2026 Southeastern Residency Conference

Title: Efficacy and Safety of Sugammadex Versus Neostigmine for Neuromuscular Blocker Reversal Following Minimally Invasive Direct Coronary Artery Bypass 
Authors: Micah Wilson and Jeannie Watson

Introduction: Neuromuscular blocking agents given for anesthesia are reversed with neostigmine or sugammadex to facilitate extubation. Due to neostigmine's shorter half-life and indirect mechanism of action1, patients may require additional doses in order to achieve extubation, leading to longer recovery times, increased risk of complications and costs2. Sugammadex however, has a longer half life, less adverse effects, and has a direct mechanism of action3. The purpose of this study was to evaluate the safety, effectiveness, and cost associated with each agent.  
Methods: This is a single-center, retrospective, cohort study utilizing electronic medical records of adult patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) procedure and receiving either sugammadex or neostigmine/glycopyrrolate at Ascension Saint Thomas Hospital West from January 2021 to September 2025. Patients were included if they were 18 years of age or older and received either sugammadex or neostigmine/glycopyrrolate post-MIDCAB. Patients were excluded if they originally failed reversal with neostigmine, returned to the operating room for complications, were on mechanical circulatory support, pregnant or incarcerated. The primary outcome was to determine whether there was a difference in the time to extubation between both cohorts. Secondary outcomes included total hospital length of stay, total time spent in the ICU (Intensive Care Unit) post-op, reintubation rates, occurrence rate of safety objectives, and cost per dose.
Results: A total of 156 patients were included in the study, with 78 patients receiving sugammadex and 78 patients receiving neostigmine. The primary outcome was found to be statistically significant, with patients receiving sugammadex spending significantly shorter time intubated when compared to neostigmine. (3.9 hours vs.7.9 hours ; p = <0.0001). There was also a statistically significant difference between the groups in total hospital length of stay as well as ICU length of stay. Additionally, both groups were similar in adverse events and reintubation rates.
Conclusion: In this study, we observed that patients reversed with sugammadex had shorter time to extubation when compared to neostigmine. These patients were also more likely to be extubated in the OR (operating room) rather than the ICU and had shorter lengths of stay in the ICU and hospital overall. Despite positive outcomes, the limiting factor to increasing the use of sugammadex for all patients, is the cost compared to neostigmine. Therefore, further studies that include more patients are warranted to fully determine the benefit of sugammadex and to justify the additional cost associated with it.