A case of recurarization in the recovery room is reported. Accumulation of
atracurium in the intravenous line led to recurarization after flushing the
line in the recovery room. A respiratory arrest with severe desaturation a
nd bradycardia occurred. Circumstances leading to this event and the mechan
isms enabling a neuromuscular blockade to occur, following the administrati
on of a small dose of relaxant, are discussed.