The Effect of Sugammadex Versus Neostigmine on Postoperative Cognitive Recovery: A Systematic Review and Meta-Analysis.

Postoperative cognitive dysfunction is a major clinical concern, particularly in elderly patients, leading to reduced quality of life and increased mortality. The impact of neuromuscular blockade reversal agents, such as sugammadex and neostigmine, on cognitive recovery remains uncertain. A systematic search of PubMed, EMBASE, and Cochrane databases identified randomized controlled trials (RCTs) and observational studies comparing sugammadex and neostigmine (± anticholinergics) for reversal of neuromuscular blockade in adults under general anesthesia for elective surgery. Studies published up to February 2025 that used the Mini-Mental State Examination (MMSE) or the cognitive domain of the Postoperative Quality Recovery Scale (PQRS) were included, as they both evaluate cognition on multiple aspects. Standardized mean differences (SMD) and standard errors (SE) were calculated, and a meta-analysis using the generic inverse variance method was performed. Heterogeneity was assessed with the I² statistic. Six RCTs and three observational studies, including 1,116 patients, were analyzed. Sugammadex was associated with better early cognitive recovery (40 to 60 minutes postoperatively) compared to neostigmine (SMD 0.20; 95% CI (0.07, 0.33); p = 0.003). No significant cognitive differences were observed immediately (≤15 minutes), on day one, or on days three to seven postoperatively. Sugammadex also improved physiological recovery at 40 minutes (RR 1.20; 95% CI (1.09, 1.30); p < 0.0001). Sensitivity analysis confirmed these findings. No differences were found in nociceptive, emotive, activities of daily living, or overall recovery domains. Sugammadex may improve early postoperative cognitive and physiological recovery over neostigmine, which could lead to a faster post-anesthesia care unit (PACU) discharge. No differences were observed at other time points or PQRS domains.