Table 4.

Factors affecting adaptation in low resource settings or low income countries

Adaptation variable	Consideration for adaptation
Priority	The decision whether to prioritise recommendations on the use of NMBA infusion in low resource settings or low-income countries depends on the prevalence and the outcomes of ARDS in this setting
Benefit and harm	Guideline developers in low resource settings or low-income countries can use the relative estimates from this document to estimate absolute treatment effect in their context
Certainty of the evidence	Guideline developers in low resource settings or low-income countries should consider downgrading the certainty of evidence for indirectness, as most of the clinical trials were conducted in tertiary care centres in high income countries, and its applicability to other contexts is unknown
Values and preferences	Values and preferences of patients are possibly different around the world, therefore, guideline developers in low resource settings or low-income countries should take into consideration the local cultural values and patients’ beliefs regarding the key outcomes such as mortality, disability, and other outcomes
Cost	While the cost of cisatracurium infusion is generally acceptable in high income countries, it could be moderate or high in low resource settings or low-income countries
Resources	Access to critical care, paralysis monitoring devices, rescue therapies, rehabilitation centres are limited in low resource settings or low-income countries
Equity	Guideline developers in low resource settings or low-income countries should consider the impact of directing resources to use NMBA infusion in ARDS on equity and other competing priorities
Acceptability	Guideline developers in low resource settings or low-income countries should consider the acceptability of using NMBA infusion to patients, healthcare workers, and policy makers
Feasibility	Several potential factors could influence the feasibility of using NMBA infusion in patients with ARDS in low resource settings or low-income countries, such as availability of medications, devices to monitor adequacy of paralysis, sedative agents, and ventilators

ARDS acute respiratory distress syndrome, NMBA neuromuscular blocking agent