Anaesthetists’ knowledge and frequency of use of neuromuscular monitoring at the University of the Witwatersrand Michael Kgowe Setsomelo A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Anaesthesiology. Johannesburg, 2022 ii Declaration I, Michael Kgowe Setsomelo declare that this research report is my own unaided work. It is being submitted for the Degree of Master of Medicine in the branch of Anaesthesiology at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at any other University. 24 March 2022 iii Abstract Background Neuromuscular blocking agents (NMBA) are commonly administered during general anaesthesia (GA). The use of these agents can result in postoperative residual neuromuscular blockade (PRNMB) as a complication. Studies have shown that such complication can be reduced with the use of neuromuscular monitors (NMM). Data from South Africa as to the knowledge and use of NMM is scanty. Therefore, the aim of this study is to assess the knowledge and the frequency of use of NMM in the Department of Anaesthesia at the University of the Witwatersrand (Wits). Methods A prospective, contextual study design was used. Data was collected using a self- administered online questionnaire developed by the researcher with the assistance of senior anaesthetists. The study population consisted of all anaesthetists working in the Department of Anaesthesia at Wits. A convenience sampling method was used and a completion with return of the online questionnaire implied consent to participate in the study. Adequate knowledge was defined by a score of 65.5% as determined by the Angoff method. Results Two hundred and eight anaesthetists were available during the period of data collection. Of these, 126 anaesthetists completed the questionnaire. There was inadequate level of knowledge of NMM among anaesthetists in our department. Sixty-four percent of the anaesthetists achieved less than the set Angoff score of 65.5%. The anaesthetist’ mean score of the questionnaire was also 57%. The level of knowledge differs significantly depending on professional designation with p-value <0.009. Medical Officers and second year registrars scored significantly below the Angoff score with p-values of 0.0005 and 0.02 respectively, while first year registrars recorded the highest score, followed by fourth year registrars. The frequency of use of NMM in the department is low at 13%. iv Conclusion The level of knowledge among anaesthetists with respect to NMM was inadequate. There is a need for improvement of knowledge regarding NMM use, by ongoing education in our anaesthesia department. Formulating evidence-based guidelines which support the use of NMM in all patient who received NMBA will be beneficial. The use of NMM in our department is also low. The commonest reason for not using NMM was unavailability of these monitors. Healthcare authorities have the obligation to increase the availability and accessibility of NMM. A national study in this subject is warranted to see if this is any different among anaesthetists in South Africa. v Acknowledgements I would like to acknowledge the massive, constructive contribution to this study by my primary supervisors being Dr Lunganga Toms Lushiku and Dr Sithandiwe Dingezweni. I would also like to thank the Department of Anaesthesia at Wits University for granting me the opportunity to do this study with their anaesthetists. I would like to acknowledge and thank Dr Ernest Welch who tirelessly assisted, contributed, and guided me during questionnaire development. I acknowledge the contribution of Dr N Madima, Dr S Mayet and Dr J Wagner who reviewed and validated the questionnaire. The author further acknowledges the contribution of Dr N Madima, Dr S Mayet and Dr A Mamoojee who made up a team to determine the Angoff method score. I acknowledge the contribution and role of Prof P Motshabi, Dr P Abrahams and Dr B Gardner in tirelessly re-distributing the online questionnaire to all anaesthetists working in the Department of Anaesthesia at Wits. I acknowledge the contribution of Ms Gill Hendry, Dr Lunganga Toms Lushiku and Dr Sithandiwe Dingezweni in statistical analysis of this research project. I would like to thank Dr Gabriel Mukucha for his support and advice when preparing my research proposal. Special mention and thanks to my family, Dr Tebogo Orapeleng and Mr Kopano Bolokwe for their support and advice throughout this research. vi Table of Contents Declaration ...................................................................................................................... ii Abstract .......................................................................................................................... iii Acknowledgements ......................................................................................................... v List of tables ................................................................................................................... ix List of figures………………………………………………………………………………….x Abbreviations ................................................................................................................. xi Statement ...................................................................................................................... xii Section 1: Review of the literature ................................................................................. 1 1.1 Introduction ............................................................................................................ 1 1.2 Neuromuscular monitoring .................................................................................... 1 1.2.1 Physics on how neuromuscular monitor works.............................................. 1 1.2.2 Clinical modes/patterns of neuromuscular monitor ....................................... 1 1.2.3 Determinants of neural stimulation ................................................................. 2 1.2.4 Site of measurement ....................................................................................... 3 1.2.5 Types of neuromuscular monitors .................................................................. 3 1.3 Clinical signs use in monitoring neuromuscular blockade ................................... 4 1.4 Why Neuromuscular monitoring ........................................................................... 4 1.5 Current practice in relation to neuromuscular monitoring use ............................. 5 1.6 Neuromuscular monitoring usage ......................................................................... 6 vii 1.7 Knowledge of neuromuscular monitoring ............................................................. 7 1.8 References ............................................................................................................ 8 Section 2: Author’s guidelines ...................................................................................... 14 1. Submission Preparation Checklist ........................................................................ 14 2. Author Guidelines .................................................................................................. 14 3. Copyright Notice .................................................................................................... 22 4. Privacy Statement ................................................................................................. 22 Section 3 Draft article ................................................................................................... 23 Section 4 Proposal ........................................................................................................ 43 4.1 Introduction and problem statement ................................................................... 44 4.2 Problem statement .............................................................................................. 48 4.3 Aim and objectives .............................................................................................. 49 4.3.1 Aim ................................................................................................................ 49 4.3.2 Objectives ..................................................................................................... 49 4.4 Research assumptions ........................................................................................ 49 4.5 Demarcation of study field .................................................................................. 50 4.6 Ethical considerations ......................................................................................... 50 4.7 Research methodology ....................................................................................... 52 4.7.1 Research design ........................................................................................... 52 4.7.2 Study population ........................................................................................... 52 viii 4.7.3 Study sample ................................................................................................ 52 4.7.4 Inclusion and exclusion criteria .................................................................... 53 4.7.5 Data collection .............................................................................................. 53 4.7.6 Data analysis................................................................................................. 54 4.8 Significance of the study ..................................................................................... 55 4.9 Validity and reliability of the study....................................................................... 55 4.10 Potential limitations ........................................................................................... 56 4.11 Project outline .................................................................................................... 56 4.11.1 Time frame .................................................................................................. 56 4.11.2 Budget ......................................................................................................... 57 4.12 References ........................................................................................................ 58 4.13 Appendices ........................................................................................................ 62 Section 5: Annexures .................................................................................................... 75 5.1 Ethics Approval ................................................................................................... 75 5.2 Graduate studies approval .................................................................................. 76 5.3 Turnitin report ...................................................................................................... 77 ix List of tables Table I: Anaesthetists’ distribution…………………………………………………31 Table II: Angoff score and professional designation…………………………….32 Table III: Distribution of mean score according to professional designation….33 Table IV: Questions and proportion of correct and incorrect answers………...34 Table V: Comparison of level of knowledge across professional designation..35 Table VI: Reasons for not using NMM…………………………………………….36 x List of figures Figure I: Use of NMM by anaesthetists……………………………………………36 xi Abbreviations AMG Acceleromyography ASA American Society of Anesthesiology CHBAH Chris Hani Baragwanath Academic Hospital DAS Difficult Airway Society DBS Double burst stimulation EMG Electromyography GA General anaesthesia MMG Mechanomyography MO Medical officer MS Millisecond NDMR Non depolarising muscle relaxants NMBA Neuromuscular blocking agents NMM Neuromuscular monitoring/Neuromuscular monitor PNS Peripheral nerve stimulator PRNMB Postoperative residual neuromuscular blockade PTC Post tetanic count SASA South African Society of Anaesthesiologists ST Single twitch TOF Train of four TORC Train of four count TOFR Train of four ratio TS Tetanic stimulation USA United States of America Wits University of the Witwatersrand xii Statement The Research Report consists of a literature review, draft article, study proposal and appendices. The study proposal is included for background reference and is not for examination. The formatting of this Research Report complies with the University of the Witwatersrand’s Style Guide for Theses, Dissertations and Research Reports. The formatting of the draft article may differ from the author guidelines of the South African journal of Anaesthesia and Analgesia (SAJAA), the journal to which it is intended to be submitted, in order to comply with the university’s style guide. 1 Section 1: Review of the literature 1.1 Introduction Neuromuscular blocking agents (NMBA) cause muscle relaxation and are often used during general anaesthesia (GA) to improve endotracheal intubation as well as the surgical condition (1, 2). The use of these agents cause postoperative residual neuromuscular blockade (PRNMB) with predominantly airway complications (3). In the 1950’s, it was reported that their use was associated with higher mortality rates than when NMBA were not used (4). In 1958 peripheral nerve stimulator (PNS) was introduced to monitor neuromuscular blockade (4-6). In 1965 Churchill-Davidson demonstrated that a PNS was the only method to assess the degree of neuromuscular blockade after using NMBA (4). The use of NMM has been shown to reduce PRNMB (7, 8). Knowledge on when to extubate a patient based on NMM guidance is paramount (9, 10). It is important to know anaesthetists’ knowledge and frequency of use of NMM to allow for focused training and reduce PRNMB complications. The principles of NMM function and its use will be described under the following headings. 1.2 Neuromuscular monitoring 1.2.1 Physics on how neuromuscular monitor works A pulse duration and current large and long enough to stimulate all nerve fibres is called maximal stimulus (11). If this stimulus is increased by 10-20% to negate the effects of skin resistance it is now called supramaximal stimulus and ensures that all muscle fibres are stimulated (4, 12). The neural response depends on constant current, therefore the voltage in a NMM should change with changes in skin resistance (4, 11). A current between 40-70 mA is adequate (4). 1.2.2 Clinical modes/patterns of neuromuscular monitor Several patterns or modes of NMM use arise from nerve stimulation. They are single twitch (ST), train of four (TOF), double burst stimulation (DBS) and tetanic stimulation (TS) (5, 13). 2 A ST is described by the frequency of 1 Hz, with a duration of 0.2 millisecond (ms), and 1 twitch per 10 seconds (s) (11). A ST is of little clinical use, and demonstrates that the muscle is stimulated (11). A TOF stimulation consists of 4 single twitches with a frequency of 2 Hz. During a TOF stimulation there is 1 twitch per 0.5 s, with a duration of 0.2 ms (5). This is the standard for NMM (13). A train of four count (TOFC) is the number of twitches present. They are called T1, T2, T3 and T4. A train of four ratio (TOFR) is T4/T1 (4, 11). A fade is the reduction in muscle response from T1 toT4 during a TOF with non-depolarizing muscle relaxants (NDMR) (4, 5). This pattern is used to differentiate depolarizing muscle relaxants (DMR) from NDMR (4). It also determines the degree of the block (4, 14). Once T2 is present neostigmine can be administered to reverse NMBA (11). TOFR is used to signify complete recovery from neuromuscular blockade (11). A DBS consists of a burst of two or three impulses separated by 0.75 seconds, with a frequency of 50 Hz per burst (4). There is a time difference of 0.02 s between twitches (11). DBS surpasses TOF in picking up fade (14). A DBS is used instead of TOF if no objective monitoring is available, but in awake patient it is more painful (4). A TS occurs at 50 Hz with a duration of 5 s (4). It may induce muscle contraction, and it is usually used with post tetanic count (PTC) (4). During PTC a tetanic stimulation is followed by 3 s of single twitch, at a 1 s interval (4). It is used to evaluate the intensity of a block when there is no twitch on TOF. The number of twitches present gives an estimation of how long it will take for T1 to appear in TOF (11, 14). 1.2.3 Determinants of neural stimulation Determinants of neural stimulation include the duration of the stimulus (Chronaxy), the distance of the nerve from the electrode, the minimum current needed to stimulate the nerve (Rheobase), and the area of electrode (4, 11). 3 1.2.4 Site of measurement The sites that are commonly used for NMM are ulnar nerve/adductor pollicis and the facial nerve/orbicularis oculi (12, 15-17). The most recommended site for NMM is the ulnar nerve (5, 15, 18, 19). The ulnar nerve is susceptible to the action of NMBA and its assessment may show the effects of NMBA at the pharyngeal muscles which are the last one to recover (12). Thilen et al (17), stated that the risk of PRNMB is five times higher if the orbicularis oculi was used instead of the ulnar nerve, therefore if the ulnar nerve was not used intraoperatively it should be changed to it before administration of muscle relaxant reversal. Orbicularis oculi muscles are more resistant to NMBA (15). The other muscle group that can be used includes the posterior tibial and the common peroneal nerve. 1.2.5 Types of neuromuscular monitors There are mainly two types of NMM available for perioperative monitoring of neuromuscular blockade which are: the qualitative (subjective) and quantitative (objective) NMM. Qualitative neuromuscular monitors A qualitative NMM, also called a PNS, is a medical equipment that provide an electrical current to a peripheral nerve and causing the response of the muscle innervated by that nerve. The evaluation of the evoked response from the innervated muscle is detected subjectively by the anaesthetist either by visual or tactile perception as the muscle responds from electrical stimulation. (3, 12, 20). Quantitative neuromuscular monitors Quantitative NMM is a medical equipment that can objectively measure and project an evoked impulse, such as TOFR (12, 20). There are few quantitative neuromuscular monitors available, namely mechanomyography (MMG), electromyography (EMG) and acceleromyography (AMG). 4 A MMG consists of fixing the hand while applying a certain preload to the thumb (11, 21). The force of the contraction is measured from the adductor pollicis muscle while the ulna nerve is stimulated. A transducer picks up the force of muscle contraction and amplifies it to produce a value of TOFR. Although considered the gold standard of NMM, a MMG is difficult to set up and is therefore not commonly used (12, 21). The EMG involves the stimulation of a specific nerve and measures the muscular contraction response by means of the action potential. This electrical activity is considered to be proportional to the force of contraction (12). The advantage of this system is that it measures electrical activity instead of force of contraction, and the patient’s limb does not need to be fixed. A disadvantage is that it is disturbed by electrical interference from electrical equipment like diathermy (12). An AMG is a piezoelectrical sensor which is used to detect the acceleration of the contracting muscle. AMG uses Newton’s second law which states that a Force (F) is equal to Mass (M) multiplied by Acceleration (A): (F= M X A) (12, 22). A constant mass is delivered by the thumb. Since the acceleration will be equal to the force of contraction it is then processed and displayed on a monitor (11), (12). AMG is the most used method for monitoring NMBA because it is reproducible, cheap, and practical (23, 24). 1.3 Clinical signs use in monitoring neuromuscular blockade Clinically assessing respiratory parameters and muscle strength which includes head lift for five minutes, tongue protrusion and grip strength is unreliable and insensitive (3, 4, 23). It is not recommended to exclude PRNMB (4). 1.4 Why Neuromuscular monitoring NMBA are commonly used during GA to facilitate tracheal intubation and surgical access (25). Unfortunately, the use of these agents comes with serious complications like PRNMB (3). 5 These include increased risk of airway obstruction, pulmonary aspiration, hypoxia, pharyngeal dysfunction, muscle weakness, reintubation, prolonged postoperative care unit stay as well as patient dissatisfaction (3, 12). The incidence of PRNMB is high and it is estimated to be around 20- 50% (3, 26). NMM use guide the management of NMBA and this help in reducing the incidence of PRNMB as demonstrated by Murphy et al (7) and Todd et al (8) in their respective studies. Baillard et al (27) demonstrated that NMM use decreased PRNMB from 62% to 3% in their centre. It is recommended that quantitative NMM should be used whenever NMBA are administered to reduce PRNMB (4, 15, 20, 28). If objective NMM is not available then subjective NMM can be used (4, 17, 29). In South Africa, Diedericks et al (30) in 2004 reported that 43% of patients had PRNMB after the use of NMBA. Chetty et al (31), conducted a study in South Africa in 2020 on 55 patients who received NMBA at Chris Hani Baragwanath Academic Hospital (CHBAH) and described an incidence of 45% of PRNMB. However, our literature search did not find South African literature describing the use of NMM. 1.5 Current practice in relation to neuromuscular monitoring use Few countries around the world have standardized guidelines on NMM use. France is the first country to publish recommendation on NMM use in 2000 to prevent incomplete neuromuscular reversal. The use of PNS with its TOFC is not adequate to assess neuromuscular recovery therefore an instrumental monitor is required (3). In 2010 the Czech Republic society published its own recommendations on quantitative NMM use, with the ulnar nerve being the recommended site of monitoring (3, 32). The Australian and New Zealand College of Anaesthetists states that “Quantitative neuromuscular function monitoring must be available for every patient in whom neuromuscular blockade has been induced and should be used whenever the anaesthetist is considering extubation following the use of non-depolarising neuromuscular blockade” (33). 6 The British guidelines states that “a measure of neuromuscular blockade using a PNS, is essential for all stages of anaesthesia when neuromuscular blockade drugs are administered, however the guidelines stress that this monitoring is best done by objective quantitative peripheral nerve stimulator” (18). The Difficult Airway Society (DAS) encourage the use of NMBA reversal as well as the PNS use before tracheal extubation of the airway. This is to maximise ventilation and restore airway reflexes as well as preventing the postoperative pulmonary complications (34). The American Society of Anaesthesiology (ASA) standard of intraoperative monitoring which was affirmed in 2015 did not include routine NMM (35). The South African Society of Anaesthesiologists (SASA) recommends the use of a peripheral neuromuscular transmission monitor when NMBA are used (36). 1.6 Neuromuscular monitoring usage The use of NMM still remains low (37). This is despite ample information stressing routine use of NMM after NMBA were used during GA (3, 4, 12, 15, 23). The use of objective NMM in Australia and New Zealand stands at 17% (9), Singapore 13% (28) , while NMM was used by 10% of anaesthetists in United Kingdom (38). For Lin et al (39) the use of NMM was at 18%. Pongracz et al (40) conducted a study in Hungary and Romania and their study findings showed that the use of NMM was as low as 8% among their anaesthetists. Naguib et al (41) in their survey found out that 19.1% of anaesthetists in Europe and 9.4% of anaesthetists in the United States of America (USA) never use a nerve stimulator to manage NMBA. Di Marco et al (42) conducted a study in Italy and found that 75% of the anaesthetists rely on clinical signs to determine recovery from NMBA during emergence from GA. Soderstrom et al (10) conducted a study in Denmark showing a relatively high use of objective NMM with 58% of anaesthetists always applying NMM whenever NMBA were administered. 7 1.7 Knowledge of neuromuscular monitoring In a study conducted by Naguib et al (43) on 1629 anaesthetists from 80 countries to explore anaesthetists’ confidence in their knowledge of the core concept in NMM, the respondents completed a 9 questions survey, in which they answered correctly 57% of the questions, which is far from the respondents’ confidence of 84%. In an Australian and New Zealand study in 2011 (9) where they investigated attitudes, knowledge and practices of their anaesthetists on the use of NMM, it was stated that “This survey identifies a lack of knowledge in the area of neuromuscular blockade equipment and monitoring among anaesthetists in Australia and New Zealand responding to this survey”. In this study they have 678 respondents out of 3188 members who were sent the online questionnaire. Hundred and eighty-one (27%) of the respondents knew that the TOFR should be more than 0.90 before extubation to ensure neuromuscular blockade recovery, while 186 (28%) knew that the use of clinical signs is unreliable. In a Danish study in 2017 by Soderstrom et al (10) conducted on 653 respondents to estimate the use of objective NMM among their anaesthetists, the findings were that their anaesthetists have adequate knowledge regarding NMM. 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South African Society of Anaesthesiologists. Practice guidelines 2018 revision. South Afr J Anaesth Analg. 2018;24(2):S1-119.Available from: https://sasaapi.sasaweb.com//Newsletters/SAJAA(V24N1)2061SASAPracti ceGuidelines_V12.pdf_636803073976212768.pdf. [Accessed 14/06/2020]. 37. Locks GdF, Cavalcanti IL, Duarte NMC, da Cunha RM, de Almeida MCS. Use of neuromuscular blockers in Brazil. Braz J Anesthesiol. 2015;65(5):319-25 DOI:10.1016/j.bjane.2015.03.001. 38. Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62(8):806-9 DOI:10.1111/j.1365- 2044.2007.05101.x. 13 39. Lin XF, Yong CYK, Mok MUS, Ruban P, Wong P. Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit. Singapore Med J. 2020;61(11):591-7 DOI:10.11622/smedj.2019118. 40. Pongracz A, Nemes R, Breazu C, Asztalos L, Mitre I, Tassonyi E, et al. International survey of neuromuscular monitoring in two European countries: a questionnaire study among Hungarian and Romanian anaesthesiologists. Rom J Anaesth Intensive Care. 2019;26:45-51 DOI:10.2478/rjaic-2019-0007. 41. Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111(1):110-9 DOI:10.1213/ANE.0b013e3181c07428. 42. Di Marco P, Della Rocca G, Iannuccelli F, Pompei L, Reale C, Pietropaoli P. Knowledge of residual curarization: an Italian survey. Acta Anesthesiol Scand. 2010;54(3):307-12 DOI:10.1111/j.1399-6576.2009.02131.x. 43. Naguib M, Brull SJ, Hunter JM, Kopman AF, Fulesdim B, Johnson KB, et al. Anesthesiologist's overconfidence in their perceived knowledge of neuromuscular monitoring and its relevance to all aspects of medical practice: An international survey. Anesth Analg. 2019;128(6):1118-26 DOI: 10.1213/ANE0000000000003714. 14 Section 2: Author’s guidelines 1. 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Infect Control Hosp Epidemiol [Internet]. 2006 Jan [cited 2007 Jan 5];27(1):34-7. Available from: http://www.journals.uchicago.edu/ICHE/journal/issues/v27n1/2004069/2004 069.web.pdf. Book references: Jeffcoate N. Principles of Gynaecology. 4th ed. London: Butterworth, 1975:96-101. Chapter/section in a book: Weinstein L, Swartz MN. Pathogenic Properties of Invading Microorganisms. In: Sodeman WA jun, Sodeman WA, eds. Pathologic Physiology: Mechanisms of Disease. Philadelphia: WB Saunders, 1974:457-472. Internet references: World Health Organization. The World Health Report 2002 - Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization, 2002. http://www.who.int/whr/2002 (accessed 16 January 2010). Other references (e.g., reports) should follow the same format: Author(s). Title. Publisher place: publisher name, year; pages. Cited manuscripts that have been accepted but not yet published can be included as references followed by '(in press)'. 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Privacy Statement The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party. 23 Section 3: Draft article Anaesthetists’ knowledge and frequency of use of neuromuscular monitoring at the University of the Witwatersrand Michael K Setsomelo, MBChB Lunganga T Lushiku, MBChB, DA, Dip HIV, FCA, Mmed Sithandiwe Dingezweni, MBChB, DA, FCA, Cert in critical care Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Corresponding Author Dr MK Setsomelo Department of Anaesthesiology Chris Hani Baragwanath Academic Hospital 26 Chris Hani Rd Diepkloof, Soweto Johannesburg 1860 mikekese@yahoo.com 0767507541 Key words: Anaesthetists, knowledge, frequency, use, neuromuscular monitoring 24 Abstract Background Neuromuscular blocking agents (NMBA) are commonly administered during general anaesthesia (GA). The use of these agents can result in postoperative residual neuromuscular blockade (PRNMB) as a complication. Studies have shown that such complication can be reduced with the use of neuromuscular monitors (NMM). Data from South Africa as to the knowledge and use of NMM is scanty. Therefore, the aim of this study is to assess the knowledge and the frequency of use of NMM in the Department of Anaesthesia at the University of the Witwatersrand (Wits). Methods A prospective, contextual study design was used. Data was collected using a self- administered online questionnaire developed by the researcher with the assistance of senior anaesthetists. The study population consisted of all anaesthetists working in the Department of Anaesthesia at Wits. A convenience sampling method was used and a completion with return of the online questionnaire implied consent to participate in the study. Adequate knowledge was defined by a score of 65.5% as determined by the Angoff method. Results Two hundred and eight anaesthetists were available during the period of data collection. Of these, 126 anaesthetists completed the questionnaire. There was inadequate level of knowledge of NMM among anaesthetists in our department. Sixty-four percent of the anaesthetists achieved less than the set Angoff score of 65.5%. The anaesthetist’ mean score of the questionnaire was also 57%. The level of knowledge differs significantly depending on professional designation with p-value <0.009. 25 Medical Officers and second year registrars scored significantly below the Angoff score with p-values of 0.0005 and 0.02 respectively, while first year registrars recorded the highest score, followed by fourth year registrars. The frequency of use of NMM in the department is low at 13%. Conclusion The level of knowledge among anaesthetists with respect to NMM was inadequate. There is a need for improvement of knowledge regarding NMM use, by ongoing education in our anaesthesia department. Formulating evidence-based guidelines which support the use of NMM in all patient who received NMBA will be beneficial. The use of NMM in our department is also low. The commonest reason for not using NMM was unavailability of these monitors. Healthcare authorities have the obligation to increase the availability and accessibility of NMM. A national study in this subject is warranted to see if this is any different among anaesthetists in South Africa. 26 Introduction NMBA cause muscle relaxation and are often used during GA to improve endotracheal intubation as well as the surgical condition (1,2). The use of these agents is not without complications, since the 1950’s, it has been reported that their use was associated with higher mortality rates than when NMBA were not used (3). In 1965 Churchill-Davidson demonstrated that peripheral nerve stimulator (PNS) was the only method to assess the degree of neuromuscular blockade after using NMBA (3). There are mainly two types of NMM available for perioperative monitoring of neuromuscular blockade which are: the qualitative and quantitative NMM. A qualitative NMM, also called a PNS, is a medical equipment that provide an electrical current to a peripheral nerve and causing the response of the muscle innervated by that nerve. The evaluation of the evoked response from the innervated muscle is detected subjectively by the anaesthetist either by visual or tactile perception as the muscle responds from electrical stimulation (4,5). Quantitative NMM is a medical equipment that can objectively measure and project an evoked impulse such as a train of four ratio (TOFR) (4,5). A quantitative NMM is recommended over a qualitative monitoring because of the ability to objectively pick up TOFR above 0.9 (3,4,6). In instances where a quantitative NMM is not available, a PNS should be used (3). The use of clinical signs such as head lift and hand grip for 5 seconds in timing the reversal of NMBA is inaccurate and unreliable (3,5). NMM should be used in all patients who receive NMBA to decrease the risk of postoperative residual neuromuscular blockade (PRNMB) (3,5,6,7). 27 Baillard et al (8) demonstrated that NMM use decreased PRNMB from 62% to 3% in their centre. In South Africa, Nell et al (9) in 2004 reported that 43% of patients had PRNMB after the use of NMBA. Chetty et al (10) conducted a study, in South Africa in 2020 on 55 patients who received NMBA at Chris Hani Baragwanath Academic Hospital (CHBAH) and described an incidence of 45% of PRNMB. Our literature search did not find South African literature describing the use of NMM. It is important to utilise NMM in patients who receive NMBA but, only few countries around the world have included NMM into their standard of care practice (6). The American Society of Anaesthesiology (ASA) standard of intraoperative monitoring which was affirmed in 2015 did not include routine NMM (11). The South African Society of Anaesthesiologists (SASA) recommends the use of a peripheral neuromuscular transmission monitor when NMBA are used (12). The use of NMM decreases the incidence of postoperative complications caused by NMBA (4,5,13). Studies from high income countries showed that a limited number of anaesthetists used NMM routinely in their daily practice, despite ample information supporting routine NMM in patients who received NMBA (3,5,6,7,14). The knowledge of anaesthetists from high income countries on NMM varies greatly (14,16). There is scarcity of literature on the knowledge and frequency of use of NMM especially in the middle and low- income countries. The knowledge as well as the frequency of use of NMM among anaesthetists in South Africa or at Wits are unknown. Therefore, the aim of this study is to determine the knowledge and frequency of use of NMM by anaesthetists working in the Department of Anaesthesia at Wits. Methods The study followed a prospective, contextual study design. Approval to conduct the study was obtained from the Human Research Ethics Committee (Medical) (certificate No: M200807 MED 20-07-154) and the Graduate Studies Committee at Wits. The Academic Head of the Department of Anaesthesia at Wits gave permission to conduct this study in the department. 28 The questionnaire was developed from reviewed literature and with the help of a senior anaesthetist with special interest in NMM. Prof Naguib gave permission to adapt and use his questionnaire (17). The content validity was ensured by extensive reading to have a representative questionnaire on the topic. Face validity was ensured by three senior anaesthetists working in the Department of Anaesthesia at Wits. The questionnaire consisted of 2 questions on demographics, 15 questions on NMM knowledge and 5 questions on frequency of use of NMM. The study population comprised of all consenting anaesthetists working in the Department of Anaesthesia at Wits. A convenient sampling method was used. During the time of the study the Department of Anaesthesia had 208 anaesthetists. An online questionnaire was sent to all anaesthetists via their email boxes and the biostatistician determined that a minimum response rate of 125 (60%) is required for this study. Medical interns were excluded from participating. The questionnaire was loaded into google forms and distributed to the participants via email because of the Covid-19 pandemic. The participants completed and made an online submission of the questionnaire. The return of the questionnaire implied consent to participate in the study while blank questionnaires were excluded from the study. The Angoff method (18,19) was used to assess the adequacy of knowledge among anaesthetists in the Department of Anaesthesia at Wits. The Angoff score of 65.5% was determined by three consultants in the Department of Anaesthesia at Wits. Data was analysed using Statistical Package for the Social Sciences (SPSS- Version 25, manufactured by IBM corporation). Categorial variables were reported using frequencies and percentages. Data was described and analysed using descriptive and inferential statistics. The Kolmogorov Smirnov test was used to assess normality. An ANOVA test was used to compare whether professional designation would make a difference in level of knowledge. 29 One sample t-test was used to compare if the mean score of the questionnaire per professional designation differs significantly from the set Angoff score. A p-value of 0.05 was considered statistically significant. Results A total of 208 anaesthetists were available during the 3 months period of data collection. After multiple reminders,128 anaesthetists were able to reply to the online questionnaire. Of the 128 completed questionnaires received, 2 were excluded as they were returned blank. Therefore, 126 questionnaires were included in this study. The 126 questionnaires were above the estimated sample size of 125 (60%) to power the study with a p-value of 0.05. The majority of anaesthetists were medical officers 29 (23%) and consultants 25 (20%). The distribution of anaesthetists according to their professional designation is illustrated in table I. Table I: Anaesthetists’ distribution Professional designation Number Percentage Consultant 25 20 Career Medical Officer 3 2 Registrar year 4 18 14 Registrar year 3 24 19 Registrar year 2 15 12 Registrar year 1 12 10 Medical officer 29 23 Total 126 100 Of the 126 anaesthetists, 45 (36%) showed adequate level of knowledge based on the set score of 65.5% using the Angoff method. Of the 45 anaesthetists with adequate knowledge 10 (22%) were consultants. The distribution of Angoff score according to professional designation is shown in table II. 30 Table II: Angoff score and professional designation Professional designation Angoff score Pass Number (Percentage) Fail Number (Percentage) Consultants 10 (40) 15 (60) Career Medical Officer 1 (33) 2 (67) Registrar year 4 9 (50) 9 (50) Registrar year 3 9 (37.5) 15 (62.5) Registrar year 2 4 (27) 11 (73) Registrar year 1 6 (50) 6 (50) Medical Officer 6 (21) 23 (79) Total 45 (36) 81 (64) The mean score attained by the anaesthetists who answered the questionnaire was 57% (SD19.1). Medical Officers and second year registrars scored significantly below the Angoff score of 65.5% with p-values of 0.0005 and 0.02 respectively. First year registrars recorded the highest score. The distribution of mean score according to professional designation is shown in table III. 31 Table III: Distribution of mean score according to professional designation Professional designation Number Mean (SD) P- Value Consultant 25 59 (17.2) 0.55 Career Medical Officer 3 42 (21.4) 0.20 Registrar year 4 18 63 (18.0) 0.55 Registrar year 3 24 61 (18.6) 0.28 Registrar year 2 15 53 (17.1) 0.02 Registrar year 1 12 66 (10.9) 0.99 Medical Officer 29 47 (21.2) <0.0005 All Anaesthetists 126 57 (19.1) <0.0005 The anaesthetists performed well in 6 questions and did not do well in 3 questions of the questionnaire. The questions and the proportion of correct and incorrect answers are shown in table IV. 32 Table IV: Questions and proportion of correct and incorrect answers Questions Answers P-value Correct Incorrect 1.Supramaximal stimulus definition 33 (26) 93 (74) <0.0005 2.Recommended site for neuromuscular monitoring 106 (84) 20 (16) <0.0005 3.Definition of postoperative residual neuromuscular blockade 72 (57) 54 (43) 0.13 4.Train of four description 74 (59) 52 (41) 0.61 5.Neostigmine administration 109 (87) 17 (13) <0.0005 6.Fade 94 (75) 32 (25) <0.0005 7.Return of airway reflexes 58 (46) 68 (54) 0.42 8.Double burst stimulus description 27 (21) 99 (79) <0.0005 9.Post tetanic count description 70 (56) 56 (44) 0.25 10.Post tetanic count application 77 (61) 49 (39) 0.02 11.Definition of deep block by post tetanic count 81 (64) 45 (36) 0.02 12.Factors that produce optimal nerve stimulation 65 (52) 61 (48) 0.79 13.Train of four prior to extubation 93 (74) 33 (26) <0.0005 14.Commonest method to monitor neuromuscular block 68 (54) 58 (46) 0.42 15.Requirements to eliminate skin resistance in a nerve stimulator 44 (35) 82 (65) 0.01 33 The ANOVA test was used to compare whether the professional designation would make a difference in the level of knowledge. The level of knowledge differs significantly depending on professional designation with p-value <0.009. First year registrars showed the best knowledge amongst the professional designations. The table V shows the comparison of level of knowledge across professional designations. Table V: Comparison of level of knowledge across professional designation Professional designation Level of knowledge Percentage Mean (SD) P-value Consultant 59 (17.2) 0.009 Career Medical Officer 42 (21.4) Registrar year 4 63 (18.0) Registrar year 3 61 (18.6) Registrar year 2 53 (17.1) Registrar year 1 66 (10.9) Medical Officer 47 (21.2) Of the 126 anaesthetists 110 (87%) do not use NMM. Only 16 (13%) mostly use NMM in their daily practice. The frequency of use of NMM by anaesthetists is shown in figure 1. 34 Figure I: Use of NMM by anaesthetists Of the 126 anaesthetists 91 (72%) reported not using NMM due to unavailability of it. Table VI shows reasons for not using NMM. Table VI: Reasons for not using NMM Reasons Number (Percentage) Lack of availability of neuromuscular monitors 91 (72.2) Limited knowledge on neuromuscular monitoring use 18 (14.3) Time consuming 4 (3.2) I use reversal agent in all patients who receive neuromuscular blocking agents 13 (10.3) Total 126 (100) 16 (13%) 110 (87%) 0 20 40 60 80 100 120 Yes No N u m b e r o f a n a e s th e ti s ts NMM usage 35 Discussion In this study we determined the level of knowledge and frequency of use of NMM among the anaesthetists working in the Department of Anaesthesia at Wits. The results had shown that the level of knowledge was inadequate among the anaesthetists in the Anaesthetic Department at Wits. Sixty-four percent of the anaesthetists achieved less than the set Angoff score of 65.5% and the mean score of the questionnaire was 57%. This inadequate knowledge may be attributed to the lack of objective NMM in the department as well as the lack of guidelines on the use of NMM in the department. A contributary reason for these low scores could be the lack of regular training, education and testing of anaesthetists on the subject. A study contacted by Phillips et al (14) in Australia and New Zealand in 2011, identified a lack of knowledge in the area of NMM among anaesthetists. More than 70% of the anaesthetists, did not know a safe criterion to exclude PRNMB during extubation or the shortcomings of clinical signs use when NMBA were administered. This was mainly due to lack of awareness on current literature on NMBA and NMM use. The study emphasized that for the lack of knowledge to be addressed there is need for availability of NMM accompanied by education. In our study 64% of the anaesthetists showed inadequate knowledge and we lack objective NMM as well as regular re-education on the use which are the same reasons highlighted in the study above, as factors to be addressed to improve knowledge on NMM. This is of concern, as PRNMB is high (6,13). Naguib et al (15) in 2019 conducted a world-wide study to explore anaesthetists’ confidence in their knowledge of the core concept in NMM, the respondents got 57 % in that questionnaire. The respondents’ confidence in getting the answers right was however high. Our anaesthetists achieved the same percentage, with both questionnaires being focused on the core concepts of NMM. In a Danish study in 2017 conducted by Soderstrom et al (16) the anaesthetists were found to have adequate knowledge on NMM. Seventy-one percent of their anaesthetists knew that TOFR need to be above 0.90 to exclude PRNMB. In other 2 previously mentioned studies the knowledge was widely varied between 27-57% (14,15). 36 The adequate knowledge was attributed to the availability of NMM in Danish hospitals. In our department we do not have NMM readily available, therefore the availability of NMM could help in improving the level of knowledge about the subject among our anaesthetists. Regarding professional designations, this study had shown that first year registrars had adequate knowledge with a mean score of 66% which was above the set Angoff score. This could be attributed to most first year registrars in our department having just wrote their anaesthesia first part of the Fellowship of the College of Anaesthesiologists (FCA) examination or their preparation to write this examination. Fourth year registrars followed with better knowledge at 63%, which could be explained by the preparation for their exit examination. Career Medical Officers scored the least however, the statistical significance was negligible because the sample size was too small for this group. Medical Officers followed with significantly lower score. This could be that most of the medical officers who join the department are novices to the anaesthetic field. Second year registrars had a low score after medical officers, of importance is that this group of anaesthetists have attempted their first part of the FCA examination and have experience in anaesthesia. We could not find a reasonable explanation for this low score in this group of anaesthetists. The use of NMM is recommended perioperatively whenever NMBA are used (3,5,6,20). PRNMB can only be assessed by NMM as clinical signs are very unreliable (7,21,22-23). Although there is consensus in the literature showing the need for NMM, the frequency of use remains low even in high income countries (24). This study had shown that the frequency of use of NMM in our department is low at 13% which is similar to the findings made by Teoh et al (7). However, their study showed this low use despite the availability of NMM. Their study found that the lack of re-education as well as the unavailability of NMM in each theatre leads to its lack of use. This is in keeping with our study which showed that 72% of the anaesthetists do not use NMM because it is unavailable. It is important to note that the same study found that there was a discrepancy between high knowledge base on use of NMM and actual practical use of monitoring among the respondents. 37 In 2020 a study conducted by Lin et al in Singapore (25) found 18% of NMM use among their anaesthetists, this is in keeping with our study finding. The reason for low rate of use of NMM in their study was found to be multifactorial and included undermining of the negative consequences and the incidence of PRNMB, inadequate training, the poor availability, and the confidence in using PNS. In our study, the 2 commonest reasons stated were the unavailability of NMM (72%) and the lack of knowledge on NMM use (14%). More studies show typical results on use of NMM around the world with 17% in Australia and New Zealand study, 8% in Hungarian and Romanian study and 10% in a United Kingdom (UK) study (14,21,26) These study results show that the use of NMM is low and this is congruent with 13% NMM use in the Department of Anaesthesia at Wits. The findings raise a serious concern as PRNMB is high with estimations around 20-50% (6,13) The study was done among anaesthetists in the Department of Anaesthesia at Wits, and it does not necessarily represent the level of knowledge and frequency of use of NMM among anaesthetists in South Africa. Conclusion The level of knowledge among anaesthetists with respect to NMM was inadequate. There is a need for improvement of knowledge regarding NMM use, by ongoing education in our anaesthesia department. Formulating evidence-based guidelines which support the use of NMM in all patient who received NMBA will be beneficial. The use of NMM in our department is also low. The commonest reason for not using NMM was the unavailability of these monitors. Healthcare authorities have the obligation to increase the availability and accessibility of NMM. A national study in this subject is warranted to see if this is any different among anaesthetists in South Africa. Conflict of interest The authors declare that we have no financial or personal relationships which may have inappropriately influenced us in writing this paper. 38 Acknowledgement This research was done in partial fulfilment of a Master of Medicine degree. 39 References 1. Boon M, Martini C, Dahan A. 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Anaesthesia. 2007;62(8):806-9 DOI:10.1111/j.1365- 2044.2007.05101.x. 43 Section 4: Proposal Anaesthetists’ knowledge and frequency of use of neuromuscular monitoring at the University of the Witwatersrand Michael Kgowe Setsomelo 2051294 Supervisor: Lunganga Toms Lushiku Department of Anaesthesiology Co-supervisor: Sithandiwe Dingezweni Department of Anaesthesiology 44 4.1 Introduction and problem statement Neuromuscular blocking agents (NMBA) cause muscle relaxation and are often used during general anaesthesia to improve endotracheal intubation as well as the surgical condition (1, 2). The use of these agents is not without complications. In the 1950’s, it was reported that their use was associated with higher mortality rates than when NMBA were not used (3). In 1958 peripheral nerve stimulators (PNS) were introduced to monitor neuromuscular blockade (3-5). In 1965 Churchill-Davidson demonstrated that PNS was the only method to assess the degree of neuromuscular blockade after using NMBA (3). Two types of neuromuscular monitors have been developed and are available for perioperative monitoring of neuromuscular blockade: the qualitative and quantitative neuromuscular monitors. A qualitative neuromuscular monitor, also called PNS, is a simple medical device that delivers a current to a peripheral nerve causing an evoked response of the muscle innervated by that nerve. The assessment of the evoked response from the innervated muscle is detected subjectively by the clinician by visual or tactile perception of the muscle contraction (6, 7). The function of a PNS involves an action potential or stimulus that is initiated when a sufficient amount of electrical current of adequate duration is applied to a nerve (3). The stimulus is increased by 10-20 % to negate the effect of skin resistance. This is known as a supramaximal stimulus, and ensures that all muscle fibres are stimulated (3). The subsequent decrease in the strength of muscle contraction will therefore be due to the effect of the NMBA, and not to the skin resistance (3). A current between 40-70 mA is often adequate. In general, a nerve stimulator that produces a constant current density is preferred as the effects of skin resistance is avoided (3, 8). 45 Quantitative neuromuscular monitors are medical devices that can objectively measure and display an evoked impulse, such as train of four ratio (TOFR) in real time (6, 7). There are few quantitative neuromuscular monitors available, namely mechanomyography (MMG), electromyography (EMG) and acceleromyography (AMG). A MMG consists of fixing the hand while applying certain preload to the thumb (8). The force of the contraction is measured from the adductor pollicis muscle while the ulna nerve is stimulated. A transducer picks up the force of muscle contraction and amplifies it to produce a value of TOFR. Although considered the gold standard for neuromuscular monitoring, a MMG is difficult to set up and is therefore not used frequently (7). The EMG involves the stimulation of a certain nerve and measures the muscular contraction response by means of the action potential. This electrical activity is considered to be proportional to the force of contraction (7). The advantage of this system is that it measures electrical activity instead of force of contraction, and the patient’s limb does not need to be fixed. It is however disturbed by electrical interference from electrical equipment like diathermy (7). An AMG is a piezoelectrical sensor which is used to detect the acceleration of the contracting muscle. AMG is based on Newton’s second law which states that a Force (F) is equal to Mass (M) multiplied by Acceleration (A): (F= M X A) (7). A constant mass is delivered by the thumb. Since the acceleration will be equal to the force of contraction it is then processed and displayed on a monitor (8). The patient’s hand should be secured on an arm board and the thumb should be free to move (7). Quantitative neuromuscular monitoring is recommended over qualitative monitoring because of its ability to objectively pick up train of four ratio (TOFR) above 0.9 (3, 7, 9). But, in instances where a quantitative monitor is not available, a PNS should be used (3). 46 The determinants of neural stimulation include the duration of the stimulus (Chronaxy), the distance of the nerve from the electrode, the minimum current needed to stimulate the nerve (Rheobase), and the area of electrode (3, 8). The smaller the electrode the higher the current density (8). Several patterns can result from nerve stimulation and are used in clinical practice for monitoring of neuromuscular blockade. These include a single twitch, a train of four (TOF), double burst stimulus (DBS), and a tetanic stimulation (4). A single twitch is described by the frequency of 1 Hz, with a duration of 0.2 millisecond (ms), and 1 twitch per 10 seconds (s). A single twitch is of little clinical use, and demonstrates that the muscle is stimulated (8). A TOF stimulation consists of 4 single twitches with a frequency of 2 Hz. During a TOF stimulation there is 1 twitch per 0.5 s, with a duration of 0.2 ms (4). A train of four count (TOFC) is the number of twitches present. They are called T1, T2, T3 and T4. A TOFR is T4/T1 (3, 8). A fade is the reduction in muscle response from T1 toT4 during a TOF with non-depolarizing muscle relaxants (NDMR) (3, 4). This pattern is used to differentiate depolarizing muscle relaxants (DMR) from NDMR. It also determines the degree of the block (3). A DBS consists of a burst of two or three impulses separated by 0.75 seconds, with a frequency of 50 Hz per burst (8). There is a time difference of 0.02 s between twitches. A DBS is used instead of TOF if no objective monitoring is available, but in awake patient it is more painful (3). A tetanic stimulation occurs at 50 Hz with a duration of 5 s. It may induce muscle contraction, and it is usually used with post tetanic count (3). During the post tetanic count (PTC) a tetanic stimulation is followed by 3 s of single twitch, at a 1 s interval. It is used to evaluate the intensity of a block when there is no twitch on TOF. The number of twitches present gives an estimation of how long it will take for T1 to appear in TOF (8). 47 The use of clinical signs such as head lift and hand grip for 5 seconds in timing the reversal of NMBA is inaccurate and unreliable (3, 6). Tracheal extubation of a poorly reversed patient from neuromuscular blockade can result in airway complications with increase in morbidity and mortality (3). Therefore, neuromuscular monitors should be used in all patients who receive NMBA to reduce the risk of postoperative complications such as postoperative residual neuromuscular blockade (PRNMB) (3, 6, 9-11). PRNMB is defined as train of four ratio below 0.9 (7, 9, 12). Its incidence is estimated to be as high as 40% (9, 10, 13). Patients with PRNMB have an increased risk of airway obstruction, pulmonary aspiration, hypoxia, pharyngeal dysfunction, muscle weakness, reintubation, prolonged postoperative care unit stay as well as patient dissatisfaction (7, 9). Unfortunately, the literature has shown that 10% and 20% of anaesthetists respectively from North America and Europe do not use any type of neuromuscular monitoring (9, 10). This was despite ample information from publications stressing routine use of neuromuscular monitoring after NMBA were used during general anaesthesia (3, 7, 9, 10, 14). The use of neuromuscular monitoring in a French hospital increased from 2% in 1995 to 60% in 2004. This has resulted in a decrease in the incidence of PRNMB form 62% to 3% (15). In South Africa, Diedericks et al (16) in 2004 reported that 43% of patients had PRNMB after the use of NMBA. Hassim, also in South Africa in 2016 described an incidence of 45% of PRNMB, after a study on 55 patients that received NMBA at Chris Hani Baragwanath Academic Hospital (CHBAH) (17). This is comparable to other studies that have been conducted elsewhere around the world. However, there was no literature describing the use of neuromuscular monitors in South Africa. Although, there is a wealth of literature showing the importance of utilising neuromuscular monitoring in patients who receive NMBA, only few countries around the world have included neuromuscular monitoring into their standard of care practice (9). 48 The American Society of Anaesthesiology (ASA) standard of intraoperative monitoring which was affirmed in 2015 does not yet include routine neuromuscular monitoring (18). In France, the Czech Republic, New Zealand and Australia neuromuscular monitoring has been incorporated into anaesthetic guidelines (9). Recently, the United Kingdom (UK) introduced PNS as a mandatory tool to be used when NMBA are used. However, the UK also stress that the best monitoring is through quantitative monitors (19). The South African Society of Anaesthesiologists (SASA) recommends the use of a peripheral neuromuscular transmission monitor when NMBA are used (20). 4.2 Problem statement The administration of NMBA is associated with perioperative complications (6, 21). It has been shown that the use of neuromuscular monitors decreases the incidence of postoperative complications caused by NMBA (6, 7, 12). Studies from high income countries have shown that only few anaesthetists use neuromuscular monitoring routinely in their daily practice, despite ample information supporting routine neuromuscular monitoring in patients who received NMBA (3, 6, 9-11). Conversely, there is a scarcity of studies assessing the knowledge and frequency of use of neuromuscular monitors in middle- and low-income countries. The knowledge as well as the frequency of use of neuromuscular monitors among anaesthetists at the University of the Witwatersrand (Wits) are unknown. Therefore, a study assessing the knowledge and the frequency of use of neuromuscular monitors in the Anaesthesia Department at Wits is necessary. 49 4.3 Aim and objectives 4.3.1 Aim The aim of this study is to determine the knowledge and use of neuromuscular monitoring by the anaesthetists working in the Department of Anaesthesia at Wits. 4.3.2 Objectives The primary objectives of this study are to: • determine the level of knowledge on neuromuscular monitoring among anaesthetists in Department of Anaesthesia at Wits. • determine the frequency of use of neuromuscular monitoring in the perioperative period among anaesthetists in Department of Anaesthesia at Wits. The secondary objective is to determine factors associated with adequate level of knowledge. 4.4 Research assumptions The following definitions will be used in this study: Anaesthetist: is any qualified doctor in the Department of Anaesthesia including medical officers, registrars and consultants. The term anaesthesiologist and specialist anaesthetist are used interchangeably in the literature, and it will be used as it appears in the literature. Medical officer: is a qualified doctor practising in the Department of Anaesthesia under specialist supervision. Medical officers with more than 10 years of experience are career medical officers and can be regarded as consultants. Registrar: is a qualified doctor who is registered with the Health Professional Council of South Africa as a trainee anaesthetist. Consultant: is a specialist anaesthetist or a career medical officer of more than 10 years of experience. 50 Knowledge: The Angoff method will be used to determine adequate knowledge. In the Angoff method two important components are needed, namely a completed test and judges who are subject experts (22). An organisation must define who is a subject expert. The group of interest for the judges are borderline or minimally competent candidates. The judges rate each item in the test, of how many minimally competent candidates will likely answer the item correct (22-24). Each item of the test will receive a score or percentage. The ratings of each item must fall within a certain percentage range from each judge such as 30% range (23). The mean of everyone’s judgement for each item is calculated. The mean of individual items is added together and divided by the total number of items in that test. This result is a percentage score that a minimally competent candidate can achieve or the cut-off mark for passing. If the judges are not in agreement, they discuss on how they arrive at their decisions. The Angoff is then recalculated or repeated (23). Neuromuscular monitoring: a qualitative neuromuscular monitor or PNS is a simple medical device that delivers a current to a peripheral nerve causing an evoked response of the muscle innervated by that nerve. The assessment of the evoked response from the innervated muscle is detected subjectively by the clinician by visual or tactile perception of the muscle contraction (6, 7). In contrast, quantitative neuromuscular monitors are medical devices that can objectively measure and display evoked impulses such as TOFR in real time (6, 7). 4.5 Demarcation of study field The study will be conducted in the Department of Anaesthesia affiliated to the Faculty of Health Sciences at Wits. The staff complement of the department is 74 consultants, 112 registrars, and 22 medical officers. 4.6 Ethical considerations The approval to conduct the study will be obtained from the Human Research Ethics Committee (Medical) and the Graduate Studies Committee at Wits. 51 The academic Head of the Department of Anaesthesia at Wits has given permission to conduct this research in her department (Appendix A). Permission has been granted by Prof Naguib to adapt and use some of his questionnaire (Appendix B). The participation will be voluntary, using a questionnaire during an academic departmental meeting. The study will be explained, an information letter (Appendix C and D) together with the questionnaire (Appendix E) will be given to participants to answer and return in a sealed container. This will constitute an implied consent. The anonymity and the confidentiality will be maintained as no personal identifying information will be used or asked. Only the primary researcher and supervisor will have access to raw data. Raw data will be stored in a secure cupboard for 6 years from the date of completion of the study. Academic meetings have been replaced by online meetings for unforeseeable time because of Covid-19 pandemic, as a result an online questionnaire using google forms was considered for data collection. Google forms is provided by Google®. An information letter (Appendix D) will be attached to the online questionnaire. Following approval of the study, anaesthetists working at Wits will be invited to participate in the study via e-mail. The e-mail will also have a link for questionnaire completion. Consent will be implied when the participant clicks on the link and proceed to answer the questionnaire and clicking on the “submit” tab to submit the response. A soft copy of captured raw data will be protected by a password only known to the primary researcher. Since this is a study assessing knowledge, findings of inadequate knowledge from the participants warrants information workshop and answers to specific questions will form part of the recommendations to the department. The study will be conducted according to the principles of the Declaration of Helsinki (25) and the South African Guidelines for Good Clinical Practice (26). 52 4.7 Research methodology 4.7.1 Research design The study will follow a prospective, contextual study design. In a prospective study data on a specific cause is collected, after which it is analysed for the outcome, or the researcher identifies a certain population and follows it over some time to observe the outcome (27). In this study data will be collected from anaesthetists who will be working at Wits Department of anaesthesia attending academic meeting or via online questionnaire. A contextual study refers to a specific population or environment (28). This study is contextual because the specific population will be anaesthetists working in Department of Anaesthesia at Wits. 4.7.2 Study population The study population will comprise of all consenting anaesthetists working in the Department of Anaesthesia at Wits. 4.7.3 Study sample Sample size A questionnaire will be distributed to anaesthetists working in the Department of Anaesthesia at Wits. In consultation with a biostatistician, it was determined that a response rate of 60% is required to assess the level of knowledge and detect a difference in knowledge between participants, assuming a 5% margin of error and a 95% confidence level. 53 Sampling method In this study a convenience sampling method will be used. It is a non-probability method of sampling in which the researcher determines and chooses the participants who know most about the subject and can comfortably articulate it to the researcher (27). In a convenience sampling, there is easy availability and accessibility of participants to the researcher (27). Participants will be anaesthetists working for the Department of Anaesthesia at Wits attending academic meeting or the online questionnaire will be sent to anaesthetists working for the Department of Anaesthesia at Wits. 4.7.4 Inclusion and exclusion criteria The inclusion criteria for this study will be all anaesthetists working in the Department of Anaesthesia at Wits: • attending the academic meeting or via email for online questionnaire. • that will give the consent to participate. The exclusion criteria for this study will be: • rotating doctors from other departments. • anaesthetic interns. • Anaesthetists included in validating the questionnaire. 4.7.5 Data collection Questionnaire development The questionnaire was developed reviewed literature and with the help of a senior anaesthetist with special interest in neuromuscular monitoring. One questionnaire was identified as appropriate for this study form (29). Approval for use of adapted questions from study was granted (Appendix B). 54 Content validity was ensured by extensive reading in order to have a representative questionnaire on the topic. Face validity was ensured by three senior anaesthetists working in the Department of Anaesthesia at Wits. Angoff method will be used to determine the level of knowledge among anaesthetists in the Department of Anaesthesia at Wits. Data collection A questionnaire (Appendix E) will be distributed to the consenting participants. It comprises of 20 questions on clinical use of neuromuscular monitoring with multiple choice and tick box questions. It also has demographic questions like age and designation. The questionnaire will be administered during our departmental academic meeting and participants will answer during a single sitting and the questionnaires will then be collected in a sealed box. The questionnaire should take approximately 15 minutes to complete. Academic meetings have been replaced by online meetings for unforeseeable time because of Covid-19 and as a result online questionnaire using Goole forms will be considered. Google forms is provided by Google®. It allows for information to be collected by simple web form. A questionnaire is electronically prepared and sent