Table 1. Description of studies included in the review.

TOF: Train-of-four, NMB: Neuromuscular blockage, PONV: Post-operative nausea vomiting, PACU: Post-anaesthesia care unit, MO: Morbidly obese, PORC: Post-operative respiratory complication, ECG: Electrocardiogram, IOP: Intra-ocular pressure, TOFR: Train-of-four ratio, TFIO: Thickening fraction of internal oblique abdominal muscle, EMG: Electromyography, CBW: Corrected body weight, CVD: Cardiovascular disease

Sr. no	Author and year	Participants	Type of surgery	Intervention	Outcome measures	Conclusion
1	Blobner et al. (2010) [17]	98 adult patients	Any elective surgery	For tracheal intubation and neuromuscular blockade maintenance, patients were allocated at random to receive either rocuronium or vecuronium. For neuromuscular blockade reversal, they were given either sugammadex 2.0 mg kg(-1) or neostigmine 50 microgram kg (-1) (with glycopyrrolate 10 microgram kg(-1)).	Neuromuscular monitoring was performed using evoked acceleromyography of the adductor pollicis muscle.	The recovery time of the TOF ratio of 0.9 following sugammadex was notably shorter than that of neostigmine, at 1.5 minutes as compared to 18.6 minutes. Sugammadex patients recovered to a TOF ratio of 0.9 in 5 minutes, compared to 11% of neostigmine patients; this indicates that sugammadex patients had a more predictable response than neostigmine patients.
2	Adamus et al. (2011) [18]	22 adult patients undergoing	Extreme lateral interbody fusion (spine surgery)	Patients undergoing surgery for rocuronium block reversal were randomised to receive either sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg).	Both the electromyographic response of the adductor pollicis muscle and TOF stimulation of the ulnar nerve at 15-s intervals were used.	In order to accurately identify lumbar nerve roots during surgery, the NMB needs to be reversed to a TOF ratio of at least 0.70 when using a stimulating current of 10 mA. Regarding a current at a 5 mA intensity, the corresponding TOF ratio ought to be 0.90. It is possible to reach these target TOF ratios with 0.04 mg/kg of neostigmine and 2 mg/kg of sugammadex.
3	Kheterpal et al. (2021) [19]	45,172 patients	Elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent	22,856 patients receiving sugammadex and 22,856 patients receiving neostigmine were matched and divided into 2 groups, they received 3.5% sugammadex and 4.8% neostigmine.	According to international consensus guidelines, the main outcome was a composite of postoperative pulmonary complications that were likely related to residual NMB. Pneumonia, respiratory failure, or other significant pulmonary complications are the possible outcomes.	Sugammadex use was linked to a statistically and clinically significant reduction in the incidence of major pulmonary complications in a generalizable cohort of adult patients undergoing inpatient surgery at US hospitals. While sugammadex quickly and efficiently restores neuromuscular tone without causing systemic anticholinergic activity, neostigmine is still the standard of care in most countries due to decades of experience and sugammadex's higher cost.
4	Brueckmann et al. (2015) [20]	154 adult patients	Abdominal surgery	Subjects receiving general anaesthesia with rocuronium-induced neuromuscular blockade during elective laparoscopic or open abdominal surgery, sugammadex (2 or 4 mg kg (-1)) or neostigmine/glycopyrrolate (dosing per usual care practice) were given to patients at random.	During surgery, the degree of neuromuscular blockade was assessed by accelerator-myography-based neuromuscular monitoring at the adductor pollicis muscle.	The duration between the administration of reversal agents and the readiness for operating room discharge was shortened in the case of sugammadex compared to standard care, suggesting a quicker recovery of neuromuscular function in the operating room and a higher level of surgical efficiency. It is more economical to reverse neuromuscular blockade completely if muscles heal quickly. Strength can be used in routine clinical practice to shorten recovery times. Top of Form
5	Carron et al. (2013) [6]	40 female patients who are MO.	Morbidly obese patients undergoing elective surgery.	NMB was obtained by using rocuronium. Sugammadex or neostigmine plus atropine was used to achieve total reversal of NMB at the conclusion of the surgical procedure. Sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg) was given.	At the time of PACU admission, an accelerator-myographic low stimulation current (30 mA) was used to assess TOFR in order to determine the extent of residual NMB.	Sugammadex reduces the chance of PORC, speeds up the recovery process from profound NMB, and enables MO patients to resume their mobility more quickly. Alongside fast-acting, short-acting volatile anaesthetics and sugammadex and opioids enable bariatric fast-track surgery.
6	Castro et al. (2014) [21]	88 MO patients	Bariatric surgery	Patients were split into two groups in order to examine the impact of sugammadex 2 mg/kg on postoperative pain: those who received or neostigmine 0.05 mg/kg.	A visual analogue scale was employed to measure pain. Four separate times were considered for evaluation: when the patient first arrived in the PACU, 30 minutes later, 60 minutes later, and right before returning to the surgery ward.	Sugammadex is linked to a reduction in pain experienced in the PACU. Sugammadex's "opioid-sparing" action, along with a decrease in PONV and a quicker discharge from the PACU, make it an essential medication for patients of this kind and permits expedited surgery in the MO.
7	Cheong et al. (2015) [22]	120 patients	Any elective surgery.	One of four groups (Groups S2, S1, SN, and N) was randomly assigned to receive intravenous sugammadex 2 mg/kg. Group S1 received sugammadex 1 mg/kg, Group SN received sugammadex 1 mg/kg plus neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg, and Group N received neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg for the purpose of reversing the neuromuscular blockade.	When the patients entered the operating room, the accelerometer was fixed on the ipsilateral thumb, two stimulating electrodes of the TOF-Watch® were placed over the ulnar nerve on the wrist at intervals of 3 to 4 cm, and the ECG, blood pressure, and pulse oximetry were recorded.	Neostigmine and sugammadex together may help to shorten the recovery period and lower the dosage of sugammadex required for the reversal of rocuronium-induced moderate neuromuscular blockade. However, when using sugammadex in conjunction with neostigmine, the clinical anesthesiologist needs to take into account the higher risk of systemic muscarinic side effects.
8	Flockton et al. (2008) [23]	84 adult patients	Any elective surgery.	The adult surgical patients were randomly assigned to receive sugammadex 2.0 mg kg21 for rocuronium-induced block reversal or neostigmine 50 mg kg21 for cisatracurium-induced block reversal (0.15 mg kg21).	Acceleromyography was used to track neuromuscular function (TOF-Watch SX).	In surgical patients, the rocuronium-induced neuromuscular block can be quickly and successfully reversed with sugammadex 2.0 mg kg21 given at the reappearance of T2. When it came to reversing rocuronium-induced neuromuscular block, sugammadex was noticeably quicker than neostigmine when it came to reversing cisatracurium-induced block. Neostigmine and sugammadex were both well tolerated and safe.
9	Gaszynski et al. (2012) [24]	70 MO patients	MO patients undergoing surgery requiring general anaesthesia.	Patients who required general anaesthesia and were given rocuronium for muscle relaxation were divided into two groups at random. The first group received sugammadex 2 mg kg21 at the end of the anaesthetic procedure, while another group received neostigmine 0.05 mg kg21 of CBW.	After surgery, the patient's response was measured by a TOF score.	The study concludes with the finding that sugammadex 2.0 mg kg21 CBW given at the onset of T2 can effectively and quickly reverse rocuronium-induced neuromuscular block and prevent PORC in patients who are morbidly obese. Compared to neostigmine, sugammadex reversed rocuronium-induced neuromuscular block much more rapidly. Sugammadex was well-tolerated and safe. Neostigmine did not completely prevent PORC from occurring, but it did cause some side effects.
10	Geldner et al. (2012) [25]	140 adult patients	Any laparoscopic surgery	Patients were randomised to receive atropine (10 mg.kg-1) plus either neostigmine (50 µg. kg-1) or sugammadex (4 mg.kg-1).	Acceleromyography was used for continuous neuromuscular monitoring at the adductor pollicis muscle following the induction of anaesthesia.	Sugammadex neuromuscular blockade reversal at a post-tetanic count of 1-2 after rocuronium was well tolerated and led to a faster recovery of the TOF ratio to 0.9 compared with neostigmine administered at the reappearance of T2 in patients undergoing laparoscopic surgery under propofol anaesthesia. Consequently, sugammadex may enable quick and painless reversal of deep neuromuscular blockade following surgery.
11	Hakimoglu et al. (2016) [26]	60 adult patients undergoing	Arthroscopic surgery	Two groups were randomly assigned to the patients. Following the procedure, Group 1 received neostigmine (50 mg/kg) plus atropine (15 mg/kg), while Group 2 received sugammadex (4 mg/kg) to reverse the neuromuscular block.	Throughout the procedure, standard monitoring was carried out, including an ECG, noninvasive blood pressure readings, heart rate, and peripheral arterial oxygen saturation. Train-of-four (TOF-Watch SX; Organon Ireland Ltd., Dublin, Ireland) was used to monitor the degree of neuromuscular blockade in addition to routine monitoring.	The sugammadex group's post-extubation IOP values resembled those of the neostigmine atropine group. Furthermore, our study found that the sugammadex group experienced a shorter extubation time than the neostigmine atropine group, which is consistent with earlier research.
12	Kaufhold et al. (2016) [27]	99 adult patients	Any elective surgery	Ninety-nine patients received either saline or sugammadex at doses of 0.25, 0.5, 0.75, 1.0, and 1.25 mg kg−1, neostigmine at doses of 10, 25, 40, 55, and 70 µg kg−1 in a mixture containing 1 µg glycopyrrolate for every 5 µg neostigmine.	Using the NMT module in an S/5 GE Datex Light monitor, evoked EMG of the adductor pollicis muscle was used for neuromuscular monitoring in accordance with international consensus guidelines.	Sugammadex (∼0.26 mg kg−1) can reverse a TOFR from 0.2 to ≥0.9 in 10 minutes in 95% of patients, but neostigmine was ineffective in this regard. Sugammadex (∼0.50 mg kg−1) can also reverse a residual neuromuscular block at a TOFR≥0.2 in 95% of patients quickly (within 5 min).
13	Kizilay et al. (2016) [28]	99 patients with class 2 or 3 CVD.	Non-cardiac surgery	Following surgery, patients in group 1 were given IV sugammadex at a dose of 3 mg/kg when the T2 level in the train of four resurfaced. After the procedure, patients in the second group received IV 0.03 mg/kg neostigmine when their T2 level returned and was tracked by a nerve-muscle stimulator.	A nerve muscle stimulator was used.	The study compared the hemodynamic effects of sugammadex and neostigmine in patients with heart conditions who had non-cardiac surgery. Between the two groups, they could not find any differences in the QT interval. Hemodynamic parameters increased significantly in both groups, but the increase was more pronounced in neostigmine-treated patients. Sugammadex is a potentially safe option to reverse neuromuscular blockade in patients with heart conditions undergoing non-cardiac surgery.
14	Choi et al. (2017) [29]	44 adult patients undergoing laryngeal microsurgery	Elective laryngeal micro-surgery	Divided into two groups at random: the moderate block group, which included rocuronium 0.45 mg kg-1 with neostigmine (50 µg.kg~1 with glycopyrrolate 10 µg.kg-1) reversal, and the deep block group, which included rocuronium 0.90 mg kg~1 with sugammadex (4 mg.kg~1) reversal.	The tracking programme TOF-Watch SX was utilised to gather train-off data automatically.	Patients receiving deep neuromuscular blockade with sugammadex as the reversal medication during elective laryngeal microsurgery, have significantly better surgical outcomes and a shorter recovery period when compared to rocuronium dosage reduction with neostigmine reversal.
15	Huang et al. (2023) [30]	58 adult patients	Micro-laryngeal surgery	Following surgery, patients were given either sugammadex (2 mg·kg−1) or neostigmine (50 μg·kg−1, maximum 5 mg) in combination with atropine (25 μg·kg−1, maximum 2.5 mg).	Using a TOFR recovery to 0.9, the TFIO and diaphragm excursion, which represent expiratory and inspiratory muscle strength, were measured by ultrasonography three times before induction (baseline), and 30 minutes after the PACU arrived. The shift in TFIO from baseline to TOFR ≥0.9 was the main result.	Immediately following extubation, sugammadex improves the recovery of expiratory muscle strength more thoroughly than neostigmine. It is necessary to provide additional evidence of the connection between the treatment allocation and the recovery of expiratory muscle strength after extubation that lasts longer than 30 minutes.