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The formula for sodium gluconate is C6H11NaO7; for sodium
acetate trihydrate, C2H3NaO2 · 3H2O; and for magnesium chloride,
MgCl2 · 6H2O.
Calculate the mEq/L of Na+ in the injection.
12.D. A patient has been taking one ferrous gluconate [Fe(C6H11O7)2]
240-mg tablet twice daily, but, due to difficulty in swallowing, needs
to change to a liquid form. How many millimoles of iron is the patient
receiving per day? If ferrous sulfate syrup contains 220 mg of ferrous
sulfate (FeSO4) per 5 mL, how many milliliters of syrup per day
would be equivalent to the iron in the tablets?
12.E. a A patient is receiving an intravenous infusion containing 40
mEq of potassium chloride in 1000 mL of dextrose 5% in half–normal
saline. The infusion has been running at a rate of 80 mL/h for the past
6.5 hours. Following a lab report showing the patient’s serum
potassium level to be 3.5 mEq/L, the physician decides to increase the
potassium dose while slowing the infusion flow rate to 40 mL/h. The
physician prescribes potassium chloride injection (14.9% KCl) to be
added to the IV such that the patient will receive a total of 80 mEq of
potassium over the remaining time for completion of the infusion.
How many milliliters of the potassium chloride injection should be
added by the pharmacist?
a
Problem courtesy of Flynn Warren, Bishop, GA.
ANSWERS TO “CASE IN POINT” AND
PRACTICE PROBLEMS
Case in Point 12.1
a.
Thus, 7.35 mL of the injection contains 10 mEq of calcium and
should be added to the 500-mL bag of normal saline solution.
b. Since 0.5 mEq of calcium is to be administered per hour and there
are 10 mEq of calcium in 507.35 mL of fluid (500 mL of NSS +
7.35 mL of calcium chloride dihydrate injection), the volume of
fluid to be administered per hour may be calculated as:
Finally, the drops per minute may be calculated:
Case in Point 12.2
b.
b.
Case in Point 12.3
a.
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b.
c.
d. Dextrose:
Sodium chloride:
Potassium chloride:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Total osmolarity:
277.78 mOsmol/L (Dextrose) + 307.69 mOsmol/L (NaCl) + 80
mOsmol/L (KCl) = 665.47 mOsmol/L
NOTE: The osmolarity of serum is about 300 mOsmol/L, so this
solution is hyperosmotic.
PRACTICE PROBLEMS
0.699 to 1.59 mcg/mL copper
3.001 mmol/mL phosphate
4.36 mEq/mL potassium
4 mEq/mL potassium chloride
9.42 mL ammonium chloride injection
0.298% potassium chloride
6.762 g calcium chloride
100 mEq ammonium chloride
14.73 mEq potassium
180.18 g sodium chloride
7.45 g potassium chloride
20 mL potassium chloride solution
1.37 mEq sodium
2.49 mEq/mL sodium chloride
74.93 g sodium bicarbonate
131 mmol/L Na
+
111 mmol/L Cl
−
5 mmol/L K
+
29 mmol/L C3H5O
3
−
2 mmol/L Ca
2+
166.67 mEq sodium lactate
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17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
153.85 mEq/L sodium chloride
20.13 mEq potassium chloride
9.34 mEq potassium
4.36 mEq/L potassium
162 g potassium citrate
25 mEq potassium
147.01 mEq sodium
4.03 mEq potassium
4.49 mEq calcium
155.53 mEq chloride
2.7 mEq sodium
a. 100 mEq ammonium
b. 0.54% ammonium chloride
0.2% sodium chloride
5.42 mEq potassium
25 mL sodium bicarbonate injection
4.65 mEq calcium
20.13 mEq potassium chloride
32.43 mEq lithium
19.996% w/v magnesium chloride hexahydrate
a. 28.08 g potassium gluconate
b. 60 mL syrup
11.61 mEq potassium
296 mg lithium carbonate per 5 mL
300 mg/L magnesium sulfate
30.2 mEq potassium chloride per day
27.07 mEq/L sodium
3.16 mEq/L magnesium
62.4 mEq Ca2+/day
57.14 mEq Mg2+/day
1092 mL isotonic sodium chloride solution
713 mL water
120 mEq sodium
38.27 mEq potassium
8.87 mEq magnesium
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
0.79 mEq/mL magnesium
15.05 to 30.11 mL calcium gluconate injection
1035 mg/L sodium
780 mg/L potassium
1242.5 mg/L chloride
108.2 mEq/L chloride
138.89 mL/h potassium acetate infusion
500.69 mEq sodium
140.04 mEq chloride
12.94 mEq/tab sodium
1.14 mEq/tab potassium
8.08 mmol/tab phosphate
a. 8.75 mEq sodium
b. 0.27 mmol/mL magnesium chloride
a. 24.9 mEq potassium chloride
b. 12.45 mL potassium chloride injection
c. 645.47 mOsmol/L
14 mOsmol/L
154 mOsmol/L
4000 mOsmol/L
a. 0.595 mEq/mL sodium bicarbonate
b. 297.62 mEq sodium bicarbonate
c. 1190.48 mOsmol/L
2000 mOsmol/L
a. 27.78 mL/h mannitol injection
b. 549.45 mOsmol mannitol
500.34 mOsmol/L
655.69 mOsmol/L
654.98 mOsmol/L
a. 3.49 mmol calcium gluconate
b. 6.98 mEq calcium gluconate
c. 10.47 mOsmol calcium gluconate
Yes, all labeled concentrations are correct
a. 3990.93 mOsmol/L
b. 75.18 mEq sodium
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64.
65.
1.
2.
3.
4.
5.
6.
7.
8.
292.84 mOsmol/kg
307.66 mOsmol/kg
References
Prince SJ. Calculations. International Journal of Pharmaceutical Compounding
2001;5:485.
US Pharmacopeial Convention, Inc. General Chapters. <785> Osmolality and Osmolarity.
United States Pharmacopeia 42 National Formulary 37 [book online]. Rockville, MD: US
Pharmacopeial Convention, Inc.; 2019.
VAPRO Vapor Pressure Osmometer [product literature]. Logan, UT: Wescor, Inc.; 1997.
Normosol-M and 5% Dextrose Injection [product label information]. ICU Medical Inc.
Available at: https://ecatalog.icumed.com/media/8129/en-2220.pdf. Accessed June 29,
2020.
Lewis JL. Water and sodium balance. In: Porter RS, ed. The Merck Manual Professional
Version [book online]. Kenilworth, NJ: Merck & Co.; 2020.
Prince SJ. Calculations. International Journal of Pharmaceutical Compounding
1998;2:378.
Prince SJ. Calculations. International Journal of Pharmaceutical Compounding
1999;3:311.
Drugs.com. Cardioplegic solution. Available at:
https://www.drugs.com/pro/cardioplegic.html. Accessed June 29, 2020.
13
Intravenous Infusions, Parenteral
Admixtures, Rate-of-Flow
Calculations
OBJECTIVES
Upon successful completion of this chapter, the student will be able to:
Perform calculations for standard adult and pediatric intravenous
infusions.
Perform calculations for critical care intravenous infusions.
Perform calculations for additives to intravenous infusions.
Perform rate-of-flow calculations for intravenous infusions utilizing
medication orders, standard tables, and nomograms.
Injections
Injections are sterile pharmaceutical solutions or suspensions of a drug
substance in an aqueous or nonaqueous vehicle. They are administered by
needle into almost any part of the body, including the joints (intra-
articular), joint fluid (intrasynovial), spinal column (intraspinal), spinal
fluid (intrathecal), arteries (intra-arterial), and in an emergency, even the
heart (intracardiac). However, most injections are administered into a vein
(intravenous, I.V., IV), muscle (intramuscular, I.M., IM), skin (intradermal,
I.D., ID, intracutaneous), or under the skin (subcutaneous, sub-Q, SQ,
hypodermic).
Depending upon their use, injections are packaged in small volumes in
ampulsa or in prefilled disposable syringes for single-dose use, in vials and
pen injectors for single- or multiple-dose use, or in large-volume plastic
bags or glass containers for administration by slow intravenous infusion.
a
An ampul (also ampule or ampoule) is a small, hermetically sealed glass container.
Some injections are available as prepared solutions or suspensions with
their drug content labeled as, for example, “10 mg/mL.” Others contain dry
powder for reconstitution to form a solution or suspension by adding a
specified volume of diluent prior to use and are labeled as, for example, “10
mg/vial.” In the latter case, the calculations required to determine the
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correct volume of diluent needed to prepare an injection of a certain
concentration are provided in Chapter 17.
Small-volume injections may be administered as such or they may be
used as additives to large-volume parenteral fluids for intravenous infusion.
The term parenteral is defined as any medication route other than oral or
topical and thus includes all routes of injection.
Intravenous Infusions
Intravenous (IV) infusions are sterile, aqueous preparations administered
intravenously in relatively large volumes. They are used to extend blood
volume and/or provide electrolytes, nutrients, or medications. Most
intravenous infusions are administered to critical care, infirm, dehydrated,
or malnourished patients or to patients prior to, during, and/or following
surgery. Intravenous infusions are widely employed in emergency care
units, in hospitals and other patient care institutions, and in home care.
Pharmacists participate in the preparation and administration of institutional
as well as home intravenous infusion therapy. The United States
Pharmacopeia has established requirements for the compounding of sterile
preparations.
1
Most intravenous infusions are solutions; however, some are very fine
dispersions of nutrients or therapeutic agents or blood and blood products.
Although some intravenous solutions are isotonic or nearly isotonic with
blood, isotonicity is not absolutely necessary because the volumes of fluid
usually administered are rapidly diluted by the circulating blood.
2
Commercially prepared infusions are available in glass or plastic bottles
or collapsible plastic “bags” in volumes of 50 mL (a minibag), 100 mL, 250
mL, 500 mL, and 1000 mL. The smaller volumes find particular application
in treating pediatric patients and adults who require relatively small
volumes of infusate. When a smaller IV bag is attached to the tubing of a
larger IV being administered, it is referred to as an IV piggyback (IVPB).
The abbreviation LVP is commonly used to indicate a large-volume
parenteral, and SVP indicates a small-volume parenteral.
Some common solutions for intravenous infusion are listed in Table
13.1. Additional components or additives frequently are added to these
basic solutions.
TABLE 13.1 SOME COMMON INTRAVENOUS INFUSION
SOLUTIONS
a
All solutions are prepared in sterile water for injection (SWI), USP. In
addition to the solutions listed, other concentrations of dextrose and sodium
chloride are commercially available. These solutions may be administered
as such or used as vehicles for therapeutic agents, nutrients, or other
additives.
An administration set is attached to an intravenous bottle or bag to deliver
the fluid into a patient’s vein. The sets may be standard (macrodrip) or
pediatric (microdrip). Depending on the particular set used, the drop volume
can vary from 10 to 15 drops/mL for standard sets to 60 drops/mL for
microdrip sets. It should be noted that in some literature, particularly that of
nursing, the abbreviations gtt for drop and mcgtt for microdrop are used.
The passage of an infusion solution into a patient’s vein of entry may be
assisted by gravity (the solution is hung on a stand well above the portal of
entry) or more commonly by electronic volumetric infusion pumps. Some
infusion pumps can be calibrated to deliver microinfusion volumes, such as
0.1 mL/h, to as much as 2000 mL/h, depending on the drug being
administered and the requirements of the patient. Electronic controllers are
often used to maintain the desired flow rate. The use of latest-technology
“smart” pumps can reduce intravenous administration errors by virtue of
software that requires fewer human programming entries at the patient’s
bedside. Errors may also be reduced through the use of bar codes to ensure
correct medication delivery and through wireless technology that allows a
nurse to monitor the rate of flow and the remaining volume of an infusion
when not physically present in a patient’s room.
In the administration of infusions, special needles or catheters provide
intravenous entry for the intravenous fluid. Large-, intermediate-, and smallgauge (bore) needles or catheters are used, with the portal of entry selected
based on the patient’s age (i.e., adult, child, infant, or neonate) and the
clinical circumstances. The narrower the gauge, the slower the flow rate and
thus the longer the period required to infuse a specified volume. Veins in the
back of the hand, forearm, subclavian, jugular, and scalp (e.g., in premature
neonates) may be used. Figure 13.1 depicts an intravenous fluid and
attached administration set (see also Fig. 14.1). Figure 13.2 shows a typical
intravenous setup with a piggyback attachment.
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