Pharmacokinetic and pharmacodynamic considerations are very much important while choosing any antibiotic specially in presence of comorbidities like chronic renal failure as the renal elimination is compromised in those patients and handling of antibiotics which excrete through kidney are altered hence needs judicious antibiotic selection and dose calculation.In this venture calculating eGFR through different online calculators make the physicians more aware of the underlying disease state and improve dose adjustment of the antibiotics. Examples are MDRD or CKD-EPI or Cockroft-Gault formula.
Clinical pharmacokinetics is the application of pharmacokinetic principles to the safe and effective therapeutic management of drugs in an individual patient. Primary goals of clinical pharmacokinetics include enhancing efficacy and decreasing toxicity of a patient's drug therapy.
The success of drug therapy is highly dependent on the choice of the drug, the drug product, and the design of the dosage regimen. The choice of the drug is generally made by the physician after careful patient diagnosis and physical assessment.
Pharmacokinetic and pharmacodynamic considerations are very much important while choosing any antibiotic specially in presence of comorbidities like chronic renal failure as the renal elimination is compromised in those patients and handling of antibiotics which excrete through kidney are altered hence needs judicious antibiotic selection and dose calculation.In this venture calculating eGFR through different online calculators make the physicians more aware of the underlying disease state and improve dose adjustment of the antibiotics. Examples are MDRD or CKD-EPI or Cockroft-Gault formula.
Clinical pharmacokinetics is the application of pharmacokinetic principles to the safe and effective therapeutic management of drugs in an individual patient. Primary goals of clinical pharmacokinetics include enhancing efficacy and decreasing toxicity of a patient's drug therapy.
The success of drug therapy is highly dependent on the choice of the drug, the drug product, and the design of the dosage regimen. The choice of the drug is generally made by the physician after careful patient diagnosis and physical assessment.
Individualisation and optimization of drug dosing regimenJyoti Nautiyal
Drug dosing regimen, dosing frequency, individualisation, Steps Involved in Individualization of Dosage Regimen, optimization, variability, Clinical experience with individualization and optimization based on plasma drug levels.
Cefdinir and its role in otitis media, clinical study, indications, dosages, advantage, role of clavunalic acid, hepatotoxicity role all the research features are includes here to be prepared for Rajshahi Medical College, Focusing ENT specialist
abscess advanced trauma life support anterio advanced trauma life support antibiotics apically repositioned flap dental diseases dr dr shabeel drshabeel’s face eye trauma lidocaine anodontia management medical medicine misuse and abuse orthodontics teeth braces pharmacy pn preparation dental students for community based ed presentations s abscess abscess tooth active orthodonti shabeel shabeel"s shabeel’s shabeelpn trends of antimicrobial usage in dental practice View all
’s abscess abscess advanced trauma life support anterio abscess tooth active orthodontics adolescent advanced trauma life support aesthetic dentistry airway management alignment of teeth amalgam anesthesia in dentistry anesthetics in dentistry anterior open bite antibiotic resistanace antibiotics antibiotics and leukopenia aphthous ulcers apically repositioned flap apicoectomy appliances arch dental arch form orthodontics braces arch length orthodontics braces arch wire orthodontist braces ayurvedha baby teeth bloger boil books braces braces teeth cancer canker sore pain cavity preparation children community based learning congenitally missing teeth cosmetic dentistry csf leaks dental dental anesthetics dental restorations dental teeth dento alveolar fractures disease
Pharmacokinetics, sometimes described as what the body does to a drug, refers to the movement of drug into, through, and out of the body—the time course of its absorption, bioavailability, distribution, metabolism, and excretion.
Pharmacokinetic concepts and principles in humans in order to design individualized dosage regimens which optimize the therapeutic response of a medication while minimizing the chance of an adverse drug reaction.
Pediatric Drug calculations |drug calculation formulasNEHA MALIK
Most drugs in children are dosed according to body weight (mg/kg) or body surface area (BSA) (mg/m2). Care must be taken to properly convert body weight from pounds to kilograms (1 kg= 2.2 lb) before calculating doses based on body weight. Doses are often expressed as mg/kg/day or mg/kg/dose, therefore orders written "mg/kg/d," which is confusing, require further clarification from the prescriber.
Therapeutic drug monitoring (TDM) of drugs used in seizure disordersAbel C. Mathew
Therapeutic drug monitoring (TDM) of drugs used in seizure disorders- Phenytoin, Valproic acid, Carbamazepine are major drugs used in epilepsy disorders. These drug need TDM to ensure their proper usage.
Individualisation and optimization of drug dosing regimenJyoti Nautiyal
Drug dosing regimen, dosing frequency, individualisation, Steps Involved in Individualization of Dosage Regimen, optimization, variability, Clinical experience with individualization and optimization based on plasma drug levels.
Cefdinir and its role in otitis media, clinical study, indications, dosages, advantage, role of clavunalic acid, hepatotoxicity role all the research features are includes here to be prepared for Rajshahi Medical College, Focusing ENT specialist
abscess advanced trauma life support anterio advanced trauma life support antibiotics apically repositioned flap dental diseases dr dr shabeel drshabeel’s face eye trauma lidocaine anodontia management medical medicine misuse and abuse orthodontics teeth braces pharmacy pn preparation dental students for community based ed presentations s abscess abscess tooth active orthodonti shabeel shabeel"s shabeel’s shabeelpn trends of antimicrobial usage in dental practice View all
’s abscess abscess advanced trauma life support anterio abscess tooth active orthodontics adolescent advanced trauma life support aesthetic dentistry airway management alignment of teeth amalgam anesthesia in dentistry anesthetics in dentistry anterior open bite antibiotic resistanace antibiotics antibiotics and leukopenia aphthous ulcers apically repositioned flap apicoectomy appliances arch dental arch form orthodontics braces arch length orthodontics braces arch wire orthodontist braces ayurvedha baby teeth bloger boil books braces braces teeth cancer canker sore pain cavity preparation children community based learning congenitally missing teeth cosmetic dentistry csf leaks dental dental anesthetics dental restorations dental teeth dento alveolar fractures disease
Pharmacokinetics, sometimes described as what the body does to a drug, refers to the movement of drug into, through, and out of the body—the time course of its absorption, bioavailability, distribution, metabolism, and excretion.
Pharmacokinetic concepts and principles in humans in order to design individualized dosage regimens which optimize the therapeutic response of a medication while minimizing the chance of an adverse drug reaction.
Pediatric Drug calculations |drug calculation formulasNEHA MALIK
Most drugs in children are dosed according to body weight (mg/kg) or body surface area (BSA) (mg/m2). Care must be taken to properly convert body weight from pounds to kilograms (1 kg= 2.2 lb) before calculating doses based on body weight. Doses are often expressed as mg/kg/day or mg/kg/dose, therefore orders written "mg/kg/d," which is confusing, require further clarification from the prescriber.
Therapeutic drug monitoring (TDM) of drugs used in seizure disordersAbel C. Mathew
Therapeutic drug monitoring (TDM) of drugs used in seizure disorders- Phenytoin, Valproic acid, Carbamazepine are major drugs used in epilepsy disorders. These drug need TDM to ensure their proper usage.
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Mastering Wealth: A Path to Financial FreedomFatimaMary4
### Understanding Wealth: A Comprehensive Guide
Wealth is a multifaceted concept that extends beyond mere financial assets. It encompasses a range of elements including money, investments, property, and other valuable resources. However, true wealth also includes non-material aspects such as health, relationships, and personal fulfillment. This guide delves into the various dimensions of wealth, exploring how it can be created, sustained, and enjoyed.
#### Defining Wealth
Traditionally, wealth is defined as the abundance of valuable resources or material possessions. It includes financial assets like cash, savings, stocks, bonds, and real estate. However, a broader understanding of wealth considers factors such as personal well-being, emotional health, social connections, and intellectual growth. This holistic view recognizes that true wealth is not solely about accumulating money but also about enhancing one's quality of life.
#### The Importance of Financial Wealth
Financial wealth remains a critical component of overall wealth. It provides security, freedom, and the ability to pursue opportunities. Key elements of financial wealth include:
1. **Savings**: Money set aside for future use. It is crucial for emergencies, large purchases, and financial goals.
2. **Investments**: Assets purchased with the expectation that they will generate income or appreciate over time. Common investments include stocks, bonds, mutual funds, real estate, and businesses.
3. **Income**: Regular earnings from work, investments, or other sources. Consistent income is essential for maintaining and growing wealth.
4. **Debt Management**: Effectively managing debt ensures that it does not erode financial wealth. This includes paying off high-interest debt and using credit wisely.
#### Creating Wealth
Creating wealth involves generating and accumulating financial and non-financial resources. The process can be broken down into several key strategies:
1. Education and Skill Development: Investing in education and skills enhances earning potential. Higher education, professional certifications, and continuous learning can lead to better job opportunities and higher salaries.
2. Entrepreneurship: Starting and running a successful business can be a significant source of wealth. Entrepreneurship requires innovation, risk-taking, and effective management.
3. Investing: Making smart investments is essential for wealth creation. This involves understanding different types of investments, assessing risks, and making informed decisions. Diversifying investments can reduce risk and increase potential returns.
4. Saving and Budgeting: Effective saving and budgeting help accumulate wealth over time. Setting financial goals, creating a budget, and sticking to it are foundational steps in wealth creation.
5. Real Estate: Investing in property can provide rental income and capital appreciation. Real estate is a tangible asset that can hedge against inflation
2. Objectives
Describe basic pharmacokinetic parameters for
vancomycin and aminoglycosides in pediatric patients
Outline dosing strategies for aminoglycosides based
on pharmacokinetic principles
Outline dosing strategies for vancomycin based on
pharmacokinetic principles
Select a monitoring plan for vancomycin and
aminoglycosides in pediatric patients
Select an adjusted dosing regimen based on serum
concentrations for vancomycin and aminoglycosides in
pediatric patients
2
3. Pharmacokinetics
Definition:
The study of the time course of a drug and its
metabolites in the body
The study of the ADME of a drug and its
metabolites in the body
Absorption
Distribution
Metabolism
Excretion
Varies greatly with age groups (pediatrics,
geriatrics)
3
5. Excretion
Because of the PK and PD characteristics
of vancomycin and aminoglycosides, the
clearance of these drugs is closely
correlated to creatinine clearance
5
6. Estimation of Creatinine Clearance
Schwartz Estimate
Estimates creatinine clearance
from serum creatinine, the
patient's height, and a
proportionality constant
CrCl = (k * Ht) / Cr
(Caution: formula tends to
overestimate the actual
creatinine clearance and
should be used with caution.)
http://www-users.med.cornell.edu
Ht height in
centimeters
Cr serum creatinine
K Constant:
(see below)
Infant (LBW < 1
year)
0.33
Infant (Term < 1
year)
0.45
Child or Adolescent
Girl
0.55
Adolescent Boy 0.70
6
7. Elimination Half-life (t½)
Associated with first-order kinetics (serum
concentration diminishes logarithmically
over time)
Time it takes for plasma concentration to
reach half of a previous concentration
Affected by metabolism and excretion
Most drugs follow first-order kinetics
(including aminoglycosides and vanco)
7
8. Steady State
Equilibrium reached:
Rate of drug in=Rate of drug out
Time to reach steady state is a function of t½
t½ % of Steady State Achieved
1 50%
2 75%
3 87.5%
4 93.75%
5 100% 8
10. Pharmacodynamic Concepts Affecting
Dosing and Monitoring of
Aminoglycosides and Vancomycin
Organism (Gram + vs. Gram -)
MIC of organism
Site of infection
Dose-response relationships of Abx
Concentration vs. time dependent bactericidal
activity
PAE
10
11. Concentration Dependent
Aminoglycosides
CONCENTRATION dependent killing
Maximize INTENSITY of exposure
As concentration at site ↑, antimicrobial action ↑
More pronounced responses to dosage
adjustments
11
16. Time Dependent
Vancomycin
TIME dependent killing
Maximize DURATION of exposure
More pronounced responses to interval
adjustments
16
17. Vancomycin
Initial Dosing Pediatrics
10-15 mg/kg/dose q6-8 hours
Renal impairment
GFR 30-50: 10 mg/kg/dose q12h
GFR 10-29: 10 mg/kg/dose q18-24 hours
GFR < 10: 10 mg/kg/dose; re-dose based on
serum concentrations
17
Lexicomp 1978-2013
18. IV Vancomycin
Initial Neonatal Dosing SBUH
PMA
(weeks)
Postnatal (days) Interval
≤ 29 0 to 14
> 14
18
12
30 to 36 0 to 14
> 14
12
8
37 to 44 0 to 7
> 7
12
8
> 44 All 6
Dose: 10 to 15 mg/kg/dose*
(*This dosing strategy targets a trough of 5-15, therefore 15 mg/kg/dose is preferred.)
Reference: Neofax
19. Vancomycin
Expected Half-Life
(Population Statistics)
Age t1/2
Neonates 6 to 10 hrs
Infants 3 to 4 hrs
Children 2.2 to 3 hrs
Adults Normal renal function: 5-11 hr
End stage renal: 5 to 7 days
Clearance approximately equal to CrCl (≈ 5% metabolized)
19
21. IV Vancomycin
Dosing Strategies
Due to pharmacodynamic characteristics,
optimal give more frequently
Want trough to remain in therapeutic range;
peak inconsequential
For renal impairment, reduce frequencies
21
22. Why Monitor?
Constant changes in Vd and clearance
Optimize therapeutic effects
Minimize toxicity
22
23. When to Monitor?
At presumed steady state
Upon initiation of therapy
After a dosage/frequency adjustment
Upon significant change in weight, fluid status, renal
function
After addition of a medication that may affect renal
function (i.e. Ibuprofen)
Every week after achieving therapeutic serum
concentrations
For vancomycin doses of > 15 mg/kg/dose q6h or > 3 g
per day, recheck first therapeutic trough in 2-3 days.
(Then follow above monitoring strategy thereafter.)
23
24. Time to Draw
Peak (aminoglycosides only)
30 minutes after dose completely infused
Trough (all drugs)
30 minutes before the next dose is due
24
25. How to Interpret Lab Results
Questions to ask yourself
Was the initial dosing appropriate? (considering renal
function etc.)
Was the trough drawn at presumed steady state?
For unexpected high concentrations, was it possible
the trough was drawn after the start of the infusion or
from a line that may not have been flushed?
Was it actually drawn at the time documented in the
system?
Should the level be redrawn?
25
26. Gentamicin Conventional Dosage
Adjustment Guidelines
26
If Peak is
High
(>10
mcg/mL)
Trough is High
Proportional DECREASE in DOSE to
bring peak to desired number.
Check to see how this change
affects trough.
If trough is still high (above
range) with this dosage
decrease, DECREASE the
FREQUENCY.
Trough is in range
Proportional DECREASE in DOSE to
bring peak to desired number.
Trough is low
(<0.5 mcg/mL)
Proportional DECREASE in DOSE to
bring peak to desired number and
INCREASE the dosing frequency.
If Peak is
Low
(less
than
target)
Trough is High
Proportional INCREASE in DOSE to
bring peak to desired number. Must
also DECREASE the dosing
frequency
Trough is in Range
Proportional INCREASE in DOSE to
bring peak to desired number.
Check to see how this change
affects the trough.
If the change will cause the
trough to be high (above
range), also DECREASE the
FREQUENCY.
Trough is low
Proportional INCREASE in DOSE to
bring peak to desired number.
Check to see how this change
affects trough.
If the change will cause the
trough to be high (above
range), also DECREASE the
FREQUENCY.
27. Gentamicin Dosage
Adjustment Guidelines
27
•If peak is in desired range and trough is
high, DECREASE THE FREQUENCY.
•After rechecking serum
concentrations, may be necessary to
increase dose with next adjustment.
•If peak is in desired range and trough is
low, most likely no adjustment is
necessary.
28. Vancomycin Dosage
Adjustment Guidelines
28
If trough
comes back
HIGH
If trough is in toxic
range, hold and draw
random serum
concentrations until
below 15 mcg/mL.
May calculate patient
half-life using formula if
there are 2
concentrations after a
dose and one value is at
least twice the other.
When
concentration is
below 15
mcg/mL,
recalculate
dose and
restart.
If half-life is
greater than
dosing interval,
increase dosing
interval to greater
than or equal to
one half-life
If trough
comes back
LOW
If trough is less than
half of target,
increase the
frequency. If the
frequency is already
Q6H, increase the
dose to 15 mg/kg. If
trough is still low,
increase the dose in
small increments
(i.e. 2 mg/kg per
dose)
If trough is more than
half of target, increase
the dose based on a
linear relationship;
calculate as a
proportional ratio to
trough. Maximum
increase of 50% at one
time.
Note: Q6h hours in the maximum frequency
29. Common Myth
Adjust the dose by 10%
Is this an appropriate recommendation?
In what situation, if ever, would this apply?
29
30. Calculating Actual Half-Life
to choose best dosage interval
K = ln C1
C2
Δ Time
t½ = 0.693/K
K=elimination rate constant
Δ Time = hours
•Can be done from random levels if spaced far enough apart
(one number at least twice the other)
•Can be done from peak and trough if at steady state
30
32. Case 1
Female
20 years old
ABW 76.6 kg
IBW 52.4 kg
SCr 0.6
CrCl 123 mL/min
Reason for visit
Chronic CSF leak
Comes to ER with symptoms of bending
down, having rhinorrhea
Started on vancomycin
Trough goal = 15-20 mcg/mL
32
33. Case 1
Date Dosing Schedule Dose Received Time
2/3/10 1 g x1 STAT 1 g 1629
2/4/10
1.5 g Q12H 1.5 g 0400
1 g Q12H 1 g 1520
2/5 /10
VANCOMYCIN TROUGH
10.1 mcg/mL
0330
1 g Q12H
1 g 0400
1 g 1530
33
34. Case 1
Pharmacy recommendation on 2/5/10
Draw a level on 2/6/10 AM
If level ≤ 10 mcg/mL, give 1 g Q8H
If level 11-12 mcg/mL, give 1.5 g Q12H
If 13-15 mcg/mL, give 1.2 g Q12h
34
35. Case 1
Date Dosing Schedule Dose Received Time
2/6/10
VANCOMYCIN TROUGH 11 mcg/mL 0300
1 g Q12H 1 g 0330
1.5 g Q12H 1.5 g 1530
2/7/10 1.5 g Q12H
1.5 g 0330
1.5 g 1530
2/8/10
VANCOMYCIN TROUGH
17.5 mcg/mL
0300
35
36. Case 2
Female
2 years old
ABW 17.5 kg
IBW 17.3 kg
SCr 0.3
CrCl 177 mL/min
Reason for admission
Lethargy
Mental status changes
Fever
Started on gentamicin
R/O sepsis (gram negative coverage)
36
37. Case 2
Target Serum Concentrations
Peak: 6-10 mcg/mL
Trough: < 2 mcg/mL
Gentamicin Dose: 2.5 mg per kg q8h
37
39. Case 2
Dosage Adjustment
Want peak 6 or greater
If 43 mg yields peak of 5.2, what dose
would bring it to 6?
Use linear proportion as long as interval is
unchanged
39
40. Case 2
Dosage Adjustment Continued
What effect would that have on trough (if
dose was increased to 49 mg q8h)?
If 43 mg yields a trough of 1.3 mcg/mL, 49
mg would bring it to what trough?
40
41. Case 2
What if trough calculated to greater than 2?
Answer: increase the interval
Monitoring
After dosage change, repeat peak and trough
around 3rd dose of the new regimen
41
42. Case Study
Term neonate
DOB: 1/25/12
Diagnosis: chorioamnionitis
Weight 3.65 kg
Start antibiotics: ampicillin
gentamicin
42
43. Case 3 ( 1) Gentamicin
43
Gentamicin ordered: 14.6 mg q 24 hours
Dosed at 4 mg per kg
44. Questions:
Was this dosed properly?
What criteria are used to determine if this
was dosed properly?
What level(s) will be drawn to properly
monitor this drug?
What serum concentrations are we
targeting?
44
56. Evaluation
Check initial dosing for correctness
Evaluate the credibility of the laboratory values
Identify possible reasons for serum
concentration to be different than what is
expected
Confirm that all doses were given as scheduled
Confirm that blood was drawn at the correct time
Repeat lab work if necessary
Make adjustments based on pharmacokinetic
relationships
56
57. Case 4 (1) Vancomycin
57
Dosed at 10 mg/kg per dose every 8 hours.
Premature infant is 3 weeks old when vancomycin
is added..
61. What is the next step?
Evaluate the initial dosing strategy
Evaluate the lab result
Target trough?
Adjust dose or change the frequency?
61
62. Summary
Basic knowledge of pharmacokinetics will
optimize prescribing by insuring:
Maximal therapeutic benefits
Minimal adverse effects
Cost effectiveness
Decreased blood sampling
62
63. CE Question #1
A patient is on vancomycin every 8 hours
and his half life is 6 hours. What is the
earliest you would expect him to be at
steady state?
a) 12 hours
b) 6 hours
c) 18 hours
d) 24 hours
63
64. CE Question #2
A patient is on gentamicin being treated
for a gram negative pneumonia. What is
the target serum concentrations?
a) Peak 4; Trough <2
b) Peak 15; Trough <2
c) Peak 7; Trough <2
d) Peak 5; Trough <2
64
65. CE Question #3
A 4 year old female child with normal renal
function (Wt = 18 kg; Ht = 40 inch) is admitted
for presumed meningitis. What would be
the appropriate starting dose of
vancomycin?
a) 1g q12h
b) 15 mg/kg/dose q6h
c) 5 mg/kg/dose q8h
d) 750mg q6h
65
66. CE Question #4
There is a 10 kg patient that is on vancomycin 150mg
q8h being treated for cellulitis. The trough comes back
at 5 at presumed steady state with all doses given at the
appropriate times. The resident calls down to the
pharmacy and asks you for a dosage adjustment. What
would be an appropriate recommendation?
a) Increase the dose by 10%
b) Change the frequency to q6h at the same dose
c) Increase the dose to 170mg at the same q8h frequency
d) Switch to linezolid because you don’t know how to adjust
vancomycin
66
68. References
1. Harriet Lane Handbook. 17th ed. Robertson, J and Shilkofski, N Editors.
Philadelphia: Mosby, Inc., 2005.
2. Shargel L, Yu ABC. Applied Biopharmaceutics and Pharmacokinetics. 3rd
ed. Appleton & Lange, 1993.
3. Thomson MICROMEDEX. 1974 - 2008 MICROMEDEX(R) Thomson
Healthcare
4. Winter ME. Basic Clinical Pharmacokinetics. 4th ed. Baltimore: Lippincott
Williams & Wilkins, 2004.
5. http://www-users.med.cornell.edu
6. www.merck.com. Merck Manual on-line
7. Young, TE and Mangum, B. Neofax. 18th ed. Acorn Publishing, Raleigh,
2005.
8. Taketomo, Hoddong and Kraus. Pediatric Dosage Handbook. Lexi-comp.
2003-2004. 68
Editor's Notes
As a review, this illustration represents volume of distribution. It demonstrates that if you give the same amount of drug (in this case 100 mg) to someone with a small volume of distribution, the serum concentration would be higher than giving the same amount to someone with a larger volume of distribution. Volume of distribution is affected by body mass, but also possibly by percentage of body water (for aqueous drugs) or fat (lipophilic drugs).
Designed to be used in children 1 to 18 years but appears to be less accurate in children < 100 cm tall. This formula tends to overestimate the creatinine clearance
First couple of days of life, crcl is reflective of mother’s crcl. So we should base renal function on urine output
This is specific to vancomycin and gent
Postmenstrual age (PMA) = GA + PNA
Peak time to draw varies with the drug and is based on the distribution time. Vancomycin peak would be drawn one hour after dose is infused IF we had the need to draw one (because it’s lipophilic and it takes 1 hour for it to distribute).
Since vancomycin follows linear kinetics, increasing/decreasing the dose by 10% would only affect the level by 10%. If your goal is to go from 10 to 11, then you would increase by 10%. Recommending a blanket statement of “increase the dose by 10%” is not accurate. For example, if the trough is 7 and your goal is 15-20, increasing the dose by 10% will not help you reach your goal. Adjusting the frequency would be an appropriate change.
This was the dosing regimen and the times at which the drug was administered. What do you think of this level? What dosing does this level reflect? Would you recommend an adjustment based on this level? Why or why not?
What do you think of these levels? How would you adjust this dose?
Now you have to ask yourself, if I just increased the dose to get a higher peak, how much of an effect would it have on my trough? Would I still remain under 2?
Dosed properly? (YES. Over 36 weeks is term and is dosed at 4 mg per kg q 24h). Premenstrual age, post natal age, weight and renal function must be considered. Evaluation of renal function is based on urine output; the serum creatinine of a neonate will reflect that of the mother for the first few days of life, and is therefore not useful in determining renal function.
Monitor peak and trough around the third dose.
Targeting of serum concentration is based on indication and bug coverage.
PMA= post menstrual age
Around the third dose
This screen shows the time the specimen is documented as being collected.
Peak is extraordinarily high. Much higher than expected. Must question if this result is “believable” and what may have happened…
Nurse started infusing the drug and then remembered to draw a level?
Nurse drew it from a line that was previously used for that drug but never flushed?
Decreasing renal function?
Pharmacy accidentally drew up the concentrated stock solution?
Need additional serum concentration to confirm or dispute the lab result.
No dose has been given since 8:08 on 1/27.
Order a trough for AM on 1/28. No need to hold dose since drug clearance appears to be adequate (At least 19 hours between random level drawn and next dose due. Even if t ½ is 6 hours, 3 half-lives can transpire before next dose is due, which would bring trough down to approximately 1.2 mcg/mL).
Trough is in target range. Calculate half-life: K= [natural log (9.3 /1.6)] /19 = 0.093
T ½= 0.693/k = 7.5 hours.
Whole picture of all the monitoring we have so far.
Give a dose (4 mg/kg dose) now (9AM) and draw a peak 30 minutes after it is infused.
Peak and trough are both in range to treat gram negative organisms as well as providing gram positive synergy.
This is a premature neonate that was dosed appropriately at every 8 hours as per Neofax. The patient’s weight is 2.63 kg and the dose is 26 mg which is 10 mg/kg (rounded off). This is within the recommended dosage range.
Current practice is to ensure that trough is at least 10 mcg/mL. Since 10 mg/kg targets a trough of 5 to 10 mcg/mL, it is not uncommon for 10 g/kg/dose to result in under-dosing.
Trough would need to be drawn on 1/31/12 at 16:00.
It appears that trough was drawn correctly.
Again, dosing at 10 mg/kg often results in under-dosing. The trough appears to have been drawn correctly with respect to the dose and to time relative to the dose. A trough of 6.6 is below the desired range, so dosage adjustment is necessary. Change the dose proportionately to target a trough of 10 mcg/mL, or go to 15 mg/kg/dose and keep the frequency the same. Draw another trough prior to the fourth dose of the new dosing strategy.