Sugammadex versus neostigmine for neuromuscular blockade reversal in adults: A systematic review and meta-analysis of randomised controlled trials
In brief
Sugammadex reverses paralysis 10 minutes faster and reduces adverse events
Across 165 trials involving 19,124 adults, sugammadex shortened neuromuscular blockade reversal by about 10 minutes compared with neostigmine; about 28% fewer patients had at least one adverse event. Evidence also favored sugammadex for several specific complications, but many trials had unclear or high risk of bias, so the size of its safety advantage remains uncertain.
- Journal
- European journal of anaesthesiology (Q1)
- Published
- 3 November 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Alessandro Putzu, Chae Hyun Park, Xiaowei Hu, Mette Lea Mortensen, Ana-Marija Hristovska, Arash Afshari
- PMID
- 42973066
- DOI
- 10.1097/EJA.0000000000002526
Why clinicians should know about it
- Picked for Anesthesiology and Pain Medicine (paper of the day, 4 November 2026): Meta-analysis compares neuromuscular-blockade reversal and perioperative safety
Abstract
BACKGROUND: Reversal of neuromuscular blockade (NMB) is a routine component of general anaesthesia with important implications for recovery quality and peri-operative safety. Recent changes in the cost of sugammadex, together with its efficacy and adverse effect profile relative to neostigmine, may influence its broader clinical use. OBJECTIVES: To evaluate the efficacy and safety of sugammadex compared with neostigmine in adult patients. DESIGN: Systematic review of randomised controlled trials with meta-analyses and trial sequential analyses. Certainty of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) framework. This is an update of a 2017 Cochrane review. DATA SOURCES: Online databases were searched up to December 2025. ELIGIBILITY CRITERIA: Randomised trials enrolling adults receiving rocuronium or vecuronium for elective procedures and comparing sugammadex with neostigmine were included. The outcomes included NMB recovery time and risk of various adverse events. RESULTS: We included 165 trials with 19 124 participants. Risk of bias was generally unclear or high. NMB monitoring technique was reported in 113 trials, mostly acceleromyography. Time to reversal of NMB from second twitch to a train-of-four ratio more than 0.9 was shorter with sugammadex 2 mg kg-1 versus neostigmine 0.05 mg kg-1 (mean difference = -10.49 min (95% confidence interval, -11.90 to -9.08), GRADE: moderate). Sugammadex probably reduces the number of patients with at least one adverse event compared with neostigmine (risk ratio = 0.72 (95% confidence interval, 0.61 to 0.84), GRADE: moderate). When looking at specific adverse events, sugammadex probably reduces the risk of residual NMB, inadequate NMB reversal, desaturation, atelectasis, increased upper airway secretion, airway obstruction, bradycardia, dry mouth and urinary retention (GRADE: moderate). CONCLUSIONS: Sugammadex probably reverses NMB more rapidly and with fewer adverse events than neostigmine. Broader use of sugammadex has the potential to improve peri-operative outcomes.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.