Pharmaceutical Calculations

CHAPTER - SIX

Some calculations involving parenteral admixtures

By
Melese Getachew (B.Pharm, MSc in Pharmaceutics)
 Calculations involving parenteral admixtures

Outline
• Dry powders for reconstitution

• Parenteral admixtures

• Parenteral hyperalimentation

• Rate of flow of IV fluids

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 Calculations involving parenteral admixtures

Introduction
Parenteral: route of medication administration other than the
alimentary canal but mainly indicates all routes of injection.

Injections:
are sterile pharmaceutical solutions of a drug substance in an aqueous
or non aqueous vehicle.
are administered by needle into almost any part of the body.
some are available as prepared solutions with their drug content
but others contain dry powder for reconstitution to form a
solution by adding a specified volume of diluent prior to use

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 Calculations involving parenteral admixtures

Intravenous (IV) infusions

• sterile, aqueous preparations administered intravenously in
relatively large volumes.
• may be:
• Continuous: large volumes of fluid (i.e., 250 to 1000 mL), with
or without added drug, are run into a vein uninterrupted
• Intermittent: administered during scheduled periods.
• administered by IV sets of either
standard sets (10 to 15 drops/mL), or
microdrip sets (60 drops/mL)

IV push (IVP) or IV Stat, or (bolus dose)

• rapid infusion of a medication into a vein is termed IV push and is
usually conducted in less than a minute.

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 Calculations involving parenteral admixtures

E.g. A physician orders enalaprilat (VASOTEC IV) 2 mg IVP for a hypertensive

patient. A pharmacist delivers several 1-mL injections, each containing 1.25 mg
of enalaprilat. How many milliliters of the injection should be administered?
Answer: 1.6 mL
E.g. D10W is to be administered to a neonate weighing 3.5 lb on the basis of 60
mL/kg/day.
i. Calculate the daily infusion volume.
ii. Using an administration set that delivers 60 drops/mL at 20 drops per
minute, calculate the total time for these infusion. Answer:
i. 96 mL
ii. 288 min
Drug dosing by infusion is varied by the:
1. drug concentration in the infusion
2. volume of infusion administered
3. infusion set used, and
4. rate of flow of the infusion

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 Calculations involving parenteral admixtures
Rate of flow of IV fluids
Rate of flow of intravenous fluids
• is specified in:
• mL/min, drops/min, mg/hr, or
• more frequently, as the approximate duration of time of administration of
the total volume of the infusion.
Volume of infusion (mL) ∗ Drip set (drops/mL)
Rate of flow (drops/minute) =
Time (minutes)

E.g.
A medication order calls for 1000 mL of D5W to be administered over an 8-
hour period. Using an IV administration set that delivers 10 drops/mL, how
many drops per minute should be delivered to the patient?

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 Calculations involving parenteral admixtures
Rate of flow of IV fluids,…
Solution
1000 mL ∗ 10 drops/mL
Volume = 1000 mL Rate of flow =
480 min
Time = 8 hrs = 480 min
= 20.8 or 21 drops/min
Drip set = 10 drops/mL
Drip set = 10
E.g. Ten (10) milliliters of 10% calcium gluconate injection and 10 mL of
multivitamin infusion are mixed with 500 mL of a 5% dextrose injection. The
infusion is to be administered over 5 hours. If the dropper set calibrates 15
drops/mL, at what rate, in drops per minute, should the flow be adjusted to
administer the infusion over the desired time interval? Answer: 26 drops/minute
E.g. An intravenous infusion contains 10 mL of a 1:5000 solution of isoproterenol
hydrochloride and 500 mL of a 5% dextrose injection. At what flow rate should
the infusion be administered to provide 5 g of isoproterenol hydrochloride per
minute, and what time interval will be necessary for the administration of the
entire infusion? Answer: 398 minutes
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Rate of flow of IV fluids,…

E.g. If 10 mg of a drug are added to a 500-mL large-volume parenteral fluid:

a. What should be the rate of flow, in milliliters per hour, to deliver 1

mg of drug per hour? Answer: 50 mL/hr
b. If the infusion set delivers 15 drops/mL, what should be the rate of
flow in drops per minute? Answer: 12.5 drops/min
c. How many hours should the total infusion last? Answer: 10 hrs

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 Calculations involving parenteral admixtures
Rate of flow of IV fluids,…

Patient’s weight (kg) ∗ Dose (units/kg/min) ∗ 60

Infusion rate (mL/hr) =
Drug concentration, infusion (units/mL)

E.g
200 mg of a drug is diluted with 10 mL of saline solution which is immediately
added to 1 L of NS. If the drug is to be administered at 10  g/kg/minute to a
patient weighing 65 kg, determine the infusion rate at mL/hr and mL/min.

Answer: 197 mL/hr and 3.28 mL/min

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 Calculations involving parenteral admixtures
Rate of flow of IV fluids,…
E.g. Compare:
a. the number of drops, and
b. the length of time, in minutes, required to deliver 50-mL of IV solution
using a micro-drip set, at 60 drops/mL, and a standard administration
set, at 15 drops/mL, if in each case one drop is to be administered per
second.
Answer:
Microdrip
a. 60 drops/mL* 50 mL = 3000 drops
b. 3000 drops / 60 drops/min = 50 min
Standard set
a. 15 drops/mL* 50 mL = 750 drops
b. 750 drops / 60 drops/min = 12.5 min

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 Calculations involving parenteral admixtures
Rate of flow of IV fluids,…
E.g. Critical patients
An order for a patient, with a 3-liter daily IV fluid limit, calls for 3 L of
D5W with a 100-mL IVPB antibiotic to be run-in alone over a 1-hour
period and administered every 6 hours. The administration set is
calibrated to deliver 10 drops per milliliter.
Answer
Calculate:
a. The flow rate of the IVPB antibiotic a. 16.6 or 17 drops per min
b. The total flow time for the IV antibiotic b. 4 hours or 240 min
c. The total volume for the IV antibiotic c. 400 mL
d. The total flow time for the D5W d. 20 hours or 1200 min
e. The total volume for the D5W e. 2600 mL
f. The flow rate for the D5W f. 21.6 or 22 drops/min

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 Calculations involving parenteral admixtures
Powders for recostitution

• Certain medications like penicillins will not be stable if they are

formulated in the form of solutions.

• so they will be formulated in powder form to be reconstituted with a

sterile water or normal saline.

• when reconstituted, the drug may or may not contribute to the final
volume of the reconstituted solution

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 Calculations involving parenteral admixtures
Powders for reconstitution,…
E.g.
A pharmacist receives a medication order for 300000 units penicillin G
potassium to be added in 500 mL of D5W. A vial of penicillin G contains
1,000,000 units, the direction says 4.6 mL should be added for the
concentration of solution to be 200,000 units/mL. So how many mL of the
reconstituted solution should be taken and added to D5W?
200000 300000
Answer: =
1 mL 𝑋 mL

X = 1.5 mL

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 Calculations involving parenteral admixtures
Powders for reconstitution,…
E.g.
A pharmacist receives a medication order for 400 mg of cefazolin sodium
to be administered IM to a patient every 12 hours. Vials containing 250 mg,
500 mg, and 1 g of cegfazolin sodium are available. According to the
manufacturer’s direction, dilutions may be made as follows:

250 mg 400 𝑚𝑔
Answer: =  𝑥 = 3.2 mL
2 mL 𝑥 𝑚𝐿

500 mg 400 𝑚𝑔
=  𝑥 = 1.76 mL
2.2 mL 𝑥 𝑚𝐿

1000 g 400 𝑚𝑔
=  𝑥 = 1.2 mL
3 mL 𝑥 𝑚𝐿
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 Calculations involving parenteral admixtures
Parenteral admixtures

The preparation of intravenous admixtures involves the addition of one

or more drugs to large volume sterile fluids such as;
 sodium chloride solution, dextrose injection, lactated Ringer’s
injection or others.

The additives are generally in the form of small-volume sterile solutions

in which some of them require reconstitution with solvent before
transfer.

Examples of intravenous additives

• electrolytes, antibiotics ,vitamins, trace minerals, heparin, and,
insulin.

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 Calculations involving parenteral admixtures
Parenteral admixtures,…
E.g. A medication order for a patient weighing 154 lb. calls for 0.25 mg of
amphotericin B per kilogram of body weight to be added to 500 mL of 5%
dextrose injection. If the amphotericin B is to be obtained from a constituted
injection that contains 50 mg/10 mL. How many milliliters should be added to
the dextrose injection? Answer: 3.5 mL

E.g. An intravenous infusion is to contain 15 mEq of potassium ion and 20 mEq

of sodium ion in 500 mL of 5% dextrose injection. Using potassium chloride
injection containing 6 g/30 mL and 0.9% sodium chloride injection, how
many milliliters of each should be used to supply the required ions?
Answer: KCl = 5.6 mL and NaCl = 130 mL

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation

Parenteral nutrition (PN) or intravenous hyperalimentation (IVH or HAL)

• is the feeding of a patient by the IV infusion of fluids and basic
nutrients.
Partial parenteral nutrition (PPN)
is nutritional support that supplements oral intake and provides only
part of daily nutritional requirements.
Total parenteral nutrition (TPN)
provides all the patient’s daily nutritional requirements.

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…

Eligible patients:
severely malnourished

those whose critical illness temporarily precludes their receiving oral or

enteral nutrition and there is need to prevent starvation-induced
complications

those whose gastrointestinal tracts are unavailable or malfunctioning,

those with a demonstrated or assessed probability of ineffective
nourishment by enteral feeding, and

patients in renal or hepatic failure

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…
Parenteral nutrition formulas contain the following:
Macronutrients:
o Carbohydrate (e.g., dextrose)
o Protein (e.g., amino acids)
o Fat (e.g., lipid emulsions)
Micronutrients:
o Electrolytes
o Vitamins
o Trace elements
Sterile water for injection

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…

The amounts of fluid and nutrients required vary with an individual’s

age, gender, physical parameters, disease state, and current nutritional
status.
Fluid requirements
Patient’s daily fluid (water) intake is determined as:
• a factor of 30 mL/kg of body weight
• 1500 mL per square meter of body surface area, or
• 1 mL/kcal of nutrition

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…
Caloric requirement
• The kilocalorie (kcal) is the unit used in metabolism studies. By definition,
the kilocalorie (or large Calorie, C, or Cal.) is the amount of heat required
to raise the temperature of 1 kg of water 1ᴼC.
• The Harris-Benedict equations, which follow, are commonly used to
estimate the basal energy expenditure (BEE) requirements for nonprotein
calories. The BEE is also referred to as the resting metabolic energy (RME)
or the resting energy expenditure (REE).
Males:
BEE = 66.67 + [13.75 * Weight (kg)] + [5 * Height (cm)] - [6.76 * Age (yr)]
Females:
BEE = 655.1 + [9.56 * Weight (kg)] + [1.86 * Height (cm)] - [4.68 * Age (yr)]
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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…
Caloric requirement
• The total daily expenditure (TDE) of energy, as calculated, may be
adjusted for activity and stress factors

TDE = BEE * activity factors * stress factors

Activity factors:
Confined to bed: 1.2
Ambulatory: 1.3
Stress factors:
Surgery: 1.2
Infection: 1.4 to 1.6
Trauma: 1.3 to 1.5
Burns: 1.5 to 2.1

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…
Caloric requirement
Carbohydrates
• carbohydrates are the primary source of cellular energy
• they provide 3.4 kcal/g (parenteral) or 4 kcal/g (enteral route)
Lipids
• lipids may be used to provide energy when the body cannot obtain all the
necessary energy requirement from carbohydrates.
• the proportion of calories provided by lipids is usually restricted to 30%
to 40% of the total daily calories.
• they provide 9 kcal of energy per gram.
• Lipids are generally administered in the form of an emulsion containing
carbohydrate-based emulsifying agents
• It has been determined that a 10% lipid emulsion provides 11 kcal/g of total
energy, and a 20% to 30% lipid emulsion provides 10 kcal/g of total energy.
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Parenteral hyperalimentation,…
Caloric requirement,
Proteins
• proteins provide 4 kcal/g of energy
• they to build tissues and body strength

Protein requirements of adults:

• 1.1 to 1.5 g/kg for a moderately stressed
• 0.8 g/kg/day in an unstressed patient; patient;
• 0.8 to 1 g/kg of body weight for a mildly • 1.5 to 2 g/kg for a severely stressed
stressed patient; patient and those with a critical illness or
• 1.2 g/kg for a renal dialysis patient; trauma; and
• 3 g/kg for a severely burned patient.
Infants: 2 to 3 g/kg/day
Children: 1.5 to 2 g/kg/day, and
Teenagers: 1 to 1.5 g/kg/day of.
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Parenteral hyperalimentation,…
Caloric requirement
The following basic steps may be used as a guide in TPN calculations.
Step 1. Calculate the total daily calories required using the Harris-Benedict equations, and apply
the appropriate stress or activity factors.
Step 2. Calculate the daily quantity (g) of amino acids (protein) required based on 0.8 g/kg of
body weight, and adjust as needed for stress factors and certain disease states.
Step 3. Calculate the number of calories supplied by the amino acids (from Step 2) at 4 kcal/g.
Step 4. Calculate the kcal of lipids required at 30% to 40% of the total daily calories.
Step 5. Calculate the grams of lipids required (from Step 4) based on 9 kcal/g or based on the
lipid emulsion used.
Step 6. Calculate the quantity of carbohydrate required based on 3.4 kcal/g after accounting for
the contribution of the lipids.
Step 7. Calculate the daily fluid requirement using 30 mL/kg/day or one of the other methods
described earlier in the text.

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 Calculations involving parenteral admixtures
Parenteral hyperalimentation,…
Caloric requirement,…
E.g. Calculate the parenteral nutrition and fluid requirements for a 58-year-
old woman who is 5 ft. 3 in. tall and weighs 140 lb., assuming that she has no
disease states that would alter her nutritional requirements.
Step 1. Total daily kcal required by Harris-Benedict equation:
655.1 + (9.56 * 63.63 kg) + (1.86 * 160 cm) - (4.68 * 58 yr) = 1289.62 kcal
Step 2. Protein required (grams):
(140 lb. /2.2 kg) * 0.8 g/kg/day = 50.91 g/day
Step 3. Protein (kcal):
50.91 g/day * 4 kcal/g = 203.64 kcal/day
Step 4. Lipids required (kcal), using 35% of total daily calories:
1289.62 kcal/day (total) * 35% = 451.37 kcal/day
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Parenteral hyperalimentation,…
Caloric requirement,…
E.g. Calculate the parenteral nutrition and fluid requirements for a 58-year-
old woman who is 5 ft. 3 in. tall and weighs 140 lb., assuming that she has no
disease states that would alter her nutritional requirements.
Step 5. Lipids required (grams), using a 10% lipid emulsion:
451.37 kcal/day * 11 kcal/g = 41.03 g/day
Step 6. Carbohydrates (dextrose) required (grams), accounting for kcal from
both protein and lipids:
1289.62 kcal/day - 203.64 kcal/day (protein) - 451.37 kcal/day (lipids)
= 634.61 kcal/day
634.61 kcal/day / 3.4 kcal/g = 186.65 g/day
Step 7. Fluid required (milliliters):
Based on 30 mL/kg/day: (140/2.2) * 30 mL = 1909.09 mL/day
Based on 1 mL/kcal/day: 1289.62 kcal/day * 1 mL/kcal = 1289.62 mL/day
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