Sugammadex in ERAS: Redefining NMB reversal to enhance perioperative care

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.