Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge

Br J Anaesth. 2010 Sep;105(3):304-9. doi: 10.1093/bja/aeq157. Epub 2010 Jun 24.


Background: Postoperative residual curarization (PORC) [train-of-four ratio (T4/T1) <0.9] is associated with increased morbidity and may delay postoperative recovery room (PACU) discharge. We tested the hypothesis that postoperative T4/T1 <0.9 increases PACU length of stay.

Methods: At admission to the PACU, neuromuscular transmission was assessed by acceleromyography (stimulation current: 30 mA) in 246 consecutive patients. The potential consequences of PORC-induced increases in PACU length of stay on PACU throughput were estimated by application of a validated queuing model taking into account the rate of PACU admissions and mean length of stay in the joint system of the PACU plus patients recovering in operation theatre waiting for PACU beds.

Results: PACU length of stay was significantly longer in patients with T4/T1 <0.9 (323 min), compared with patients with adequate recovery of neuromuscular transmission (243 min). Age (P=0.021) and diagnosis of T4/T1 <0.9 (P=0.027), but not the type of neuromuscular blocking agent, were independently associated with PACU length of stay. The incidence of T4/T1 <0.9 was higher in patients receiving vecuronium. Delayed discharge significantly increases the chances of patients having to wait to enter the PACU. The presence of PORC is estimated to be associated with significant delays in recovery room admission.

Conclusions: PORC is associated with a delayed PACU discharge. The magnitude of the effect is clinically significant. In our system, PORC increases the chances of patients having to wait to enter the PACU.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Anesthesia Recovery Period
  • Atracurium / analogs & derivatives
  • Atracurium / pharmacology
  • Female
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Monitoring, Physiologic / methods
  • Neuromuscular Blockade
  • Neuromuscular Blocking Agents / pharmacology*
  • Neuromuscular Junction / drug effects*
  • Neuromuscular Junction / physiology
  • Postoperative Period
  • Prospective Studies
  • Vecuronium Bromide / pharmacology
  • Young Adult


  • Neuromuscular Blocking Agents
  • Atracurium
  • Vecuronium Bromide
  • cisatracurium