,

How to Use Post-Tetanic Count (PTC) in the Clinical Setting

Post-Tetanic Count EMG Tracing During Deep Neuromuscular Blockade Description

PTC (post-tetanic count) is the number of responses to single twitch stimulation spaced 1 second apart following high frequency tetanic stimulation (5-second 50 Hz), but why is it actually useful?

Post-tetanic count monitoring mode provides a way to quantify deep neuromuscular blockadewhen a patient has a TOF Count of 0 [3, 4]. A typical intubation dose of neuromuscular blocking agent will cause a patient to lose all 4 twitches, but how long does it take a patient to recover their first twitch, and what if you don't want the first twitch to reemerge?

Perfusion, potentiating drugs and several other factors make patient response to neuromuscular blocking agents highly variable [4]. Debaene determined the clinical duration of a typical intubation dose of rocuronium (0.6 mg/kg) can range from 15 to 85 minutes [1]. Post-tetanic count provides data on the individual patient's spontaneous recovery much earlier in the case, well before they recover the first twitch on a train-of-four. This new visibility enables the anesthesia provider to effectively predict recovery timing and proactively intervene to maintain optimal surgical conditions.

Beyond proactive intervention, PTC can also help the provider determine the appropriate intervention. For example, you are mid-case and the surgeon indicates that the patient is breathing and requests more roc. Will a redose of neuromuscular blocking agent effectively suppress respiration? Unfortunately, there is no set quantitative measurement indicative of diaphragmatic suppression, and some patients regain or even maintain diaphragmatic function at deep levels of blockade. See Figure 1 for an example of a patient overbreathing the ventilator with a PTC 2 measured at the adductor pollicis. This ability to breathe spontaneously, maintain normal tidal volumes and end-tidal CO2 while profoundly relaxed is well documented [2, 5, 6]. Using PTC, you can identify a recovery threshold and target measurement for each patient and case. If your patient begins breathing at a PTC 14 or TOFC 1, a proactive redose of neuromuscular blocking agent prior to could be considered. If your patient’s recovery threshold resembles the patient in Figure 1, an alternate intervention may be more effective at suppressing respiration.

Vent Displays Spontaneous Breathing at PTC 2Figure 1: Image displaying patient spontaneous breathing, 43 mmHg EtCO2 and 550 ml tidal volume with a simultaneous post-tetanic count of 2. Source: Author

How does PTC work? In the post-tetanic sequence, 50 Hz tetanic stimulation is applied, which causes post-tetanic potentiation (that is, the neuromuscular junction becomes more likely to respond to an incoming stimulus). After a three second pause, single twitches are repeated once a second. The number of times muscle depolarization occurs equals the post-tetanic count or PTC (Figure 2). A patient with twelve responses to the single stimuli (PTC 12) is very close to recovering the first twitch on a train-of-four, while a patient with only one response to the single stimuli (PTC 1) is deeply relaxed [4].

PTC Figure Explained-2
Figure 2: Tetanic stimulation and post-tetanic count EMG tracing during deep neuromuscular blockade (b) and after spontaneous recovery (d) [4].

What does a PTC measurement actually look like? Quantitative neuromuscular monitors with PTC functionality will provide a number between 0 and 15, (i.e. the number of responses to the single stimuli). The higher the number, the sooner the patient is expected to recover their first twitch in the train of four. 

TwitchView, an electromyography-based neuromuscular monitor released in 2018, further simplifies the provider's workflow with a mode called Auto PTC, an automatic measurement mode based on the patient’s real-time level of blockade. When the Auto PTC function is enabled, TwitchView will automatically switch between Train of Four and PTC measurement modes as the patient recovers and the provider redoses neuromuscular blocking agent.

Post-Tetanic Count Display on TwitchView

Figure 3: Auto-PTC sequence on the TwitchView Monitor facilitates automatic switching between TOF and PTC monitoring modes. Image source: author

To learn how continuous neuromuscular monitoring can reduce the overall need for sugammadex, click learn more below.

LEARN MORE

 

References:
1.   Debaene B, Plaud B, Dilly M-P, Donati, F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98:1042-1048.
2.   Fernando PU, Viby-Mogensen J, Bonsu AK, et al. Relationsip between posttetanic count and response to carinal stimulation during vecuronium-induced neuromuscular blockade. Acta Anaesthesiol Scand. 1987;31:593–6.
3.   Naguib M, Brull SJ, Kopman AF, et al. Consensus statement on perioperative use of neuromuscular monitoring. Anest Analg. 2018:127(1):71-80.
4.   Naguib, M., Brull, S.J. and Johnson, K.B. (2017), Conceptual and technical insights into the basis of neuromuscular monitoring. Anaesthesia, 72: 16-37. https://doi.org/10.1111/anae.13738
5.   Murphy, Glenn S. MD; Szokol, Joseph W. MD. Monitoring Neuromuscular Blockade. International Anesthesiology Clinics 42(2):p 25-40, Spring 2004.
6.   Donati, F. Residual paralysis: a real problem or did we invent a new disease?. Can J Anesth/J Can Anesth 60, 714–729 (2013). https://doi.org/10.1007/s12630-013-9932-8

We've been implementing twitch monitors for a decade. Get tips from leading experts and hospital systems worldwide.