Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade in Adults and Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract

Background: Cholinesterase inhibitors, such as neostigmine and edrophonium, commonly used to reverse the residual effects of nondepolarizing neuromuscular blocking drugs at the end of surgery are associated with a high rate of residual neuromuscular blockade (NMB). Due to its direct mechanism of action, sugammadex is associated with rapid and predictable reversal of deep NMB. The current analysis compares the clinical efficacy and risk of postoperative nausea and vomiting (PONV) on using sugammadex or neostigmine for routine NMB reversal in adult and pediatric populations. Methods: PubMed and ScienceDirect were searched as the primary databases. Randomized controlled trials comparing sugammadex with neostigmine for routine NMB reversal in adult and pediatric patients have been included. The primary efficacy endpoint was the time from initiation of sugammadex or neostigmine to the recovery of a time-of-four ratio (TOF) ≥ 0.9. PONV events have been reported as secondary outcomes. Results: A total of 26 studies have been included in this meta-analysis, 19 for adults with 1574 patients and 7 for children with 410 patients. Sugammadex, when compared to neostigmine, has been reported to take a shorter time to reverse NMB in adults (mean difference = -14.16 min; 95% CI [-16.88, -11.43], P < 0.01), as well as in children (mean difference = -26.36 min; 95% CI [- 40.16, -12.57], P < 0.01). Events of PONV have been found to be similar in both the groups in adults, but significantly lower in children treated with sugammadex, i.e., 7 out of 145 with sugammadex versus 35 out of 145 with neostigmine (odds ratio = 0.17; 95% CI [0.07, 0.40]). Conclusion: Sugammadex is associated with a significantly shorter period of reversal from NMB in comparison to neostigmine in adult and pediatric patients. Regarding PONV, the use of sugammadex for NMB antagonism may offer a better option for pediatric patients.