Impact of Neuromuscular Blockade Reversal on Emergence Agitation in Adults Undergoing Nasal Surgery: A Prospective Randomized Controlled Trial

Introduction/Objective Emergence Agitation (EA) is a concern during recovery from general anesthesia, particularly after nasal surgery, where airway discomfort may contribute to agitation. This study aimed to compare the incidence and severity of EA in adults undergoing nasal surgery who received sugammadex or neostigmine for neuromuscular blockade reversal. Methods This prospective, randomized controlled trial included 154 adults with American Society of Anesthesiologists (ASA) physical status I or II undergoing nasal surgery under general anesthesia. Patients were randomly allocated to receive either sugammadex (2 mg/kg intravenously) or neostigmine (0.05 mg/kg intravenously) combined with glycopyrrolate (0.01 mg/kg intravenously). EA was assessed at extubation and at 5 and 10 minutes afterward. Secondary outcomes included time to full consciousness, the interval to extubation following neuromuscular recovery, hemodynamic variables, and postoperative complications. Results The incidence of EA was lower in the sugammadex group than in the neostigmine group (9/77 [11.7%] vs. 26/77 [33.7%], respectively; p < 0.001). Time to full consciousness was shorter in the sugammadex group (10.8 ± 5.1 vs. 15.6 ± 6.8 minutes, respectively; p < 0.001). The interval from a TOF count greater than 2 to extubation after achieving a TOF ratio ≥ 0.9 was also shorter in the sugammadex group (2.78 ± 1.09 vs. 5.20 ± 1.47 minutes, respectively; p < 0.001). EA scores were lower in the sugammadex group, with significant group, time, and group-by-time interaction effects on repeated-measures analysis. No statistically significant differences were observed in rescue sedation requirements or postoperative nasal bleeding among patients who developed EA. Discussion The findings suggest that the choice of neuromuscular blockade reversal agent may be associated with emergence characteristics after nasal surgery. Faster recovery with sugammadex may partly explain the observed differences; however, the contribution of Residual Neuromuscular Blockade (RNMB) to EA could not be directly established because quantitative TOF recovery was not evaluated as a study outcome. Conclusion Sugammadex use was associated with a lower incidence and severity of EA and faster recovery to full consciousness than neostigmine in adults undergoing nasal surgery. These findings should be interpreted cautiously because surgical duration differed between groups and other perioperative factors may have influenced the results. Further studies incorporating quantitative neuromuscular monitoring and adjustment for potential confounders are warranted. Trial registration ClinicalTrials.gov: NCT07253428.