Si un frasco de suspensión indica que contiene $200\ mg$ en $5\ ml$, y usted necesita administrar $100\ mg$, ¿cuántas cucharaditas debe indicar al paciente?

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Fórmulas Básicas para Cálculo de Dosis Dominar las ecuaciones matemáticas y conversiones fundamentales para calcular dosis precisas de medicamentos, incluyendo la regla de tres, la velocidad de infusión intravenosa y la dosificación pediátrica en función del peso corporal. El cálculo correcto de dosis es una competencia fundamental en el primer nivel de atención y en el ámbito hospitalario. Un error en la conversión de unidades o en la aplicación de las fórmulas puede derivar en fallos terapéuticos o toxicidad severa. ### 1. La Regla de Tres La regla de tres es el principio matemático más utilizado para obtener el volumen exacto a administrar a partir de una presentación farmacológica conocida. Fórmula que permite calcular el volumen de medicamento a administrar relacionando la dosis que el médico ha prescrito con la concentración del fármaco disponible en la clínica. $$Volumen = \frac{Dosis\ deseada \times Volumen\ disponible}{Dosis\ disponible}$$ Siempre asegúrese de que la **Dosis deseada** y la **Dosis disponible** estén en la misma unidad de medida (por ejemplo, ambas en miligramos) antes de realizar la multiplicación. ### 2. Cálculo de Goteo Intravenoso Para administrar fluidos o medicamentos continuos sin bomba de infusión, se debe calcular la velocidad de goteo según el equipo utilizado. Se utiliza para administrar volúmenes grandes. El factor de goteo estándar suele ser de 20 gotas por mililitro. $$Gotas/min = \frac{Volumen\ (ml) \times 20}{Tiempo\ (minutos)}$$ Se utiliza en pediatría o para medicamentos delicados, ya que permite mayor precisión. El factor es de 60 microgotas por mililitro (1 microgota/min = 1 ml/h). $$Microgotas/min = \frac{Volumen\ (ml)}{Tiempo\ (horas)}$$ ### 3. Dosis Pediátrica Los niños no son adultos pequeños; su medicación se dosifica estrictamente en función de su peso corporal, habitualmente expresado en $mg/kg/día$ o $mg/kg/dosis$. 1. Calcular la dosis total diaria multiplicando el peso del paciente por la dosis indicada: $$Dosis\ total\ al\ día = Peso\ (kg) \times Dosis\ (\frac{mg}{kg/día})$$ 2. Dividir la dosis total entre el número de tomas al día (por ejemplo, cada 8 horas = 3 tomas): $$Dosis\ por\ toma = \frac{Dosis\ total\ al\ día}{N^{\circ}\ de\ tomas}$$ 3. Aplicar la regla de tres para convertir los miligramos por toma en mililitros a administrar. ### 4. Equivalencias y Conversiones El dominio de las unidades de masa y volumen es obligatorio. Memorice las siguientes equivalencias: Unidad Origen | Equivalencia 1 gramo (g) | 1000 miligramos (mg) 1 miligramo (mg) | 1000 microgramos (mcg o $\mu g$) 1 cucharadita | 5 mililitros (ml) Si un frasco de suspensión indica que contiene $200\ mg$ en $5\ ml$, y usted necesita administrar $100\ mg$, ¿cuántas cucharaditas debe indicar al paciente? Correcto. Si $5\ ml$ contienen $200\ mg$, $100\ mg$ (la mitad) estarán en $2.5\ ml$. Como una cucharadita equivale a $5\ ml$, $2.5\ ml$ corresponde a media cucharadita. Las tres herramientas fundamentales del cálculo farmacológico son: la **regla de tres** para obtener volúmenes, las fórmulas de **goteo** (normo y microgotero) para terapia intravenosa, y el cálculo por **peso corporal** en pediatría. ------ ## Aplicación Práctica en el Primer Nivel de Atención Esta sección aplica las fórmulas anteriores a los escenarios clínicos más comunes utilizando los fármacos de mayor circulación en el primer nivel de atención. ### Bloque A: Antibióticos El error más común al prescribir antibióticos en suspensión es no dividir la dosis diaria entre la frecuencia de administración. **Caso:** Niño de $18\ kg$ con faringitis. **Indicación:** Amoxicilina $50\ mg/kg/día$ cada 8 horas. **Presentación:** Suspensión $250\ mg/5\ ml$. **Paso 1: Dosis total diaria** $$18\ kg \times 50\ mg/kg = 900\ mg/día$$ **Paso 2: Dosis por toma (cada 8h = 3 veces al día)** $$900\ mg \div 3\ tomas = 300\ mg/toma$$ **Paso 3: Volumen por toma (Regla de 3)** $$Volumen = \frac{300\ mg \times 5\ ml}{250\ mg} = 6\ ml$$ **Respuesta:** Administrar $6\ ml$ por toma. Nunca confunda la dosis total diaria con la dosis por toma. Administrar la dosis de todo un día en una sola toma (cuando se indicó fraccionada) causará sobredosificación. ### Bloque B: Analgésicos y Antipiréticos A diferencia de algunos antibióticos que se calculan por día, muchos analgésicos se calculan **por dosis** ($mg/kg/dosis$). **Caso:** Niño de $12\ kg$ con fiebre de $39^{\circ}C$. **Indicación:** Paracetamol $15\ mg/kg/dosis$ cada 6 horas. **Presentación:** Suspensión $120\ mg/5\ ml$. **Paso 1: Dosis por toma directa** $$12\ kg \times 15\ mg/kg/dosis = 180\ mg/toma$$ *(Al estar la indicación por dosis, no hay que dividir entre el número de tomas).* **Paso 2: Volumen** $$Volumen = \frac{180\ mg \times 5\ ml}{120\ mg} = 7.5\ ml$$ **Respuesta:** Administrar $7.5\ ml$ en caso de fiebre. ### Bloque C: Terapia Respiratoria y Urgencias En casos de urgencia respiratoria, a menudo se prescriben broncodilatadores o corticosteroides que requieren dilución. **Caso:** Dosis indicada de Salbutamol es $2.5\ mg$ nebulizado. **Presentación:** Solución para nebulizar $5\ mg/ml$. **Cálculo del fármaco:** $$Volumen = \frac{2.5\ mg \times 1\ ml}{5\ mg} = 0.5\ ml$$ **Dilución:** En terapia respiratoria pediátrica, el volumen total en la mascarilla debe ser de unos $3\ ml$ para asegurar un tiempo adecuado de nebulización. Por lo tanto, a los $0.5\ ml$ del fármaco se le añaden $2.5\ ml$ de Solución Salina Normal (SSN al 0.9%). Al preparar una dosis intravenosa de Omeprazol de $40\ mg$ a partir de un vial de polvo liofilizado, ¿qué consideraciones de dilución y tiempo se recomiendan generalmente? Se debe diluir en $10$ a $20\ ml$ de solución salina o dextrosa y administrar de forma lenta en un tiempo mínimo de $3$ a $5$ minutos. ------ ## Cálculo y Farmacología de Aminas Vasopresoras Comprender la farmacocinética, farmacodinamia y cálculo de dosis en infusión continua de las aminas vasoactivas de uso hospitalario: Dopamina, Adrenalina, Noradrenalina y Dobutamina. Las aminas vasopresoras se administran en infusión continua a través de bombas perfusoras. Pequeñas variaciones en la dosis generan cambios drásticos en la hemodinamia del paciente. ### 1. Farmacocinética General de las Aminas Aunque cada amina actúa sobre diferentes receptores, comparten un perfil farmacocinético sumamente rápido: 0.5 - 1 min :: Inicio de acción inmediato (30 a 60 segundos). 2 min :: Vida media de eliminación en el plasma plasmático. 5 - 10 min :: Tiempo de acción máxima alcanzado tras iniciar la infusión. Metabolismo :: Degradación enzimática rápida a nivel de hígado, riñones y plasma. Debido a su vida media de apenas {{2 minutos}}, estas drogas no pueden suspenderse abruptamente; deben ser "destetadas" (disminuidas gradualmente) para evitar el colapso hemodinámico del paciente. ### 2. Dopamina: Efecto Dependiente de Dosis La dopamina es única porque su efecto predominante cambia por completo dependiendo de la velocidad de infusión. ```mermaid flowchart TD D["Dosis de Dopamina"] ==> A["Baja: 2 a 5 mcg/kg/min"] D ==> B["Media: 5 a 10 mcg/kg/min"] D ==> C["Alta: > 10 mcg/kg/min"] A -->|"Receptores Dopa"| A1["Aumenta perfusión renal y mesentérica"] B -->|"Receptores Beta-1"| B1["Efecto Inotrópico (Fuerza cardiaca)"] C -->|"Receptores Alfa-1"| C1["Efecto Vasopresor (Sube presión arterial)"] ``` ### 3. Comparativa de Aminas y Receptores A medida que se aumenta la dosis de otras aminas, también se reclutan diferentes receptores adrenérgicos. **Dosis baja ($<0.05\ \mu g/kg/min$):** Aumenta el Gasto Cardiaco (GC) y Volumen Sistólico (VS), con disminución de las Resistencias Vasculares Sistémicas (RVS) por efecto Beta-1 y Beta-2. **Dosis media ($0.05 - 0.1\ \mu g/kg/min$):** Pierde el efecto Beta-2 vasodilatador. Produce aumento marcado del GC y la Frecuencia Cardiaca (FC). **Dosis alta ($0.1 - 0.2\ \mu g/kg/min$):** Fuerte efecto Alfa-1. Aumenta drásticamente las Resistencias Vasculares (RVS). **Noradrenalina:** Dosis general de $0.05 - 20\ \mu g/kg/min$. Su acción principal y directa es sobre receptores Alfa-1, incrementando rápidamente las Resistencias Vasculares Periféricas (RVP). También estimula receptores Beta-1 aumentando la frecuencia cardiaca. **Dobutamina (Inotrópico puro):** Isómero (+ y -) que funciona principalmente como agonista Beta-1. De $2 - 10\ \mu g/kg/min$ aumenta el GC y disminuye las RVP. Más de $10\ \mu g$ pierde el efecto vasodilatador periférico. ### 4. Efectos Adversos Comunes El uso de soporte vasopresor exige vigilancia estricta en Unidad de Cuidados Intensivos debido al alto riesgo de complicaciones. Efecto Adverso | Dopamina | Noradrenalina | Dobutamina Necrosis por extravasación | Sí | Sí | Sí Incremento consumo de O2 | Sí | Sí | Sí Arritmias y Taquicardia | Sí | Sí | Sí Hipertensión Arterial | Sí | Sí | No Hiperglicemia | Sí | Sí | No documentado Efecto inmunosupresor | Sí | No | No La infusión de aminas debe realizarse preferentemente por un **catéter venoso central**. Si ocurre extravasación en una vía periférica, la isquemia producida por la intensa vasoconstricción local provocará necrosis de los tejidos. ### 5. Cálculo en Bomba de Infusión La programación de las bombas perfusoras requiere convertir la indicación médica en mililitros por hora ($ml/h$) o mililitros por minuto ($ml/min$). **Nota sobre Fórmulas Aritméticas** En diversos manuales clínicos, las fórmulas de preparación pueden simplificarse o utilizar constantes precalculadas que, a simple vista, difieren de la regla de tres estricta. La ecuación universal para determinar la velocidad en una bomba volumétrica es: $$Velocidad\ (ml/h) = \frac{Dosis\ (\mu g/kg/min) \times Peso\ (kg) \times 60\ (min/h)}{Concentración\ del\ preparado\ (\mu g/ml)}$$ A continuación, se muestra cómo se estructura habitualmente la indicación de una dilución (según los ejemplos del manual de referencia): **Caso:** Paciente de $70\ kg$. **Indicación:** Dosis de $0.05\ \mu g/kg/min$. **Preparación estándar:** 2 ampollas de Noradrenalina (cada una de $4\ mg/4\ ml$, total $8\ mg$) más $42\ ml$ de Solución Salina. **Volumen total:** $8\ ml\ (fármaco) + 42\ ml\ (SSN) = 50\ ml$. **Concentración final:** $8\ mg$ equivalen a $8,000\ \mu g$. En $50\ ml$, la concentración es $160\ \mu g/ml$. *El cálculo determina exactamente a cuántos ml/minuto o ml/hora debe correr la bomba para entregar los microgramos requeridos cada minuto.* Confundir miligramos ($mg$) con microgramos ($\mu g$) al calcular la concentración final de la mezcla en la bomba de infusión es un error crítico. 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Taller de cálculo de dosis

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