Pragmatic Adaptation of Emergency Drug Infusion Protocols for Adult Patients in Resource-Limited Emergency Departments: A Consensus-Based Guideline Adaptation Using GRADE-ADOLOPMENT from Ethiopia

Background: Emergency drug infusions in low- and middle-income countries (LMICs) face high medication error rates due to absent infusion pumps, unreliable electricity, staffing shortages, and variable practices. International guidelines require contextual adaptation for safe use in resource-limited emergency departments (EDs). Methodology: A multidisciplinary Ethiopian panel (n=22) used the GRADE-ADOLOPMENT framework to adapt high-quality source guidelines. The process followed the RIGHT-Ad@pt reporting checklist. Evidence-to-Decision frameworks considered benefits, harms, resources, equity, acceptability, and feasibility. Decisions were considered agreed upon when at least 80% of the panel reached consensus. Recommendations were graded for strength (strong/conditional) and for the certainty of the evidence. Results: The guideline provides standardised concentrations, weight-based dosing tables with gravity-driven rates (20 drops/mL tubing), nurse-driven titration, and safety measures for >15 critical infusions (vasopressors, sedatives, antiarrhythmics, antiepileptics, thrombolytics, and others). Key adaptations address LMIC constraints while preserving core benefits of source recommendations. Conclusion: This first Ethiopian context-adapted emergency infusion guideline offers a practical, low-cost framework to improve medication safety and the timeliness of care in resource-limited African EDs.