Purchase replacement installation CD here

Vancomycin is a difficult drug to dose because of extreme inter-patient variability of pk parameters. No single model will fit all patient populations.

• Look at the divergent models from the literature

The two models roughly parallel the two divergent one compartment methods:

• The Normal or CL model calculates a clearance and was derived from the work of Winter.
• The Outlier or Kel model calculates an elimination rate constant (Kel), and was derived from the works of Matzke.

Patients who may be more appropriately dosed with the outlier model include:

• obese patients (BMI > 30)
• underweight and/or malnourished patients
• nonambulatory patients (likely to have low muscle mass)
• diabetics
• patients with acute or chronic renal failure

You may analyze a single trough, a single peak, or a random level drawn at any point within the dosing interval by selecting the single point Bayesian method.

One way to grasp this concept is to understand that the serum level is the result of a dose which has been given, not from a future dose.

The difference is most likely due to the weight that you are using in your hand calculation. Because creatinine is produced by muscle tissue, C&G recommend that you use lean body weight, except in morbidly obese patients. Because creatinine is produced by muscle tissue, not fat, additional weight in form of fat does not significantly alter the production of creatinine.

There is considerable difference of opinion among practitioners concerning the most appropriate creatinine clearance equation to use. Kinetics© includes multiple creatinine clearance methods from which to choose. Use the method which is most appropriate for your patient. Please refer to this page for more information on creatinine clearance calculations:

Dosing of renally excreted drugs

Enter an infusion length of 90 minutes, which is the average time for IM absorption of aminoglycosides. Be sure to draw your peaks at least 90 plus 15 minutes after the injection.

You do not have to assume steady-state if you use the 3-point method. Draw a trough before the 600mg dose, a peak after, then a mid-point level after that. The program will use the pre-dose trough and the peak level to calculate the volume of distribution. The two post-dose levels are used to calculate the elimination rate.

Version 2.1.8 of Kinetics© added non-steady-state Bayesian analysis for the one-compartment model.

Please refer to this consensus document which appeared in the June 1997 issue of the International J. of Clinical Pharmacology and Therapeutics:

Read "Once daily dosing of aminoglycosides"

If you wish to use the more aggressive 7mg/kg dose utilized by Hartford, you may edit the model. Please see the help file for more information on how to use the model editor.

In many respects the nomogram approach to aminoglycoside dosing is just as simplistic as giving 80mg Q 8 hours to all patients with a "normal" serum creatinine. Instead, all patients should be individually dosed in order to maximize therapeutic efficacy and minimize the risk of toxicity. The patient should receive a large enough dose to produce a peak level that is 8 to 10 times greater than the MIC. The dosing interval should then be extended to produce a trough less than 0.5 mcg/ml in order to provide a washout of aminoglycoside in the renal tubule thereby reducing toxicity.

Bayesian places significant weight on the population model. Because of this reliance on the population model, it is very important with Bayesian that you pick the right model for your patient. This is a particular problem with vancomycin because of the *extreme* inter-patient variability in pk parameters.

When the program flags an "outlier", it means that, for whatever reason, the serum levels can't be statistically reconciled with the population model. If, after 100 iterations, the Bayesian object (sum of least squares) is not reduced, it gets kicked out of the loop and the patient is labeled an outlier.

Outliers are especially challenging when we are analyzing a single trough level. If the patient's trough is out of range, then you need to get a truer picture of the patient's pk parameters by measuring a peak and trough series instead of a single trough.

If a significant percentage of your patients are flagged as outliers, then there is a good possibility that the model you are using is not appropriate for your patient population. This is a situation where the population analysis tool will be helpful. Each time you print a consult based on serum level data, the calculated pk parameters are saved. This data is a virtual gold mine of information about your patient population. With this tool you can derive a model better fitted to your patients.

Yes, that's the goal of this program, to give you the ability to customize it to fit your practice. The Edit drug model function is accessed via the drop down menu tree or by the keyboard shortcut Ctl+E. The care plan field is free form text entry, you can enter anything you like in this field.

The care plan function in Kinetics© is basically just a skeleton that you can expand on because plans will differ depending on the practice setting in which the program is being used. Acute care, home care and long term care all have different monitoring parameters and schedules.

Read this review of the pharmaceutical care planning process

Please read this step-by-step tutorial, using a Vancomycin 1-compartment model as an example:

View the Kinetics© model entry tutorial

Here is a step-by-step tutorial, using glyburide as an example:

View this table entry tutorial

Unfortunately, this information is not found in one single reference. Bennett's Drug Prescribing in Renal Failure and Chernow's Critical Care Pharmacotherapy have tables of pk data for common drugs. The FDA package insert of newer drugs usually has an excellent pharmacokinetics section.

For a detailed tutorial on creating one compartment models, please see this page:

• View one-compartment tutorial

Here is a compilation of pk parameters for some common antibiotics:

• View antibiotic pk parameters

Kinetics© has had a built-in update checker since version 2.1.2, it is accessed via the Help menu:

There are three steps to the web update process, and there are three buttons on the web update dialog which correspond to the three steps.

1. Click Check for updates to access the RxKinetics web site to check for available updates. If an update is available, the "Download" button will be activated.
2. Select an update from the list by clicking on the check box next to the description, then click the Download updates button to proceed. If the download was successful, the "Install" button will be activated.
3. A running program cannot be replaced.
   Therefore, you must exit Kinetics before installing an update. Web update will not proceed with the install step until you close Kinetics.
   After you have closed the Kinetics program, click the Install updates button to begin the update process.

Kinetics© version history

As stated on the home page on the website, Kinetics© is for adults only. Also, please read the help file (press the F1 key) the patient data limits are clearly stated there.

APK© (Adult and Pediatric Kinetics) includes support for pediatrics.

Learn more about APK©.

Unfortunately, late doses can not be avoided, so how can you use these levels? There are at least two late dose scenarios, each would be handled differently, depending on the methodology you are using.

The first late dose scenario we'll describe occurs if the dose was late but the levels were correctly drawn relative to the actual hang time. For example, the nurse is supposed to be giving gent 80mg Q 8 hours, at 6-14-20, but the sample dose is given late, at 1600. The trough was drawn at 1530 and the peak at 1730. As you can see, the levels are correctly drawn relative to the late dose.

First, let's examine the Sawchuk and Zaske method. This method is the gold standard for evaluation of peak and trough levels in the one-compartment open model. Sawchuk and Zaske drew three levels: a trough before the dose, a peak after the dose, and another trough after the dose. However, many institutions take a shortcut and only draw two levels, a trough before the dose and a peak after. If the patient is at steady-state, then you can assume that the second trough after the dose will be the same as the trough before the dose. Under most circumstances, this is a valid assumption and will save laboratory expenses.

Next, look at Sawchuk and Zaske's equations for calculating pk parameters, you can find them in the program help file (Press the F1 key). Where is the dosing interval in these equations? ...... nowhere! The dosing interval is not used in any calculation.

If you are using the 3-point method, the interval is not used, and it doesn't matter if the dose was given late, as long as the levels are correctly drawn, relative to the time the dose was actually given.

If you are using the two point method, the dosing interval is only used to extrapolate the pre-dose trough to simulate the after-dose trough. Therefore, in the Kinetics© program, instead of entering the "ordered" interval, you would enter the time between the last dose and the sample dose. Using our same example, if the nurse is supposed to be giving gent 80mg Q 8 hours, at 6-14-20, but the sample dose is given late, at 1600. In the Kinetics© program you would enter an interval of 10 hours. Again, this is because the interval is only used to extrapolate the pre-dose trough.

The second late dose scenario occurs when the dose is give late and the levels are correctly drawn relative to the scheduled hang time, not the actual hang time. For example, if the nurse is supposed to be giving gent 80mg Q 8 hours, at 6-14-20, the sample dose is given late, at 1600, but the trough was drawn at 1330 and the peak at 1530. As you can see the levels are correctly drawn relative to the scheduled dose, not the actual hang time, the "peak" is not a peak at all, but a trough drawn before the dose was given.

This scenario is the result of a lack of communication between lab and nursing. In this case, throw out the peak and just use the trough. With Bayesian you only need a single trough level.

The Kinetics© program is deceptively simple in this area. When you hit a snag like this, you have to stop and think, and that's the downside to having such a simple interface for entering levels. The other alternative, and the one taken by most other PK programs, is to have you enter each and every dose and the time each dose was administered. This approach punishes you each time you have to enter a simple set of levels. The Kinetics© program only makes you work hard in a problem situation.

The program does not make any specific adjustments for amputees, so you'll need to do some calculations the old-fashioned way. Enter the patient's pre-amputation height. The program will calculate a baseline lean body weight.

Because creatinine is produced by lean tissue, to get a more accurate estimate of CrCl, you'll need to estimate post-amputation muscle mass. Start with the LBW calculated from the patient's pre-amputation height. Then deduct a percentage depending on the extent of the amputation:

• Hand - Decrease LBW by 0.7%
• Forearm and hand - Decrease LBW by 2.3%
• Total arm - Decrease LBW by 4.9%
• Foot - Decrease LBW by 1.5%
• Calf and foot - Decrease LBW by 5.8%
• Total leg - Decrease LBW by 16%

In this case, since your patient is a double amputee, you would decrease the LBW by 32%. Let's call this the Amputee-Adjusted LBW (AALBW).

If the patient's actual weight is less than the AALBW, then the patient is underweight and you should use the patient's current weight to calculate CrCl.

If the patient weighs more than the AALBW, then you should hand calculate the CrCl using the AALBW.

References

1. John Murphy's Clinical Pharmacokinetics, 2nd ed. 2001
2. Brunnstrom, S. Clinical kinesiology. 4th ed. 1983

Beginning with build 1.1.7, the Kinetics© program now includes both 1- and 2-compartment Vancomycin models, you choose whichever model best fits your practice and your patient population.

A useful feature of Kinetics© is that the drug models are not hard-coded into the program. You can edit any model to better fit your patient population, you can even add your own 1- and 2- compartment Bayesian models for any drug and for multiple patient populations, a "Swiss army knife" for pharmacokinetics if you will.

Read this tutorial on how to enter a drug model

Vancomycin is a difficult drug to dose because of extreme inter-patient variability of pk parameters. No single model will fit all patient populations.

Look at the divergent models from the literature

Vancomycin is not a predictable drug, I've had repeat patients with the same creat & weight, for whom I've recommended the same dose but the levels were completely different each time.

Read this vancomycin case from my files.

The default 2-compartment model is based on Lake and Peterson's method. I've been a fan of Lake and Peterson's method since their first paper in 1984. L&P's is the only published vancomycin dosing method which has been independently verified by other researchers.

Before you choose a dose, examine the pharmacodynamics of vancomycin. Because it is a cell-wall active drug with a short post-antibiotic effect, the trough level must remain above the MIC in order for the bactericidal activity to continue without interruption. Therefore, it is more logical to give smaller vancomycin doses more frequently with the goal of lower peak levels and higher trough levels. The 2-compartment model that comes with Kinetics© is intended to do just that, i.e., recommend smaller doses administered more frequently.

However, there is still the popular method of giving large 15-20mg/kg doses over extended intervals, every 12, 24, 48+ hours. If that is your preferred method, and you draw your peaks 1 or 2 hours after the dose, then you will get much better results with the 1-compartment model. This apparent dichotomy is understandable given the variability in vancomycin kinetics and the divergent views on its dosing.

Please realize that there is no easy answer to the dilemma of vancomycin kinetics. My advice is, don't hang your "PK hat" on your ability to predict vanco levels. I've been looking for twenty years and have yet to find a method or model that accurately predict vancomycin levels in all patients.

The Kinetics© program offers you the choice of either a 1- or 2-compartment Vancomycin model. The 1-compartment model allows you to enter target peak and troughs, however, the 2-compartment model targets a trough level only.

Choose the model which best fits your practice and your patient population. Please realize that there is no consensus on vancomycin dosing. If, in your practice, you administer "large doses less frequently" (eg, 1g Q 12-24h) then the 1-compartment model may be more appropriate. If you tend to use "small doses more frequently" (eg, 500mg Q 6-8 h) then the 2-compartment model may be more appropriate. Regardless of which model you choose, please understand that vancomycin is not a predictable drug. In other words, don't stake your pharmacokinetic reputation on your vancomycin level predictions.

Yes, here is a step-by-step how-to:

1. On the menu tree click "Tools" then "Database Report" to view the report dialog
2. Under report type, select "Consults"
3. Select the starting and ending dates
4. Under Create consult report, select "Consultant"
5. In the "Find" box enter the user's log-in name
6. Under "Sort", select how you want the report sorted

Kinetics© may be interfaced with a PIS, using our open interface specification. Please contact your PIS vendor to request implementation.

RxKinetics software interface specs

The "Calculation Detail" section displays several parameters which are used to evaluate the accuracy, reliability, and expected performance of the Bayesian derived model.

Interpreting Bayesian results

The program ships without a password.

• The first time you access the edit drug models function it will ask for a password. Before saving the password, the Kinetics© program will ask you to reenter the password to confirm it.
• Thereafter, this will be your password required to access the edit drug models function, so choose one that you can easily remember.

By default Kinetics saves the last screen position on exit. If you have multiple users with different monitor settings or are switching between laptops and desktop monitors of various sizes, windows sometimes sets the start position off screen.

To fix just turn this feature off in the setup dialog. On the "general" tab there is a check box "save window size and position", uncheck that box to turn off the save feature.

Kinetics© uses the Microsoft Jet database which gets its date format from Windows. Therefore, you must change the short-date format in the Windows Control Panel on your PC to four digit years. This will also help ensure that all your Windows programs are Y2K compatible:

1. Open Control Panel
2. Choose Regional options (or settings)
3. Select Short Date style = MM/dd/yyyy, or, if British system utilized, dd/MM/yyyy.
4. Click Okay

Build 1.1.6 (32-bit only) added an automatic date formatting function on program startup. Each time you start up the Kinetics© program it checks the current Windows date format and, if necessary, changes it to a 4-digit year. However, because Windows is an unstable and unpredictable platform, you should check the date format in Control Panel if you are having date entry problems. To obtain the latest build please check the Downloads page on this site.

In the latest versions, patient entry is separate from drug model selection. While in edit or add mode your only options are to "Save" or "Cancel", all other functions are disabled. You must "Save" or "Cancel" the current patient before the drug model selection (or any other function) becomes re-activated.

There are several visual clues on the interface meant to help you, the toolbar icons are "greyed-out", all the databar icons except Save and Cancel are "greyed-out", the drug model selection box is disabled, the tab titles are "greyed-out". The most notable clue is the status line to the left of the data bar. You cannot select a drug model (or any other function) while you are "Adding" or "Editing", only after you click "Save" or "Cancel" do these functions become reactivated. Only when the status line says "Browsing" are you able to select a drug model.

In the older versions it was possible to accidently change patient data while browsing the records. This change improves the stability and integrity of the patient database.

Follow these steps:

1. Copy these two files from your current install folder (usually c:\clinical) to a temporary folder, a floppy disk or any other removable media:
   • kinetics.mdb = database
   • kinetics.ini = settings
2. Install Kinetics© onto your new computer from the original installation CD.
   Purchase replacement installation CD
3. Copy the data files saved in step 1 to the install folder in your new computer.
4. Download and install the latest update patch from the website:
   Update request form

There is a known issue with dDoc on some video cards (driver problem) where the card is set to 24-bit or 32-bit color. This issue causes a *blank* preview window to display initially. Clicking on the window to resize the preview will display the previewed document. Also, clicking the print button will print the report just fine (it's a video-only problem).

One work around for this is to set the color depth in the video display settings down to 16-bit color (this is a faster mode anyway, with very little difference in video quality).

Otherwise, you may download the updated dDoc print engine here:

Download dDoc print preview engine

That is a good question. A patient may also have scoliosis or severe contractions that prevent a true height measurement. There are (at least) three methods that may be used to estimate height when actual measurement is not possible: knee height, forearm length and demi-span.

Estimating height in bedridden patients

"Y-intercept less than zero" is displayed when the regression line intercepts the Y axis below zero. "Regression analysis yielded a negative slope" is displayed when the regression line is inverted.

The regression line is a plot of Y vs X where X is creatinine clearance (the independent variable) and Y is the elimination rate (the dependent variable). The Y intercept is the Nonrenal Kel, the slope of the regression line is the Renal Kel for the following equation:

Kel = NonRenalK + [CrCl x RenalK]

Both of these "errors" are caused by a widely scattered data set for which a regression line cannot be accurately calculated. This would be expected with a drug like Vancomycin which has a wide variability in pk parameters. Usually it takes a higher N in your data set before the data becomes analyzable. Keep saving your consults and eventually you will acquire a data set that will give usable results.

When attempting to access the product help, you may see a message similar to this one:

Beginning with Windows Vista, the Windows Help program (WinHlp32.exe) is no longer distributed with Windows. The question is, WHY? Microsoft will let us run the older programs, but does not want us to use HELP for these programs? A little silly, eh? So, Microsoft maintains, currently, SIX different installs for winhlp32.exe:

Microsoft KB Article 917607

It serves no purpose for Microsoft to continually create install files for winhlp32.exe with each new version of Windows because it is THE EXACT SAME PROGRAM, nothing has changed!

Microsoft asks developers to use a different help format. What they can't seem to comprehend is, there are multiple problems with all of the suggested replacements (CHM, HTML, XML). And none of these formats is as user-friendly as WinHelp.

Now, Microsoft wants us to wait until they decide to make an installer for Windows 10. Well, I am tired of waiting and found a way to create my own WinHelp installer for Windows 10. Although it is technically "illegal" to distribute winhlp32.exe, here it is. Download, right click on the file, and select Run as administrator.

Download WinHelp for Windows 10

If you can't use this fix, you may view the help file online here:

Kinetics help

Yes.

All versions of 64-bit Windows (XP, Vista, 7, 8, 10) are able to run 32-bit programs seamlessly through WOW64 which is provided with the operating system and does not have to be explicitly enabled. In other words, it's 100% automatic. (Ref: Microsoft)

According to Microsoft, 32-bit software running under WOW64 has a similar performance when executing under 32-bit Windows. (Ref: Microsoft)

Check the active task list in your Windows Task Manager (Ctrl+Alt+Del). If it's there, then the Kinetics window is off screen. This behavior is sometimes triggered when you switch between different monitor resolutions and orientations.

How to resolve:

1. Click on the Kinetics icon to start the app.
2. Login blindly, i.e., type your user login name, press the Tab key, then press the enter key.
3. Hold the Alt key down and press the space bar. This brings up the Windows move function.
4. Press and release the M key.
5. Use the Arrow keys or wiggle the mouse to move the window into view.
6. When the window comes into view press the Enter key.

This is caused by missing or improperly installed dDoc print preview engine. Please reinstall from the CD, or download from the web site.

Download dDoc print preview engine

This error too is caused by missing or improperly installed dDoc print preview engine. As above, please reinstall from the CD, or download from the web site.

Download dDoc print preview engine

This error too is caused by missing or improperly installed dDoc print preview engine. As above, please reinstall from the CD, or download from the web site.

Download dDoc print preview engine

This is usually caused by improper Windows or Netware folder permissions. Users must have "full" read and write permissions on ALL program related folders on the workstation and the server. You must have administrator privileges to change permissions.

'Error 91' is a nonspecific error which is usually caused by a missing or incorrectly installed component required by Kinetics©.

• If this is a new install, then there was an error during the installation. Please reinstall from the CD. Also, some antivirus programs may interfere with the installation, please temporarily stop your antivirus program.
• If this occurred after an upgrade, then please download and install the "Complete Update Package".
• If this is a new problem on a previously working PC, then another software application you recently installed may have corrupted the Windows registry. To fix this problem: first re-install Kinetics© from the original install disks or CD, then download and install the "Complete Update Package".
• If this occurred on a Windows XP computer with more than 768MB of RAM, then please download and install the "Version 2 Upgrade Package".

If the error persists, please download the Kinetics component checker program. Clicking the "Register" button on the component checker usually fixes the problem.

If you believe the Kinetics database was corrupted, e.g., following a server crash, do not attempt to repair the database with desktop Access. Access will irreversibly change the structure of the Kinetics database, rendering it useless. Instead, please download the Kinetics database repair tool.

This problem usually occurs when some other software application corrupts the Windows registry or installs an incompatible version of a control, causing Kinetics© to be unable to load and use the control.

This is usually easier to fix than the Error 429, because Windows reports back with the name of the control that is causing the problem. Please note the name of the control and e-mail RxKinetics support with the specifics.

Also, please download the Kinetics component checker program.

You have inadvertently erased or removed the reference to the Microsoft Data Access Objects, or your Windows registry is corrupted.

The easiest way to fix this problem is to re-install Kinetics© from the original install disks or CD, then download and install the "Complete update package".

RegClean is a free utility from Microsoft that is designed to remove errors from the Windows 95/98/NT Registry. These errors usually consist of corrupted, unused, or unnecessary information. The program scans your Registry for problems and provides you with the option of automatically fixing them. Please note that this program does not work on Windows 2000 and XP.

Unfortunately, the Microsoft page describing RegClean is no longer available, but the program is still widely available from various download sites and can be found by a web search for the keywords 'RegClean' and 'download'.

Google search for RegClean

If the error persists, please download the Kinetics component checker program.

This problem usually occurs when some other software application installs an incompatible version of a shared file, causing Kinetics© to be unable to load and use the file.

This error message is often difficult to troubleshoot because Windows does not report back with the name of the file that is causing the problem.

Please download the Kinetics component checker program.

This is an error in the Windows OLE automation object, it is usually caused by a corrupt key in your Windows registry. RegClean is a free utility from Microsoft that is designed to remove errors from the Windows 95/98/NT Registry. These errors usually consist of corrupted, unused, or unnecessary information. The program scans your Registry for problems and provides you with the option of automatically fixing them. Please note that this program does not work on Windows 2000 and XP.

Unfortunately, the Microsoft page describing RegClean is no longer available, but the program is still widely available from various download sites and can be found by a web search for the keywords 'RegClean' and 'download'.

Google search for RegClean

This is another misleading error message from Windows. This problem only occurs on Windows XP systems with more than 768MB of RAM, so the cause is actually "too much" memory. This particular problem has only recently come to our attention because of the popularity of 1GB RAM chips in newer PC's.

This problem occurs because the Microsoft Jet 3.0 database engine used by Kinetics© 1.X.X. does not work within the XP memory manager. The reason for this is, Microsoft has dropped support for the Jet 3.0 engine and is no longer ensuring its' compatibility with newer versions of Windows.

Please download and install the "Version 2 Upgrade Package".

To obtain the latest build please visit the Kinetics download request page.

You are attempting to open the latest database with an old version of Kinetics.

Download and install the Kinetics update patch to fix the problem.

A required supporting file (DLL or OCX) is missing or is incorrectly installed.

If you have the original install disk, re-install Kinetics©, then download and install the "Complete update package".

If you don't have an original install disk, then installation of the "Complete update package" may fix the problem.

If the error persists, please download the Kinetics component checker program.

This is another folder permission issue with Windows NT4, 2000 and XP only. Change the user permissions for the folder containing Kinetics© to allow Write permissions for all users.

The problem occurs if you would happen to enter Patient, RPh, or Physician names greater than the maximum allowed length. These are the same field restrictions as in the DOS version, however in DOS the fields automatically truncate, in Windows it crashes! This is what Microsoft refers to as "an undocumented feature". Build 1.1.4 and later has code to prevent this error.

To obtain the latest build please check the Downloads page on this site.

A required supporting file (DLL or OCX) is missing or is incorrectly installed.

If you have the original install disk, re-install Kinetics©, then download and install the "Complete update package".

If you don't have an original install disk, then installation of the "Complete update package" may fix the problem.

If the error persists, please download the Kinetics component checker program.

A required supporting file (DLL or OCX) is missing or is incorrectly installed.

If you have the original install disk, re-install Kinetics©, then download and install the "Complete update package".

If you don't have an original install disk, then installation of the "Complete update package" may fix the problem.

If the error persists, please download the Kinetics component checker program.