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summary
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Time to achieve full reversal (TOFR > 0.9) was significantly faster with sugammadex (107s ± 61) than neostigmine (1044 ±590s) or edrophonium (331s ± 27).
All sugammadex-reversed patients were completely reversed within 5 minutes, compared with no patients receiving neostigmine.
Reversal with sugammadex lead to less increase in heart-rate than when neostigmine-glycopyrrolate or edrophonium-atropine and almost total avoidance of the dry-mouth associated with the later (5% vs 85-95%)
Sacan O, White PF, Tufanogullari B et al. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth. Analg. 2007 Mar 1;104(3):569-74.
  Daniel Jolley
summary
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Miller enthusiastically states:
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.”
...and hints at where benefits may begin:
“Will sugammadex’s increased effectiveness, in comparison to neostigmine, lessen the need for or use of monitoring neuromuscular function?”
Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology? Anesth. Analg. 2007 Mar 1;104(3):477-8.
  Daniel Jolley
comment
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Sugammadex is a great drug, but not a universal magic bullet.
Kyle BC, Gaylard D, Riley RH. A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex. Anaesth Intensive Care. 2012 Mar 1;40(2):344-6.
  Daniel Jolley
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An interesting CICO case study highlighting that while sugammadex will rapidly and completely reverse paralysis, this is only one consideration when managing an airway crisis. The use of any reversal agent in an airway crisis should be considered within the context of the case and a clear understanding of the objective of our actions.
Neuromuscular reversal will only improve a CICO scenario if spontaneous ventilation will improve patient oxygenation, otherwise return of muscle function may actually make other CICO interventions more difficult.
Kyle BC, Gaylard D, Riley RH. A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex. Anaesth Intensive Care. 2012 Mar 1;40(2):344-6.
  Daniel Jolley
pearl
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Adequate reversal of neuromuscular blockade may not always be helpful when successfully managing a cannot intubate-cannot-ventilate crisis.
Kyle BC, Gaylard D, Riley RH. A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex. Anaesth Intensive Care. 2012 Mar 1;40(2):344-6.
  Daniel Jolley
comment
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Concerns regarding hypersensitivity to sugammadex are reportedly one of the primary sticking points for sugammadex still lacking FDA approval.
Godai K, Hasegawa-Moriyama M, Kuniyoshi T et al. Three cases of suspected sugammadex-induced hypersensitivity reactions. Br J Anaesth. 2012 Aug 1; 109 (2): 216-8.
  Daniel Jolley
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A reminder that hypersensitivity reactions are possible with almost any drug or chemical. At the time of this publication, the risk of anaphylaxis to sugammadex appeared to be lower than that for muscle relaxants – however newer studies from Merck (Kam 2018 and Min 2018) worryingly suggest that sugammadex sensitivity may be a lot more common than we thought.
The FDA’s caution now no longer seems quite so unwarranted...
Godai K, Hasegawa-Moriyama M, Kuniyoshi T et al. Three cases of suspected sugammadex-induced hypersensitivity reactions. Br J Anaesth. 2012 Aug 1; 109 (2): 216-8.
  Daniel Jolley
pearl
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Reversal with sugammadex produces better recovery of diaphragm function than neostigmine reversal.
Schepens T, Cammu G, Saldien V et al. Electromyographic activity of the diaphragm during neostigmine or sugammadex-enhanced recovery after neuromuscular blockade with rocuronium: A study in anaesthetised healthy volunteers. Eur J Anaesthesiol. 2015 Jan 1;32(1):49-57.
  Daniel Jolley
comment
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A collection of evidence looking specifically at the issue of our poor stewardship of neuromuscular blocking agents can be found here: Neuromuscular myths: the lies we tell ourselves
Collection: Is sugammadex as good as we think?
  Daniel Jolley
summary
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Collection: Is sugammadex as good as we think?
Possibly... but with some important caveats.
“Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s.” – RD Miller (2007).
Sugammadex (Bridion®) is a remarkable drug – and the anaesthesia community has moved very quickly to embrace the potential of this first ‘selective relaxant binding agent’ (SRBA), despite it’s considerable cost.
Sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular from rocuronium. The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex’s onset is 10 times faster than neostigmine and three times faster than edrophonium.
Though beyond the parlour-trick of speedy action, or the possibility of rescuing a cannot-intubate-cannot-ventilate crisis – the biggest benefit of sugammadex for our patients may be in the dramatic reduction of post-operative residual paralysis. A common problem with serious consequences that the anaesthetic community has ignored for far too long.
  Daniel Jolley