Comparison of the effect of neostigmine and sugammadex on postoperative delirium in surgical patients: A systematic review and meta-analysis

초록

Background: Postoperative delirium (POD) frequently occurs in elderly surgical patients and is associated with adverse outcomes. This review aimed to evaluate whether sugammadex, a selective neuromuscular blockade reversal agent, reduces postoperative delirium-incidence (POD-I) compared with neostigmine. Methods: PubMed, EMBASE, and Cochrane CENTRAL were searched up to May 2025 for randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) comparing sugammadex and neostigmine regarding to POD-I. Primary outcome was POD-I, with subgroup analyses according to postoperative period (within 24 hours vs after postoperative 1 day) and the type of anticholinergic coadministered with neostigmine (atropine vs glycopyrrolate). Secondary outcome was perioperative changes in Mini-Mental State Examination scores (preoperative vs postoperative). Analyses were performed separately for RCTs and NRCTs using RevMan 5.4. Results: Twelve studies (7 RCTs, n = 759; 5 NRCTs, n = 50,115) were included. In RCTs, sugammadex significantly reduced POD-I compared with neostigmine (risk ratio (RR), 0.67; 95% confidence interval (CI), 0.49-0.91; I-2 = 0%; P = .008). Subgroup analysis of RCTs on POD-I within the 1st 24 hours postoperatively showed a significantly lower incidence in the sugammadex group (RR, 0.64; 95% CI, -0.45 to 0.90; P = .010). Subgroup analysis of RCTs by coadministered anticholinergics did not significantly influence POD-I (atropine: RR, 0.67; P = .06; glycopyrrolate: RR, 0.66; P = .06). In contrast, subgroup analysis of NRCTs on POD-I showed no significant difference between the groups (RR, 1.15; 95% CI, 0.88-1.50; I-2 = 82%; P = .33). Preoperative and postoperative Mini-Mental State Examination scores in RCTs were similar between groups (preoperative: mean difference 0.03, P = .78; postoperative: mean difference 0.75, P = .12). Conclusion: Sugammadex is associated with a reduced incidence of POD compared to neostigmine, particularly within the 1st 24 hours after surgery, based on consistent findings from RCTs. This benefit was not observed in NRCTs. Further well-designed RCTs using standardized delirium assessments are required.

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