Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action

Anesthesiology. 2003 May;98(5):1042-8. doi: 10.1097/00000542-200305000-00004.


Background: Residual neuromuscular blockade remains a problem even after short surgical procedures. The train-of-four (TOF) ratio at the adductor pollicis required to avoid residual paralysis is now considered to be at least 0.9. The incidence of residual paralysis using this new threshold is not known, especially after a single intubating dose of intermediate-duration nondepolarizing relaxant. Therefore, the aim of the study was to determine the incidence of residual paralysis in the postanesthesia care unit after a single intubating dose of twice the ED(95) of a nondepolarizing muscle relaxant with an intermediate duration of action.

Methods: Five hundred twenty-six patients were enrolled. They received a single dose of vecuronium, rocuronium, or atracurium to facilitate tracheal intubation and received no more relaxant thereafter. Neuromuscular blockade was not reversed at the end of the procedure. On arrival in the postanesthesia care unit, the TOF ratio was measured at the adductor pollicis, using acceleromyography. Head lift, tongue depressor test, and manual assessment of TOF and DBS fade were also performed. The time delay between the injection of muscle relaxant and quantitative measurement of neuromuscular blockade was calculated from computerized anesthetic records.

Results: The TOF ratios less than 0.7 and 0.9 were observed in 16% and 45% of the patients, respectively. Two hundred thirty-nine patients were tested 2 h or more after the administration of the muscle relaxant. Ten percent of these patients had a TOF ratio less than 0.7, and 37% had a TOF ratio less than 0.9. Clinical tests (head lift and tongue depressor) and manual assessment of fade showed a poor sensitivity (11-14%) to detect residual blockade (TOF < 0.9).

Conclusion: After a single dose of intermediate-duration muscle relaxant and no reversal, residual paralysis is common, even more than 2 h after the administration of muscle relaxant. Quantitative measurement of neuromuscular transmission is the only recommended method to diagnose residual block.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Androstanols / adverse effects
  • Atracurium / adverse effects
  • Female
  • Humans
  • Male
  • Middle Aged
  • Movement / drug effects
  • Neuromuscular Nondepolarizing Agents / adverse effects*
  • Paralysis / chemically induced*
  • Paralysis / diagnosis
  • Paralysis / epidemiology
  • Postoperative Complications / chemically induced
  • Postoperative Complications / epidemiology
  • Rocuronium
  • Sensitivity and Specificity
  • Vecuronium Bromide / adverse effects


  • Androstanols
  • Neuromuscular Nondepolarizing Agents
  • Atracurium
  • Vecuronium Bromide
  • Rocuronium