drip: 500mg/500mL D5W/NS Concentration 1mg/mL Dose: 0.5 1.5 mg/kg/hr

Amiodarone
Anthiarrhythmic with effects on Na, K and Ca channels, as well a Beta blocking properties AE: Hypotension in 16% of patients (related to rate of indusion); Bradycardia occurs in 5%; New onset Vtach/Vfib or Torsades De Pointes, pulmonary infiltrates

Amiodarone

hours

Prep: 50mg/mL in 3mL amp IVP: 150mg in 100mL D5W over 10 mins Drip: 900mg/500mL (D5W-Glass)\ Concentration: 1.8mg/ml
* stable in plastic up to 2 hours, stable in glass up to 24

Dose: 1mg/min X 6 hours to give 360, then 0.5mg/min X 18 hours to give 540mg If breakthrough Vtach occurs: 150mg in 100D5W bolus then increase drip rate

Diltiazem
Ca channel blocker with potent negative chronotropic and mild negative inotropic effects; for acute Afib and Aflutter AE: Hypotension, flushing, 2nd or 3rd degree AV Block, bradycardia, asystole, Vtach, Vfib, LV failure, dyspnea, peripheral edema, chest pain, Nausea, vomiting, dry mouth, constipation, injection site reaction

Diltiazem
Prep: 5mg/ml in 25 & 50 mL vials IVP: 0.25 mg/kg (about 20mg) over 2 mins; if inadequate response, wait 15 mins, then 0.35mg/kg Drip: 125mg/25mL Diltiazem + 100ml D5W/NS Concentration: 1mg/mL Dose: 5-15mg/hr Titrate to HR Do not give >15mg/hr or for >24 hours

Dobutamine
Synthetic sympathomimetic catecholamine with inotropic, chronotropic & vasodilator effects. For heart failure, especially with SVR & PVR, and for RV infarction. AE: Dose related tachycardia can Myocardial ischemia. PVCs, & infarct size. vent. Response to A fib, Headache, nausea, tremor, BP (may be precipitous), K, HA, dyspnea, palpitations, nausea.

Dobutamine
Prep: 250mg in 20mL vial. IVP: N A Drip: 500mg/500mL D5W, NS, D5NS, RL Conc: 1000 g/mL Or: 1000mg/500mL D5W, NS, D5NS, RL Conc: 2000 g/mL OK if solution is pink, avoid alkaline solutions Dose: 2-10 g/kg/min (up to 40 g/kg/min) May need to dose for pt on -blockers

Dopamine
Cathecolamine precursor of epinephrine & norepinephrine with inotropic, chronotropic and vasoactive effects. For bradycardia that is refractory to atropine For heart failure, hypotension unresponsive to fluids, septic and anaphylactic shock. No longer recommended for oliguric renal failure AE: At low dose may decrease BP, at high dose increase HR & SVR, tachycardia, increase MVO2, PVCs, myocardial ischemia, atrial and ventricular arrhythmias, renal ischemia at high dose

Dopamine
Prep: 40mg/mL in 5mL; 80mg/mL in 5mL IVP: NA Drip: 800mg/500mL (D5/D5NS/NS/RL) Conc: 1600g/mL Dosing:
1-3 g/kg/min: increase renal perfusion 3-10 g/kg/min: increase contractility >10 g/kg/min: vasoconstriction >20 g/kg/min like Levophed

Epinephrine
Natural & potent cathecolamine with both alpha and beta adrenergic agonist effects; increases BP, HR, SVR, cerebral and coronary blood flow, myocardial O2 demand, contractility, automaticity; For PEA, asystole, bradycardia, VTach, Vfib unresponsive to defibrillation; anaphylaxis AE: hypertension, headache, tremors, myocardial ischemia, increase MVO2, tachycardia, ectopy, Vfib, renal ischemia, CVA

Epinephrine
Prep: 1mg/mL in 1mL amp IVP: for cardiac arrest 1mg q3-5 mins Drip: 2mg/250mL (D5/NS) Conc: 8 g/mL Dose: start at 1 g/min then 2.0-10 g/min ET: 2-2.5 times the IV dose

Furosemide
Potent, rapid acting diuretic (inhibits the reabsorption of Na, K H2O) & venodilator for pulmonary edema associated with LV failure, also for nephrotic syndrome, ascites and hypertension AE: dehydration, hypotension, hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hyperosmolality, metabolic alkalosis, ototoxicity at high doses

Furosemide
Prep: 10mg/mL in 2, 4, 10 mL amps & vials IVP: 0.5-1.0 mg/kg over 1-2 mins repeat to total of 2mg/kg Drip: 250mg/250mL (D5W, NS, RL) Conc: 1mg/mL Dose: 2-20mg/hr (do not exceed 1g/day total)

Lidocaine
An antidysryhtmic, may be used to supress ventricular ectopy and treat Vfib/Vtach that persists after defibrilation, epinephrine, and Amiodarone. Second choice behind Amiodarone and Procainamide for hemodynamically stable V Tach Ineffective against atrial arrhythmias AE: Myocardial depression, BP. Aggravation of arrhythmia, respiratory depression / arrest. Bradycardia. Toxicity: drowsy, disoriented, paresthesias, muscle twitching, grand mal seizure.

Lidocaine
Prep: For IVP: 100 mg/ 5 mL in syringe For drip: 1 gram in 50 mL IVP: 1.0-1.5 mg/kg; if no response, repeat q 510 mins to total 3 mg/kg (1/2 these dosages if pt has hepatic blood flow or is over 70 y/o) Drip: 2 gm/500 mL D5W Conc: 4mg/mL Dose: 1-4 mg/min, titrate in increments of 1 mg/min, repeat bolus with each

Magnesium Sulfate
Replacement therapy for Mg deficiency. Hypomagnesemia can precipitate refractory Vtach, Vfib, pump inefficiency, sudden cardiac death May benefit polymorphic VTach (Torsades de Pointes) AE: hypermagnesemia, expecially in pts with renbal insufficiency, flushing, sweating, sensation of heat, hypotension (keep patient supine), paralysis, respiratory paralysis, circulatory collapse, cardiac arrest, CNS depression (have Ca on hand)

Magnesium Sulfate
Prep: 10% = 0.10 g/mL = 0.8 mEq/mL 20% = 0.20 g/mL = 1.6 mEq/mL 50% = 0.50 g/mL = 4.0 mEq/mL IVP: 1-2 g in 50 -100 mL D5W over 5-60 mins Drip: 1-2g/100mL D5W/NS Conc: 0.01-0.20 g/mL or 0.08-0.16 mEq/mL Dose: 1-2 g/hr (or 8-16 mEq/hr)

Nicardipine
A calcium channel blocker with potent vasodilatory effect on systemic, coronary, cerebral and renal vasculature Used to treat hypertension and angina During PTCA, pretreatment with intracoronary Nicardipene protects against ischemia AE: irritation at infusion site (rotate site q12 hrs), hypotension, flushing, dizziness, tachycardia, PVCs, palpitations,

Nicardipine
Prep: 25mg/mL in 10mL amp (2.5mg/ml) IVP: NA Drip: 25mg/250mL D5W/NS Conc: 0.1mg/mL Dose: 5mg/hr (50mL/hr), increase increments of 2.5mg/hr (25ml/hr) q14 mins to max of 15mg/hr Reduce dose in pts with hepatic disease

Nitroglycerin
Dilates peripheral/coronary vasculature by relaxing vascular smooth muscle. For treatment of myocardial ischemia and infarction and to coronary blood flow in CHF. Also to preload and afterload in left ventricular failure. Preferred over Nipride in pts with CAD. To treat hypertension after cardiac surgery.

Nitroglycerin
AE: Hypovolemia, hypotension, (put head down, feet up). Fainting if pt sits up, Reflex tachycardia, Headache, flushing, 15% are resistant to its antihypertensive effects, Develop tolerance over 1-2 d.

Nitroglycerin
Prep: 5 mg/mL in 1, 5, & 10 mL vials. IVP: May give 12.5-25 g bolus Drip: 50 mg/ 250 mL D5W in glass, with nonabsorbing tubing Conc: 200 g/mL Dose: 5-20 g/min, in increments of 5 g/min q 5-10 mins (max dose is 200 g/min). If topical or po doses started, drip to < 20 g/min.

Norepinephrine (Levophed)
Naturally ocurring catecholamine with potent 1, 2, 1, 2 agonist activity. Vasoconstrictive effects used for the treatment of hypotension due to low SVR (septic shock). Increases contractility and MVO2. 1 effects are similar to the Epi, has minimal 2 effect.

Norepinephrine (Levophed)
AE: Hypertension, Myocardial ischemia, Arrhythmias, bradycardia, Renal/mesenteric blood flow, Tissue slough if it infiltrates.

Norepinephrine (Levophed)
Prep: 1 mg/mL in 4 mL amp. IVP: NA Drip: 8 mg/500 mL D5W, D5NS, not NS Conc: 16 g/mL Dose: 2-12 g/min (up to 30 g/min) Start at 0.5 g/min Expect great individual differences in dose required.

Potassium Chloride
To prevent or treat potassium deficiency. K is most often due to: Corticosteroids Diuretics NG suction, vomiting, diarrhea, Metabolic acidosis

Potassium Chloride
AE: If given peripherally, pain / irritation of IV site and peripheral vein. Toxicity (K > 5.5): confusion, irritability, flaccid paralysis, respiratory distress, BP arrhythmias, widened QRS, prolonged PR and QT -> V fib.

Potassium Chloride
Prep: 2 mEq/mL in 10 & 20 mL vials IVP: Never Drip: Rapid replacement: 10-40 mEq/100 mL D5W (use central line) Slow replacement: 20-40 mEq/1000mL (peripheral line) Dose: 5-40 mEq/hr (Never > 40 mEq/hr)

Sodium Bicarbonate
The most widely used buffering agent, but no longer routinely used in cardiac arrest unless pt has: Preexisting metabolic acidosis Hyperkalemia Tricyclic or phenobarb overdose Prolonged CPR

Sodium Bicarbonate
AE: Iatrogenically induced alkalosis, Hypernatremia, Hyperosmolality, Left shift of O2 / Hgb curve can compromise release of O2 to tissues.

Sodium Bicarbonate
Prep: 1 mEq/mL in 50 mL syringe IVP: 1.0 mEq/kg, then guided by ABG Drip: 300 mEq/500 mL = 5% solution Dose: Titrate to ABG