Comparison of rocuronium‑sugammadex and mivacurium on recovery efficiency after pediatric isolated adenoidectomy: a propensity score‑matched cohort study

Background Mivacurium and rocuronium-sugammadex are two commonly used neuromuscular blocking regimens in pediatric otorhinolaryngological surgery. However, existing comparative studies frequently combine isolated adenoidectomy with adenotonsillectomy, introducing significant confounding variables; consequently, dedicated head-to-head comparisons restricted to isolated adenoidectomy remain scarce. This study aimed to compare postoperative recovery efficiency between rocuronium-sugammadex reversal and mivacurium monotherapy, two routinely used clinical regimens, in children aged 3–12 years undergoing isolated adenoidectomy. Methods Of 877 eligible children, 616 children (308 matched pairs) were analyzed after 1:1 propensity-score matching. The primary endpoint was the time from cessation of anesthetic maintenance agents to tracheal extubation. Secondary endpoints included time from anesthetic cessation to post-anaesthesia care unit (PACU) discharge, emergence quality, and postoperative pain scores. Results The median time from anesthetic discontinuation to extubation was 23 min in the rocuronium-sugammadex group versus 25 min in the mivacurium group Hodges-Lehmann (HL) pseudomedian difference − 2 min; (95% CI − 4.00 to − 0.0001; P = 0.022). However, this modest between-group difference was not statistically significant in a paired sensitivity analysis ( P = 0.069). The median interval from drug cessation to PACU discharge was shorter in the rocuronium-sugammadex group (38 [30.00–48.00] min) than in the mivacurium group (42 [34.00–51.00] min), with a HL pseudomedian difference of − 4.00 min (95% CI − 6.00 to − 2.00; P < 0.001). Steward scores were comparable ( P = 0.416); VAS pain scores differed statistically ( P = 0.016) but the absolute difference was minimal. Subgroup analysis showed that shorter extubation time was observed only in children receiving intraoperative midazolam. Shorter PACU discharge duration was also seen in this subgroup and in both age subgroups, but not in children without midazolam. Conclusion In children undergoing isolated adenoidectomy, the rocuronium-sugammadex regimen was associated with modestly shorter extubation time in primary analysis, though this finding was not confirmed in paired sensitivity analysis, together with significantly reduced PACU discharge time and delayed discharge risk, without compromising postoperative recovery safety or comfort. Benefits in extubation time and PACU discharge duration were observed primarily in children receiving intraoperative midazolam; however, formal interaction analysis for this exploratory subgroup comparison did not demonstrate significant effect modification. Taken together, under real-world clinical dosing conditions, these findings suggest that this rocuronium-sugammadex anesthetic strategy may help optimize patient turnover in high-volume pediatric day-surgery centers.