Sugammadex versus anticholinesterase reversal of neuromuscular blockade in adult surgical patients: a systematic review and meta-analysis

Abstract

Residual neuromuscular blockade after general anaesthesia is a cause of postoperative pulmonary complications and delayed recovery. Sugammadex, a relaxant-binding agent, is a fast-acting antidote for aminosteroid neuromuscular block which works through encapsulation, in contrast to acetylcholinesterase inhibitors like neostigmine. This study evaluated the effectiveness, postoperative recovery and complications associated with sugammadex versus conventional anticholinesterase reversal drugs in adult surgical patients. This systematic review and meta-analysis was done based on the PRISMA 2020 statement. Databases like PubMed/MEDLINE and Scopus were used to search the literature from January 2000 to December 2025. Studies comparing the use of sugammadex to anticholinesterase agents in adult surgical patients were included, both randomised and non-randomised. Two independent reviewers screened, extracted data and assessed the risk of bias. Analyses were carried out in RevMan 5.3 software using random-effect models; the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes were used with 95% confidence intervals (CI). Evidence certainty was assessed using the GRADE approach. Total of ten studies ( n  = 4,082) were included; 5 randomised control trials and 5 observational studies. There was no statistically significant reduction in postoperative pulmonary complications with sugammadex compared to anticholinesterase (3 studies, n  = 688; OR 0.75, 95% CI 0.47–1.20; p  = 0.23; I 2 = 77%). There was faster recovery of neuromuscular function with sugammadex, however, there was very high heterogeneity among the studies and the pooled estimate cannot be interpreted as one single effect size (2 studies; I 2 = 100%). Recovery time after surgery was reduced (3 studies, n  = 260; MD -6.66 min, 95% CI −6.96 to −6.35; p  < 0.00001; I 2 = 87%) and time to first bowel movement was also earlier (2 studies, n  = 559; MD −13.81 h, 95% CI -19.16 to −8.45; p  < 0.00001; I 2 = 0%). There were no statistically significant differences for PACU stay (MD 1.55 min, 95% CI −1.60 to 4.69), readmission rate (OR 0.93, 95% CI 0.62–1.39) and postoperative nausea/vomiting (OR 0.86, 95% CI 0.48–1.56). Faster neuromuscular recovery, shorter recovery time after surgery and early return of bowel function was associated with the use of sugammadex rather than the anticholinesterase agents. There were no differences found for postoperative pulmonary complications, PACU stay, readmission rate or nausea and vomiting. These results are based on small number of clinically heterogeneous studies, in which only 2–4 studies were used in pooling and thus should be considered as preliminary results. CRD420261364292.