Sugammadex versus neostigmine for neuromuscular blockade reversal in adults

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.