Paradigm shift of sugammadex from routine anesthesia to emergencies: a narrative review

Purpose: Sugammadex, introduced in South Korea in 2013, has fundamentally changed the management of neuromuscular blockade. This review summarizes the pharmacology, clinical applications, and safety of sugammadex and analyzes its impact on anesthesia practice in South Korea over the past 12 years.Current concepts: Sugammadex is a modified γ-cyclodextrin that encapsulates rocuronium or vecuronium, enabling rapid reversal at any depth of neuromuscular blockade. Compared with neostigmine, it provides faster and more complete recovery, reduces postoperative residual paralysis, and avoids cholinergic side effects. International guidelines (American Society of Anesthesiologists 2023, European Society of Anaesthesiology and Intensive Care 2023) recommend quantitative neuromuscular monitoring and the preferential use of sugammadex. Experience in South Korea reflects these changes, with improvements in patient safety and expanded use in emergency situations and high-risk populations.Discussion and conclusion: Sugammadex is a paradigm-shifting drug that improves both routine and emergency anesthesia care. Although rare adverse events, such as anaphylaxis and severe bradycardia, require continued vigilance, its overall safety profile is favorable. In South Korea, insurance and policy constraints continue to affect utilization, but greater alignment with international guidelines is expected to broaden access. Future directions include research in infants and patients with renal failure, cost-effectiveness analyses, and further standardization of neuromuscular management.