# Letter regarding “Sugammadex vs neostigmine in post-anesthesia recovery: A systematic review and meta-analysis”

## TL;DR

This letter critiques a meta-analysis comparing sugammadex and neostigmine, highlighting issues with heterogeneity and reporting that may affect clinical conclusions.

## Contribution

The paper emphasizes the need for improved meta-analytic methods and subgroup analyses to better understand anesthetic effects on recovery.

## Key findings

- High heterogeneity in key outcomes suggests variability in pooled estimates.
- Volatile anesthetic concentration may influence airway safety after sugammadex.
- Inconsistent reporting of effect sizes reduces interpretability.

## Abstract

This correspondence comments on the systematic review and meta-analysis by Zhu and Li comparing sugammadex with neostigmine for neuromuscular block reversal and postoperative outcomes. While the authors provide a useful synthesis suggesting faster recovery and less residual blockade with sugammadex, several issues may limit the validity and clinical generalizability of the pooled conclusions. Many key outcomes show extreme heterogeneity (I2 frequently >90%), raising concerns that combined estimates may obscure clinically important variation in anesthetic technique, blockade depth, monitoring, and recovery protocols. In particular, emergence safety depends not only on neuromuscular indices (e.g., TOF ≥ 0.9) but also on hypnotic depth at the time of reversal; evidence indicates that volatile anesthetic concentration (MAC) can meaningfully modify airway obstruction risk after sugammadex. Additionally, inconsistencies in the reporting of time-based effect sizes, specifically between standardized mean differences (SMD) and mean differences (MD) with identical values, necessitate clarification to enhance interpretability. We highlight the need for more cautious interpretation, targeted subgroup analyses incorporating anesthetic depth and other effect modifiers, and more robust meta-analytic methods to strengthen precision and applicability of the findings.