Clinical Mathematics for Anesthetists

http://healthprofessions.udmercy.edu/academics/na/agm/mathweb09.pdf

Michael P. Dosch CRNA PhD

Professor, Nurse Anesthesia, University of Detroit Mercy
(http://healthprofessions.udmercy.edu/academics/na/)
Revised Aug. 30, 2022

“I only took the regular course…Reeling and Writhing, of course,

to begin with,' the Mock Turtle replied; 'and then the different
branches of Arithmetic — Ambition, Distraction, Uglification, and
Derision.”
Alice's Adventures in Wonderland, by Lewis Carroll

Objectives
Please keep in mind that all dosages in this document are for learning mathematics only. Please
check with your colleagues or reliable published sources to determine appropriate dosage for your
patients.

The purpose of this document is to collect mathematical tools useful in anesthesia practice, and
increase patient safety by helping providers avoid drug errors. While the five rights of drug
administration1 and attention to systems that prevent errors are fundamental, they are not
mentioned here. Opioid-sparing and ERAS techniques (because of their reliance on continuous
infusions) have increased the frequency of calculations needed in clinical anesthesia practice.

1. Convert fractions to ratio or decimal, decimals to percent, ratios to mg/mL or mcg/mL, percent
solutions to mg or mcg/mL.
2. Know common SI (metric system) prefixes and be able to convert quantities between them.
3. Perform temperature conversions between Fahrenheit, Celsius, and Kelvin scales.

1 https://www.ismp.org/resources/five-rights-destination-without-map

Dosch Clinical Mathematics 2021 1

4. Calculate desired rate setting for IV infusion pumps, given weight, drug concentration, and
desired dose.
5. Convert weights in pounds to kilograms, and calculate mean arterial pressure.
6. Calculate FIO2 when air is being used rather than N2O.
7. Calculate ideal body weight when given actual weight and height in any units.
8. Calculate how long an E tank of oxygen will last at a given liter flow.

Math Tools Review

Further Reading

• Kee JL, Marshall SM. Clinical Calculations. 7th ed. 2013 (or newer editions).
• Drug Calculations for Health professionals- Quiz page2
• Shubert D, Leyba J. Chemistry and physics for nurse anesthesia. 2nd ed. 2013
• Cruikshank S. Mathematics & Statistics in Anaesthesia. Oxford Univ Press 1998

Basic Approaches

Four basic techniques for solving many math problems are: Dimensional analysis, proportions,
desired & available, and Lester’s Rule for IV infusions.

Dimensional analysis

To convert units, multiply by an identity (these are sometimes called conversion factors and are
shown in parentheses in the formulae below). Examples:

14.7psi (1.1)
760mmHg × ( ) = 14.7psi
760mmHg

1013mBar (1.2)
29.9inHg × ( ) = 1013mBar
29.9inHg

2.2lb (1.3)
454gm × ( ) = 1lb
1000gm

50microgm 1mg 0.05mg (1.4)

×( )=
mL 1000microgm mL

In each example, the fraction is an identity. For example, in formula 1.3, multiplying by an identity
(2.2 lb = 1,000 gm) changes 454 gm into the equivalent weight in pounds. Multiplying any
quantity by an identity doesn't change the underlying quantity, only the units it is expressed in.

2 http://www.testandcalc.com/quiz/index.asp

Dosch Clinical Mathematics 2021 2

 Proportions

Proportions are used to determine the answers to questions like "How far can I go on a half tank of
gas, if a full tank will let me drive 300 miles?" or, more pertinently, "How many mL of 0.75%
bupivacaine do I need to draw up to give the patient 12 mg?" To solve this question, you calculate
that 0.75% bupivacaine contains 7.5 mg/mL (see "Percentage solutions" below on this page), then
set up and solve a proportion:

1mL x mL (2.1)
=
7.5mg 12mg

1mL x mL (2.2)
(12mg) × = × (12mg)
7.5mg 12mg

12 (2.3)
mL = x
7.5

And 1.6 mL = x

Diluting drugs: “Desired & Available”

The name desired and available is meant to indicate that you work from what you have available,
diluting it to what you desire or need (i.e. a more useful concentration).

Some thoughts before beginning. Many medications:

• require dilution or reconstitution: e.g. phenylephrine, ephedrine, epinephrine, ketamine,
vecuronium, remifentanil, and others.
• come in different concentrations- from one site to the next, sometimes even from one day
to the next, as shortages dictate changes in supplier. It is imperative to read the
concentration on the vial! Examples: ketamine (10, 50, or 100 mg/mL), epinephrine
(1:1,000, 1:10,000, and 1:100,000), neostigmine (0.5 or 1 mg/mL), etc.

Example 1: Ephedrine. You have ephedrine 50 mg in 1 mL. You want to prepare a syringe with
10 mg/mL. What size syringe should you use? In the second step, you set up a proportion to
answer the question, If the final concentration is to be 10 mg/mL, how much diluent do you add to
1 mL of ephedrine (50 mg/mL)?

Available Ephedrine 50 mg in 1 mL vial

Desired
1 mL x mL (3.1)
=
10 mg 50 mg

1 mL x mL (3.2)
50 mg × = × 50 mg
10 mg 50 mg

Dosch Clinical Mathematics 2021 3

Solving step 3.2 gives 5 mL total volume. So, take the 1 mL Ephedrine from the vial and add 4 mL
sterile diluent in a 5 mL syringe.

Example 2: Remifentanil. If you want to create a remifentanil infusion at the recommended adult
dilution of 50 mcg/mL, and it is supplied as a vial containing 1 mg powder3, how many mL of
diluent should you add to the vial?

The first proportion (step 3.3) cannot be solved as it is, since the denominator is in milligrams (on
the left) and micrograms (on the right). So, in step 3.4, we multiply the right side by an identity
(i.e. conversion factor) which changes the denominator on the right side of the equation to mg, like
the left.

x mL 1mL (3.3)
=
1mg 50mcg

x mL 1mL 1000mcg (3.4)

= ×( )
1mg 50mcg 1mg

x mL 1000mL (3.5)
=
1mg 50mg

x mL 1000mL (3.6)
(1mg) × = × (1mg)
1mg 50mg

And thus, x = 20 mL. Take the 1 milligram of remifentanil and add 20 mL diluent, which will
result in a final concentration of 50 mcg/mL.

Example 3: Ketamine You have ketamine 500 mg in 5 mL. You want to prepare a 10 mL syringe
with 10 mg/mL. In the first step, you figure out where you are going (by finding the total drug
mass that needs to be in that syringe). In the second step, you determine what volume you need to
withdraw from the vial to get the total drug mass you want in the syringe.

Desired 𝟏𝟎 𝐦𝐠 (3.7)
× 𝟏𝟎 𝐦𝐋 = 𝟏𝟎𝟎 𝐦𝐠 (𝐭𝐨𝐭𝐚𝐥 𝐝𝐫𝐮𝐠 𝐢𝐧 𝟏𝟎 𝐦𝐋)
𝟏 𝐦𝐋

Available 500 mg 100 mg (3.8)

=
5 mL X mL

3 Remifentanil is supplied as a powder, in vials containing 1, 2, or 5 mg. https://www.rxlist.com/ultiva-drug.htm#dosage

Dosch Clinical Mathematics 2021 4

Solving 3.8 gives 100 mg per 1 mL. Therefore take ketamine 1 mL from the vial (which gives the
100 mg total drug you want in your 10 mL syringe) and add 9 mL of diluent. Label it properly, of
course, as containing 10 mg/mL ketamine.

Example 4: Epinephrine is available, marked "1/1,000" and "1 mg/mL." You are asked to
"double-dilute" it, so you take 1 mL of the epinephrine 1:1,000 and add 9 mL diluent. Then you
discard all but one mL of the new mixture, and add 9 mL diluent. What is the resulting
concentration of epinephrine in micrograms/mL?

• Epi 1:1,000 contains 1 mg/mL (= 1,000 mcg/mL). Taking 1 mL and adding 9 mL diluent
yields a syringe with 1,000 mcg/10 mL (100 mcg/1 mL).

• Taking 1 mL of this mixture (containing 100 mcg/mL) and adding 9 mL diluent to it yields
a syringe containing 100 mcg/10 mL. Each mL of the “double-diluted” new mixture
contains 10 mcg/mL.

Example 5: Epidural syringe preparation. Available: bupivacaine 0.25% (2.5 mg/mL), fentanyl
50 mcg/mL, and sterile diluent. Desired: A 60 mL syringe, containing 0.0625% (this is often called
1/16 %) bupivacaine with fentanyl 5 mcg/mL.4

Here’s Method 1: First, what is the total drug mass that you will end up with in the 60 mL
syringe?
• Bupivacaine: 0.0625% contains 0.625 mg/mL.
o How do we know this? A percent solution means grams per 100 mL. So 0.0625 %
means 0.0625 grams of drug in 100 mL of solution (and 0.625 mg/mL).

𝟎. 𝟎𝟔𝟐𝟓 𝐠 𝟏, 𝟎𝟎𝟎 𝐦𝐠 𝟔𝟐. 𝟓 𝐦𝐠 𝟎. 𝟔𝟐𝟓 𝐦𝐠 (3.9)

𝐱 = =
𝟏𝟎𝟎 𝐦𝐋 𝟏𝐠 𝟏𝟎𝟎 𝐦𝐋 𝟏 𝐦𝐋

• We want a 60 mL syringe with 0.625 mg/mL. The syringe will contain a total mass of
bupivacaine of 37.5 mg (= 60 mL * 0.625 mg/mL).

• The total mass of fentanyl in the syringe is desired to be 5 mcg/mL * 60 mL = 300 mcg.

Now we are ready to prepare the 60 mL syringe:

• The total drug mass of bupivacaine is 37.5 mg/60 mL. Take the bupivacaine 0.25% (2.5
mg/mL) and draw up 15 mL (37.5/2.5 mg = 15) in the 60 mL syringe.
• The total drug mass of fentanyl is 300 mcg/60 mL. Take the fentanyl (50 mcg/mL) and
draw up 6 mL in the 60 mL syringe. The total volume you have drawn up so far is 15 mL
(bupivacaine) + 6 mL (fentanyl) = 21 mL.
• Add 39 mL diluent to achieve a total volume of 60 mL.

4 Please keep in mind that all dosages in this document are for learning mathematics only. Please check with your colleagues to
determine an appropriate concentration & dosage to give to your patients!

Dosch Clinical Mathematics 2021 5

What if, for some reason, you had to prepare a 20 mL syringe? (Let’s say you only happen to have
a 20 mL syringe at hand.) The method is the same, if the same final concentration is desired.

• Bupivacaine: 0.0625% contains 0.625 mg/mL.

o We want a 20 mL syringe with 1/16% (0.625 mg/mL). A 20 mL syringe will
contain a total mass of bupivacaine of 12.5 mg (= 20 mL * 0.625 mg/mL).
• The total mass of fentanyl in the syringe is desired to be 5 mcg/mL * 20 mL = 100 mcg.

Now we are ready to prepare the 20 mL syringe:

• The total drug mass of bupivacaine is 12.5 mg/20 mL. Take the bupivacaine 0.25% (2.5
mg/mL) and draw up 5 mL (= 12.5/2.5 mg) in the 20 mL syringe.
• The total drug mass of fentanyl is 100 mcg/20 mL. Take the fentanyl (50 mcg/mL) and
draw up 2 mL in the 20 mL syringe. The total volume you have drawn up so far is 5 mL
(bupivacaine) + 2 mL (fentanyl) = 7 mL.
• Add 13 mL diluent to achieve a total volume of 20 mL.

Here’s Method 2: Some find it (much) easier to make the calculation of total drug mass for
bupivacaine in the 60 mL syringe in another way.

It is easy to see that the same drug mass is present in two solutions, the second of which is twice as
concentrated as the first, but contains only half the volume. Therefore, all the rows below contain
the same total mass of drug. The first row starts with what you want to end up with, and proceeds
down to what you need to start with.

“Bupivacaine 60 mL of 1/16% contains the same mass of drug as 30 mL of 1/8%.

Bupivacaine 30 mL of 1/8% contains the same mass of drug as 15 mL of 1/4%.”

Concentration of bupivacaine Volume Total mass of drug present

1/16 % (= 0.0625% = 0.625 mg/mL) 60 mL 37.5 mg

1/8 % (= 0.125% = 1.25 mg/mL) 30 mL 37.5 mg

1/4 % (= 0.25% = 2.5 mg/mL) 15 mL 37.5 mg

So, to prepare a 60 mL syringe with bupivacaine 1/16%, and fentanyl 5 mcg/mL: draw up
bupivacaine (1/4 %) 15 mL, add 6 mL fentanyl, and finally add 39 mL of diluent.

Similarly, to prepare a 20 mL syringe with bupivacaine 1/16%, and fentanyl 5 mcg/mL: draw up
bupivacaine (1/4 %) 5 mL, add 2 mL fentanyl, and finally add 13 mL of diluent.

Dosch Clinical Mathematics 2021 6

Example 6: Dexmedetomidine preparation, loading, maintenance. Available:
dexmedetomidine 200 mcg/2 mL. Add to 48 mL 0.9% normal saline, yields concentration of 4
mcg/mL. For procedural sedation, or as adjunct to general anesthesia5

Dose* Volume of 4mcg/mL dilution Rate mL/hr

(for 70 kg)
Loading Dose 0.5 mcg/kg/10 min 8.75 mL/10 min 52.5 mL/hr (for 10 min only)
Maintenance 0.5 mcg/kg/hour 8.75 mL/hr 8.75 mL/hr continuous

*Dose range for loading 0.5 to 1 mcg/kg/10 min; for maintenance 0.5 to 1 mcg/kg/hr . Base dose on LBW (Lean
Body Weight) in morbidly obese.6

Lester's No-Math Rule for Intravenous Infusions

Lester's No-Math Rule for intravenous infusions is:

The number of mg in 250 mL comes out in mcg in 1 min. at a setting of 15mL/hr, (and)
The number of grams in 250 mL comes out in mg in 1 min. at a setting of 15mL/hr.

• Why 15 mL/hr? At that rate, the volume delivered is 0.25mL (1/1,000 of a 250 mL bag) per
minute.

15mL 1hr 15mL (4)

×( )=
1hr 60min 60min

• And by division, 15 mL/60 min = 0.25 mL/min.

• 0.25 mL is a very useful quantity- it is 1/1,000 of a 250 mL IV bag. Because it is 1/1,000th of
the volume, 0.25 mL contains 1/1,000 of the mass of drug in the whole 250 mL bag.

5https://www.drugs.com/dosage/precedex.html
6Br J Anaesth 2010;105(Suppl_1):i16 doi: 10.1093/bja/aeq312; ASA Annual Meeting Abstract 2015:A4143.
Br J Anaesth 2018;120:969. doi: 10.1016/j.bja.2018.01.040

Dosch Clinical Mathematics 2021 7

 If this whole bag contains Dopamine 400 mg in 250 mL…

Then in each 0.25 mL (1/1,000th of the volume), there is

1/1,000th of the drug mass the entire bag holds.
• 400 mg x 0.001 = 0.4 mg = 400 mcg
• 250 mL x 0.001 = 0.25 mL

Examples of Lester’s No-Math Rule:

1. What is the dose of lidocaine (1 gm in 250 mL) running at 15 mL/hr?

1 mg/min. At 30 mL/hr? 2 mg/min. At 60 mL/hr? 4 mg/min.

2. What is the dose of epinephrine (1 mg/250 mL) running at 15

mL/hr? 1 microgm/min. At 30 mL/hr? 2 microgm/min. At 60 mL/hr? 4
microgm/min.

3. What rate should you set to deliver dopamine 3 mcg/kg/min for a patient who weighs 70 kg?
The dopamine concentration is 400 mg/250 mL.
o 7 mL/hr will deliver 200 microgm/min, which is approximately 3 microgm/kg/min.

Fraction, Ratios, & Decimals

• Fractions and ratios are nearly identical, except when the numerator and denominator are
small. For example, 1/3 signifies 0.33, but 1:3 signifies a ratio of 1 part to 3 parts (and thus
4 parts in total) or 0.25.
• To convert a fraction to a decimal
1 ÷ 3 = 0.3333 (5)

• To convert a decimal to a percent, divide, then multiply by 100.

(0.3333) × 100 = 33.33 % (6)

Ratios in anesthesia

• Ratios are expressed in grams/mL (recall that 1 mL of H2O weighs very close to 1 g).
• The ratio 1:100,000 is frequently encountered. So (starting with 1 gm in 100,000 mL), take
the following steps to determine the number of microgm/mL in a 1:100,000 solution. The
fractions in parentheses are conversion factors:

1gm 1000mg 1000mg (7.1)

×( )=
100,000mL 1gm 100,000mL

1000mg 0.001 1mg (7.2)

×( )=
100,000mL 0.001 100mL

Dosch Clinical Mathematics 2021 8

 1mg 1000microgm 1000microgm (7.3)
×( )=
100mL 1mg 100mL

1000microgm 0.01 10microgm (7.4)

×( )=
100mL 0.01 1mL

So a solution containing epinephrine 1:100,000 has 10 microgram of epinephrine per mL. By the
same logical steps, a solution marked 1:200,000 has 5 microgram epinephrine per mL, and a
solution marked 1:1,000,000 has 1 mcg/mL.

Percentage Solutions

● The "number of parts of drug in every hundred" is the percentage of a solution, which is
conventionally expressed as “grams per 100 mL”. Drugs commonly labeled as % include
local anesthetics, & magnesium.
● "To find the mg/mL in a % solution, move the decimal point one place to the right" is
the shortcut. For example, a 1% solution (1 g/100 mL) has 10 mg/mL:

𝟏𝐠 0.01 0.01 g 1000 mg 𝟏𝟎 𝐦𝐠 (8)

(× )= (× )=
𝟏𝟎𝟎 𝐦𝐋 0.01 1 mL 1g 𝟏 𝐦𝐋

Two easier ways to do frequent calculations

1. Convert pounds to kg (Pilchak's No-Math Rule)

To quickly convert pounds to kilograms (a formula that’s easy to do in your head): "Take half the
weight in pounds, then subtract another 10%."

Pounds (9)
( ) − 10% = Weight kg
2

2. Calculate mean arterial pressure (MAP)

The heart spends 2/3 of each cycle in diastole. So we calculate a weighted average that takes this
time factor into account. Most of us learned to do it by the following (equation 10). To me this is
slightly cumbersome (three steps needed--multiply, add, divide).

Systolic pressure + (Diastolic × 2) (10)

= MAP
3

 For example, 120/60:

120 + (60 × 2)
= 80
3

Dosch Clinical Mathematics 2021 9

Try this second method instead. While it too has three steps (subtract, divide, add), it is simpler (in
your head, adding or subtracting are easier than multiplying or dividing).
Systolic − Diastolic (11)
+ Diastolic = MAP
3

 For example,
120 − 60
+ 60 = 80
3

Ideal Body Weight (IBW) Estimation- two methods

Why is this important? 1. To protect the lungs from ventilator-associated lung injury, we use tidal
volumes (VT) of 5-7 mL/kg ideal body weight. After all, the lungs don’t get bigger when body
weight is excessive. For example, ventilating a male of average height (69 in) weighing 325 lbs
(BMI = 48)7 at 7 mL/kg using
 actual body weight (ABW), we would use VT = 1,023 mL
 using IBW (approximately 72 kg), VT = 504 mL.

2. Another important reason for calculating IBW is because the basis for drug dosages differs:8

 Dose based on Ideal (or Lean) BW: propofol (induction), NDMR (e.g. rocuronium,
cis-atracurium), narcotic loading dose, remifentanil, Tidal Volume, dexmedetomidine
(LBW).
 Dose based on Actual BW: propofol (maintenance), sugammadex9, succinylcholine,
narcotic maintenance (fentanyl, sufentanil), thiopental, midazolam.

Regardless of which method of calculating IBW you choose, keep in mind that none of these work
well at extremes of height (particularly for females whose height is < 60 in). There are excellent
discussions of IBW online10 and in print.11 Also, “these formulas have no method to compensate
for Age and Current Weight. They are only based on Height. For people who are very overweight
or obese, the Devine, [and other] formulas would suggest an ideal weight that is virtually
impossible to achieve or maintain through dieting.”12

1. Simple rule13 Easy to remember, since we most often think of height in inches and feet:

Females = 100 lb + (5lb/inch over 5 ft) (12.1)

Males = 105 lb + (6lb/inch over 5 ft) (12.2)

7 https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
8
AANA Journal April 2011: 79 (2):147; Br J Anaesth 2010;105(Suppl_1):i16; Nagelhout & Elisha. Nurse Anesthesia 6th ed. p. 1007
9
https://www.merckconnect.com/static/pdf/bridion-sugammadex-dosing-considerations.pdf
https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06782.x
10
https://halls.md/ideal-weight-formulas-broca-devine/
11 Martin and Richards BMC Pulmonary Medicine (2017) 17:85, doi 10.1186/s12890-017-0427-1
12 https://halls.md/ideal-weight-formulas-broca-devine/
13
Nagelhout & Elisha. Nurse Anesthesia 6th ed. P. 320. Also see p. 998, which gives a rule similar to Broca’s.

Dosch Clinical Mathematics 2021 10

 • Devine (1974) converted this simple rule to metric (the conversion is
approximate). An electronic medical record (Epic) uses this formula to calculate
IBW (I am told). Note- also called Predicted Body Weight (PBW).14

Females IBW kg = 45.5 kg + 2.3 kg⁄each inch over 5 feet (12.3)

Males IBW kg = 50 kg + 2.3 kg⁄each inch over 5 feet (12.4)

2. Body Mass Index (BMI) is a way to relate the actual weight to the ideal. Be sure to specify
height in meters squared. Normal BMI is less than 25, obese is less than 28, morbid is more
than 35. To use this to find IBW, set BMI to 25 and solve for weight. Hall suggests using
BMI of 23.0 for males, and 21.1 for females to estimate IBW.15

Weight kg (12.5)
BMI =
Height meters 2

Lean Body Weight (LBW)

Although less often used, "Lean" BW refers to the weight of all body tissues (muscle, bone,
organs) without fat. LBW is a way to determine the percentage of the obese weight that is
metabolically active (also known as “adjusted” BW). It might be reasonable to calculate fluids or
drugs in morbidly obese individuals based on metabolically-active tissue weight – the Lean BW.

Lean BW First Method

 The multiplier is between 0.2 and 0.5 of the difference between Actual and Ideal BW
(median .32).16 Nagelhout gives IBW x 1.3 = LBW.17 Miller uses 0.218
𝐋𝐁𝐖= 𝐈𝐁𝐖 + 𝟎. 𝟐(𝐀𝐜𝐭𝐁𝐖 − 𝐈𝐁𝐖) (13.1)

 For example, a male 6 ft 0 in. (1.83 m) and 270 lbs. (122.7 kg)
122.7 kg
• BMI = 3.34 Ht (m2) = 36.7

• IBW (using 25 BMI) = 25 ∗ 3.34 = 83.5 kg (183.7 lbs)

• Lean BW (using formula 13.1) is 91.34 kg (200.9 lbs)
 91.34 kg Lean BW= 83.5 kg + 0.2(122.7 − 83.5 kg)

14
Martin and Richards BMC Pulmonary Medicine (2017) 17:85, doi 10.1186/s12890-017-0427-1. Also see N Engl J Med. 2000;342:1301;
http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf; and Ann Pharmacother 2000;34:1066.
15
https://halls.md/ideal-weight-formulas-broca-devine/
16
Nutr Clin Pract 2005;20(4):468
17
Nagelhout Nurse Anesthesia 6th ed p. 998
18 Miller's Anesthesia 7th Ed. 2009. p. 2099.

Dosch Clinical Mathematics 2021 11

Lean BW Second Method19
Lean BW= BMI ∗ Height (m2 ) (13.2)

Males Females

For Normal Body mass, Lean BW = Ideal BW IBW=23*Ht (m2) IBW=21*Ht (m2)
Morbidly Obese (IBW same as above) LBW=26*Ht (m2) LBW=22*Ht (m2)
 For example, a male 6 ft 0 in. and 270 lbs.
122.7 kg
• BMI = 3.34 (Ht m)2 = 36.7

• IBW (using 23 BMI) = 23 ∗ 3.34 = 76.8 kg (169 lbs)

• and Lean BW = 26 ∗ 3.34 = 86.8 kg (191 lbs)

Metric System

The metric system is also known as "SI" (Systeme Internationale). The NIST Metric System
Teaching Site20 has a wealth of information on every aspect of the metric system, very clearly
presented. It's easier to learn if you start thinking of all your everyday quantities metrically- your
height, your soda can, a jar of salsa- what is their volume and weight expressed in metric system
units? A gram is 1000 mg, a mg is 1000 mcg, and a mcg is 1000 ng.
Metric Prefixes
In scientific
Prefix Associated quantity
notation
mega (M) 1,000,000 106
kilo (k) 1000 103
hecto (h) 100 102
centi (c) 0.01 10-2
milli (m) 0.001 10-3
micro (mc) 0.000001 10-6
nano (n) 0.000000001 10-9

Metric pressure units (the first two below), based on the Pascal, may be unfamiliar to those in US.

1 Bar
1000 hPa = 1,019 cm H2O = 1,013 mBar
760 torr = 760 mm Hg
1 atmosphere equals
100 kPa
29.9 in Hg
14.7 psi

19
Br J Anaesth 2012;109(5):829

20 http://physics.nist.gov/cuu/Units/index.html

Dosch Clinical Mathematics 2021 12

Temperature Conversions
℃ = 5/9 (℉ − 32) (14.1)
℉ = (9/5 × ℃) + 32 (14.2)
Or (better yet) remember the two together with:
9 × ℃ = (5 × ℉) − 160 (14.3)
Also,
Degrees Kelvin = ℃ + 273 (14.4)

Figuring oxygen concentration when air or N2O are used

It is useful as a backup to know what your oxygen analyzer "should" read. You can calculate
expected FIO2 in the total fresh gas flow (FGF). The total volume of oxygen includes all volume
from the oxygen flowmeter, plus 21% of the volume indicated on the air flowmeter (and none of
the rest of the flowmeters). Examples:

• What is the percent oxygen when 2 L/min oxygen and 2 L/min air are flowing? 60.5%

2000mL O2 + (0.21 × 2000mL Air) = 2420mL O2 (15.1)

(2420mL O2 )/(4000mL total FGF) = 60.5% O2 (15.2)

• What percent oxygen is inspired when FGF is 2 L/min O2? 1 L/min O2? 8 L/min O2?
Answer: 100% in each case
• What percent O2 is inspired when FGF is 2 L/min O2 + 2 L/min N2O? Answer: 50%
• What percent O2 is inspired when FGF is 1 L/min O2 + 2 L/min N2O? Answer: 33%

DOT-123

A clinical rule useful in (quick and roughly accurate) estimation of respiratory parameters for
infants and children. For example, you would expect a VT of 21 mL in a newborn of 7 lb.
• Dead space = 1 mL per lb,
• O2 consumption = 2 mL per lb, and
• Tidal Volume = 3 mL per lb.

Calculating how long a cylinder will last

A perennial Board-type question with clinical importance. Use a proportion to solve (there are
approximately 660 L in a full E tank of oxygen, at a service pressure of 2000 psi). Don't forget to
consider fresh gas flow (FGF).

Example: Your oxygen tank pressure gauge reads 200 psi. How long can an O2 flow of 2 L/min be
maintained?
xL 660 L (16)
=
200 psi 2000 psi

o x = 66L. Thus the tank will last 33 min, if the 66 L in the tank flows out at 2 L/min.

Dosch Clinical Mathematics 2021 13

 Acceptable blood loss (ABL)

There are many online calculators on the web.21 Try searching for "allowable blood loss
calculator." Estimated blood volume (EBV) by age and gender:

EBV mL/kg
Adults- Male 75
Female 65
Pediatrics- Premature infants 90
Neonate at term 85
Children 1-2yr 75

Then calculate allowable blood loss

Hct initial − Hct final (18)
ABL = × EBV
Hct initial

Using this formula, you still have to decide what your transfusion trigger is: lowest acceptable
hemoglobin, arterial oxygen content, or final hematocrit. While individuals vary, the allowable blood
loss by the formula above may be too lenient. The 20% rule for ABL (= EBV x 0.2) is a more
conservative, alternative approach to replacement (taking into consideration the procedure type/length
and patient history).

For example, a 70kg male patient with hematocrit 42. EBV = 5,250 mL (75mL x 70kg):

 Using HCT rule (equation 18), ABL= 5,250mL x [(42-21)/42] = 2,625mL

 Using 20% rule, ABL = 5,250mL x 0.20 = 1,050mL

Again, taking into account the patient’s history, current hemodynamic status, and procedure type
and length, it seems more reasonable to begin thinking (not necessarily transfusing) about
replacement earlier (at 1,050 mL blood loss rather than 2,625 mL). Of course, both of these
formulas are to be used as a guideline, not an absolute.22

Alternatively to both of these approaches, using hemoglobin of between 6 to 10 g/dL in addition to

patient history has been recommended.23

21 http://manuelsweb.com/nrs_calculators.htm, or https://www.mdcalc.com/maximum-allowable-blood-loss-abl-without-transfusion
22 “…the [Pirate] Code is more what you'd call guidelines than actual rules." Hector Barbossa, Pirates of the Caribbean: The Curse of
the Black Pearl
23 See discussion in Nagelhout Nurse Anesthesia 6th ed p. 369-71

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 Fluid maintenance

Pediatric fluid balance:

1. For the first 10 kg, give 4mL/kg/hr, then (19)

2. For the next 10 kg (10-20 kg), give 2mL/kg/hr, then
3. Give 1mL/kg/hr for kg greater than 20 kg.

For example, a 12 kg child gets (10 × 4) + (2 × 2) = 44 mL/hr.

And a 22 kg child gets (10 × 4) + (10 × 2) + (2 × 1) = 62 mL/hr

Adults

A fast way to calculate Maintenance/NPO fluid requirements on patients over 20kg: Instead of
equation 19, you get the same results with:

(Weight kg + 40) × Hours NPO = NPO replacement mL (20)

For example, 60kg female, NPO 8 hours

• Using equation 19: (4mL x 10) + (2mL x 10) + (1mL x 40) = 100mL x 8hrs NPO = 800mL
• Using equation 20: 60kg + 40 = 100mL x 8hrs NPO = 800mL

Endotracheal tube size, length (pediatric)

Age + 16 (21.1)
ET internal diameter (mm) =
4
Age (21.2)
Lip line = + 12
2

An equivalent formula which some use instead of 21.1:24

● Predicted Size Uncuffed Tube = (Age / 4) + 4
● Predicted Size Cuffed Tube = (Age / 4) + 3

Alveolar air25

pAO2 = FI O2 (pB − pH2 O) − 1.2 × paCO2 (22.1)

Note how alveolar (and thus arterial) oxygenation can suffer if arterial CO2 is elevated. Normal
alveolar oxygen is

101.73 torr = 0.21(760 − 47) − 1.2 × 40 (22.2)

24 https://www.mdcalc.com/pediatric-endotracheal-tube-ett-size citing Clin Intensive Care. 1991;2(6):345.

25 http://www.globalrph.com/martin_4_most2.htm

Dosch Clinical Mathematics 2021 15

But, if CO2 increases to 60 torr, alveolar oxygen must fall from 101 to 77.7 torr (!). This equation
assumes that pH2O = 47 torr at body temperature, PB is barometric pressure, and R is normal (R is
the respiratory quotient, found by dividing CO2 excreted by O2 consumed).

Arterial oxygen content26

CaO2 (mL⁄100mL blood) = (1.34 × Hb × SaO2 ) + (paO2 × 0.003) (23)

Expected pO2 for changes in FIO2

A rough thumbnail estimator based on Henry’s Law. If you increase FIO2 10%, expect paO2 to
increase 50 torr (starting values FIO2 21%, paO2 100 torr approximately).

Time constant27
Capacity
Time Constant =
Flow (24)

• A system reaches 63% of equilibrium in one time constant; 86% of equilibrium in 2 time
constants; 95% of equilibrium in 3 time constants. Applications are wash-in and washout
of gases, or time to complete preoxygenation/ denitrogenation at varied fresh gas flow
rates.

Remembering drug doses

It's always advisable with a family of drugs to work out their relative doses per 70 kg. That way,
you have a baseline for comparison and can increase or decrease your starting dose in proportion to
the patient's weight. Also, you're less likely to choose a much too big (or much too small) dose for
a patient when you have memorized what the "average weight" patient would typically receive.
● For example, reasonable intubating doses for the muscle relaxants (assume 70 kg weight)
are vecuronium 7 mg, rocuronium 42 mg, cis-atracurium 14 mg, and pancuronium 7 mg.
(Of course you would modify these doses based on body habitus and past history.)

Remember "same as…" doses. For example, vecuronium and pancuronium. Or similar doses like
the pair esmolol (bolus 0.5 mg/kg) and rocuronium (roughly the same for a low-range intubating
dose).

26 http://www.globalrph.com/martin_4_most2.htm
27 https://www.openanesthesia.org/time_constant_definition/

Dosch Clinical Mathematics 2021 16

Work out doses for a typical person

Dose mg/kg Dose/70kg

1 70 mg
0.5 35 mg
0.1 7 mg
0.05 3.5 mg
0.01 0.7 mg

Again, that way you have a concept of what those numbers mean for the "average" patient. You
can then use this concept as a means of double-checking your answer derived from the electronic
calculator, or for mental math done in haste.

Keep in mind the expected volume (number of mL) for usual doses of drugs, especially
narcotics and muscle relaxants. If you are drawing up and preparing to administer more than 3 to
10 mL of muscle relaxant as an intubating dose, it is likely your math is faulty (provided the
patient is anywhere near normal weight).

Spinal (intrathecal) doses

1. Have somewhere to start for a reasonable level (T10) for each drug.
● For example tetracaine 10 mg (1 mL of 1%)
● A reasonable lidocaine dose for the same effect is 50 to 60 mg (1 to 1.2 mL of 5%).
● A reasonable bupivacaine dose is 12 mg (1.6 mL of 0.75%).
2. Know the range of doses found to be useful at your institution, in your patients.
Modify the dose based on height, medical history, pregnancy, or whatever other factors you
like.
● When you add or subtract, remember the amount of drug in some usefully-small
quantity (spinal syringes are marked every 0.2 mL)
● lidocaine 5% has 10 mg per 0.2 mL,
● tetracaine 1% has 2 mg per 0.2 mL , and
● bupivacaine 0.75% has 1.5 mg per 0.2 mL.
3. Alter the baricity of the drug, if needed, for the effect you want. Typically, hyperbaric
spinals are given. The spinal medications may or may not come mixed in hyperbaric 7-10%
dextrose. If they do not come so mixed, add an equal volume of dextrose solution to the
local anesthetic.
4. Add any extras, have someone double-check your figures if you have the SLIGHTEST
doubt (once given, the medication is irretrievable and has profound effects), then
administer.
● Epinephrine (1:1000) 0.2 mL is a common additive.
● Preservative-free morphine 0.5-0.7 mg (0.5-0.7 mL of Duramorph 0.1%) is also
common, as is fentanyl.
● Please don't ask me how I know about the "irretrievable and profound" part.

Epidural doses

1. The rule of thumb is With a lumbar epidural placement, 10 mL of drug will generally
produce a T7 to T9 level in the average size patient, 20 mL will result in a T4 level.

Dosch Clinical Mathematics 2021 17

 2. Larger volumes of drug will be required for higher blocks, more concentrated drugs for
more intense motor block, and more dosage (total mass of drug) for increased sensory
block.28

Questions?
Return to Anesthesia Course Notes site at UDM.

28 Reese CA. Spinal and epidural blocks. 2nd ed. Park Ridge, Illinois: AANA; 1996 p. 104-5

Dosch Clinical Mathematics 2021 18