Patient Name:   (optional)

Ordering Doctor:   (optional)

Attending Pharmacist:   (optional)

Please enter the patient's weight in Kg (Kilograms):
Weight Range: 18 Kg up to 700 Kg [ 40 lbs up to 1540 lbs]

Patient Weight: Kg [ x 2.2 = lbs ]
Amount of Xigris needed per hour: mg/hr
Exact Amount of Xigris needed for 96 hrs: mg
Rounded Amount of Xigris needed for 96 hrs: mg

Preparation Guidelines:

Step 1:
Prepare bags [ mg total ] in the following manner:
----Dilute mg of Xigris in mls of 0.9% Sodium Chloride for Injection
     and infuse at mls/hr
-------Xigris concentration in each bag = mg/ml
-------Infusion Time for each bag = hr and minutes
-------Infusion Time for all = hr and minutes

Step 2:  
Prepare a final bag in the following manner:
----Dilute mg of Xigris in mls of 0.9% Sodium Chloride for Injection
     and infuse at mls/hr
-------Xigris concentration in each bag = mg/ml
-------Infuse last bag for only = hr and minutes


Please print a copy of this form for your records.