The enhanced recovery after surgery (ERAS) initiative offers an evidence-based, multidisciplinary framework designed to reduce surgical stress, accelerate functional recovery, and optimize hospital resource use. Dr Shu-Lin Guo of the Department of Anesthesiology, Chia-Yi Christian Hospital, Chia-Yi City, Taiwan, shared his expert opinion with MIMS Doctor on how sugammadex, a novel neuromuscular blockade (NMB) reversal agent, can be integrated into ERAS pathways to improve patient outcomes, reduce complications, and enhance perioperative efficiency and cost-effectiveness.
Burden of perioperative care failures
Perioperative care is a complex pathway that includes preoperative assessment, intraoperative management, and postoperative recovery. Failures at any stage can lead to serious consequences. [CPOC Strategy 2023–2026, February 2023: cpoc.org.uk]
“Uncontrolled surgical stress can result in haemodynamic instability, organ dysfunction, increased intensive care unit [ICU] utilization, delayed recovery, and prolonged hospitalization. Inefficiencies along the care pathway can further reduce operating room turnover, decrease ward productivity, and increase hospital resource use,” noted Guo.
Postoperative complications significantly increase costs. The presence of any complication is associated with a 1.5-fold rise in direct hospital costs, while respiratory complications are linked to a 3.1-fold increase. [Ann Surg 2022;275:e375-e381]
“Residual NMB is a major contributor to respiratory complications and is closely associated with delayed tracheal extubation, unplanned ICU admissions, and prolonged post-anaesthesia care unit [PACU] stays,” noted Guo. [Anesth Analg 2010;111:120-128; Anesth Analg 2019;128:1129-1136]
The WHO estimates that at least half of surgery-related harm is preventable, highlighting the critical need for improved surgical safety. [WHO, 2021, Safe Surgery: https://www.who.int/ teams/integrated-health-services/patient-safety/research/safe-surgery]
“Systemic failures in perioperative care often arise from fragmented care delivery, including inadequate risk assessment and involvement of multiple stakeholders — each with incomplete knowledge of the patient’s status. These gaps can lead to poor coordination, medical errors, and increased patient safety risks,” explained Guo. “Effective perioperative care depends on clear communication, strong teamwork, adherence to evidence-based protocols, and multidisciplinary collaboration guided by shared goals to prevent complications and improve patient outcomes.”
ERAS: A framework for safer, smarter perioperative care ?
The ERAS initiative, originally developed for colorectal surgery, has been widely adopted across various surgical specialties. Consistent with the WHO’s “Safe Surgery Saves Lives” principles, ERAS offers an evidence-based, multidisciplinary framework to reduce surgical stress, enhance recovery, optimize healthcare resource use, and improve patient satisfaction and quality of life. [Cureus 2023;15:e48795; Textbook of Patient Safety and Clinical Risk Management 2021;177-188; World J Surg 2019;43:659-695]
“Implementation of ERAS pathways requires proactive collaboration among all stakeholders across the perioperative continuum, including surgeons, anaesthesiologists, nurses, nutritionists, and physiotherapists,” emphasized Guo. “ERAS success depends on multiple incremental improvements [marginal gains] across the care continuum that collectively optimize recovery. Real-world evidence demonstrates that high adherence to ERAS protocols reduces postoperative complications, shortens hospital length of stay [LoS], and improves long-term survival. For patients, compliance with ERAS measures supports a smoother surgical experience and a faster return to normal activities such as eating, drinking, sleeping and mobilization.” [World J Surg 2016;40:1092-1103; World J Surg 2016;40:1741-1747]
Sugammadex supports ERAS objectives
Revolutionary MoA
Sugammadex is the first selective relaxant-binding agent and represents a major advancement in the reversal of NMB. Its novel mechanism of action (MoA) involves encapsulation of free aminosteroidal neuromuscular blocking agents (NMBAs), including rocuronium and vecuronium, within the plasma. By binding circulating NMBAs, sugammadex prevents their diffusion back into the neuromuscular junction (NMJ), creating a concentration gradient that promotes the movement of unbound NMBAs from the NMJ into the plasma for further sequestration. This process enables rapid and predictable reversal of NMB. Unlike neostigmine historically used for NMB reversal, sugammadex does not exert muscarinic effects and therefore does not require co-administration of anticholinergic agents. [Reversal of neuromuscular blockade: Sugammadex, OpenAnesthesia, 2023: https://www. openanesthesia.org/keywords/reversal-of-neuromuscular-blockade-sugammadex/]
Rapid and profound recovery
Sugammadex provides rapid reversal of moderate-to-deep NMB, typically achieving recovery within 2 minutes of administration vs approximately 10 minutes for neostigmine. In addition, sugammadex is more reliable than neostigmine for reversal of deeper levels of NMB. [J Clin Med 2024;13:861]
In the double-blind, randomized DATA trial in thoracic surgery patients (n=70), sugammadex produced faster recovery from NMB and led to earlier extubation compared with neostigmine. The median time to recovery to a train-of-four ratio (TOFR) of 0.9 was significantly shorter with sugammadex (88 vs 278 seconds; p<0.001). Among patients with moderate-to-deep residual NMB, recovery remained significantly faster with sugammadex (115 vs 420 seconds; p<0.001). (Figure 1) [J Anesth Analg Crit Care 2024;4:9]
In elderly patients (generally >65 years of age), age-related physiological changes can alter the pharmacokinetic and pharmacodynamic profiles of both NMBAs and sugammadex, which may prolong neuromuscular recovery by approximately 1–2 minutes compared with younger adults. However, this modest delay does not compromise the efficacy of sugammadex, nor does it increase the risk of adverse effects in the elderly population. [Clin Interv Aging 2017;13:13-24]
Enhanced haemodynamic stability
“Using sugammadex helps maintain more stable heart rate and blood pressure, with minimal impact on other vital signs,” noted Guo. In a post-hoc analysis evaluating adverse events in the PACU among patients undergoing elective surgery with general anaesthesia and endotracheal intubation, bradycardia was significantly less frequent in patients receiving sugammadex vs neostigmine (10.2 vs 16.9 percent; p<0.001). [Healthcare 2023;11:240]
Clinical benefits across a wide patient spectrum
“Sugammadex provides reliable, safe and complete recovery of neuromuscular function across the patient spectrum, including high-risk groups and a wide range of surgical procedures,” highlighted Guo.
Children
According to a meta-analysis evaluating the efficacy and safety of sugammadex vs neostigmine or placebo for reversing NMB in paediatric patients, sugammadex provided more rapid reversal of rocuronium-induced NMB and was associated with a lower incidence of bradycardia. [Sci Rep 2017;7:5724]
In a randomized controlled trial (RCT) of paediatric patients aged 1–6 years undergoing fast-track cardiac surgery, sugammadex significantly shortened the recovery time to TOFR of 0.9 and extubation time vs neostigmine (3.4 vs 76.2 minutes and 31.0 vs 125.5 minutes, respectively; p<0.001). These improvements were accompanied by significant reductions in ICU stay (1.2 vs 1.6 days; p<0.01) and postoperative hospital LoS (5.8 vs 6.5 days; p=0.03). [J Cardiothorac Vasc Anesth 2021;35:1388-1392]
Elderly
Studies show that the elderly are at increased risk for postoperative residual NMB and associated adverse outcomes, including muscle weakness, airway obstruction, hypoxaemia, postoperative pulmonary complications (PPCs), and prolonged LoS in both the PACU and hospital. [Anesthesiology 2015;123:1322-1336; Anesth Analg 2016;123:859-868] “A meta-analysis involving 510 older patients further showed that sugammadex reduced the risk of early PPCs [before surgical ward discharge] by 41 percent compared with neostigmine [relative risk (RR), 0.59; 95 percent confidence interval (CI), 0.37–0.95],” noted Guo. (Figure 2) [Br J Anaesth 2022;128:e259-e262]
Burns and surgical patients
Similarly, sugammadex administration was associated with a 38 percent reduction in the risk of PPCs in patients with severe burns undergoing major surgery vs those who did not receive sugammadex (adjusted hazard ratio [HR], 0.62; 95 percent CI, 0.43–0.91; p=0.013). [Sci Rep 2024;14:525]
“Sugammadex also provides predictable and reliable airway safety in bariatric surgery patients — a population with elevated airway risk due to higher body mass index [BMI] — facilitating smooth and controlled recovery,” said Guo. A study of 40 morbidly obese female patients undergoing bariatric surgery demonstrated that sugammadex enabled faster and more complete reversal of profound NMB compared with neostigmine, resulting in earlier transfer to the surgical ward and quicker return to mobility. [Obes Surg 2013;23:1558-1563]
Cost-effectiveness of using sugammadex
“The clinical benefits of sugammadex can translate into economic advantages through improved perioperative efficiency,” highlighted Guo. A single-centre retrospective observational analysis of 8,120 surgical patients compared sugammadex and neostigmine for NMB reversal and evaluated their impact on perioperative efficiency. Sugammadex was associated with significant improvements in several surgical outcomes, including shorter extubation time (by approximately 3 minutes; p<0.001) and reductions in operating room (OR) time (by approximately 12 minutes; p<0.001) and PACU LoS (by approximately 4 minutes; p<0.001) vs neostigmine. (Table) [Proc (Bayl Univ Med Cent) 2022;35:599-603]
Another single-centre retrospective cohort study evaluated the efficacy of sugammadex in facilitating early extubation in the ICU after coronary artery bypass grafting surgery. The findings showed that introducing sugammadex significantly reduced total ICU intubation time by 34 percent (p<0.05), without a corresponding increase in adverse effects or complications. [J Clin Med 2025;14:1660]
“Better OR and ICU outcomes [eg, reduced postoperative complications; earlier extubation; decreased ICU bed use; shorter PACU, ICU or hospital LoS] can increase turnover rates and improve efficiency in both settings,” pointed out Guo. “These benefits may offset the drug acquisition costs and lead to net cost savings.” [J Clin Med 2025;14:4128]
Guidelines endorse sugammadex
Both the American Society of Anesthesiologists and the European Society of Anaesthesiology and Intensive Care have issued guidelines recommending sugammadex for reversal of deep, moderate, and shallow NMB induced by rocuronium or vecuronium. Neostigmine is considered acceptable only for reversal of minimal blockade. Both guidelines also strongly recommend routine use of quantitative neuromuscular monitoring. [Anesthesiology 2023;138:13-41; Eur J Anaesthesiol 2023;40:82-94]
“Sugammadex also aligns well with the 2018 ERAS anaesthesia protocol, which recommends quantitative monitoring and complete reversal of NMB,” noted Guo. [World J Surg 2019;43:659-695]
Patient education and engagement
Guo’s team promotes patient awareness and engagement through bilingual (Chinese and English) educational materials, including online resources and hospital posters, to support informed decision-making and adherence to ERAS protocols. Clear explanations using analogies such as comparing NMB depth to diving depth help patients understand the intervention and its safety implications.
“In line with ERAS principles, we perform early, systematic risk assessment during preoperative counselling, where patients complete a preoperative risk questionnaire to help identify factors such as older age [>65 years], higher BMI [>30 kg/m2], sleep apnoea, myasthenia gravis, and cardiovascular disease,” explained Guo. “Patients at low risk of developing complications receive education, while those at higher risk are recommended to use sugammadex as part of an optimized ERAS [anaesthetic] protocol.” [World J Surg 2019;43:659-695]
Collaboration with stakeholders
In addition to collaboration with stakeholders in the perioperative continuum, successful ERAS implementation also requires partnerships with industry, government, and hospital administrators to support awareness campaigns on safe anaesthesia and ERAS benefits.
“Sugammadex use can be leveraged as a starting point for dialogue with stakeholders about optimizing perioperative protocols and enhancing patient safety,” suggested Guo.
Conclusion
Sugammadex is a cornerstone of perioperative care within ERAS, providing rapid, safe, and reliable reversal of any depth of NMB across diverse populations, including high-risk and elderly patients. It reduces postoperative complications, shortens extubation, PACU and ICU times, and enhances hospital efficiency. Sugammadex use, combined with early risk assessment, patient education, and stakeholder collaboration, represents a paradigm shift in anaesthesia practice, prioritizing patient safety and clinical outcomes while considering economic stewardship and aligning with ERAS and international guidelines.