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©The Author(s) 2026. Published by Baishideng Publishing Group Inc. All rights reserved.
Rocuronium-sugammadex as an alternative muscle relaxant to succinylcholine in electroconvulsive therapy: A meta-analysis
Rishi Anand, Deb Sanjay Nag, Roshan Lal Gope, Manoj Kumar Sahoo, Pratul Bhushan, Bappa Ditya Pal, Roushan Patel, Srirala Shivani, Murari Kumar Bharadwaj, Mohd Amir Ansari
Rishi Anand, Deb Sanjay Nag, Roshan Lal Gope, Pratul Bhushan, Bappa Ditya Pal, Roushan Patel, Srirala Shivani, Murari Kumar Bharadwaj, Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jhārkhand, India
Rishi Anand, Roshan Lal Gope, Pratul Bhushan, Bappa Ditya Pal, Roushan Patel, Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831017, Jhārkhand, India
Manoj Kumar Sahoo, Department of Psychiatry, Tata Main Hospital, Jamshedpur 831001, Jhārkhand, India
Manoj Kumar Sahoo, Department of Psychiatry, Manipal Tata Medical College, Jamshedpur 831017, Jhārkhand, India
Mohd Amir Ansari, Department of Community Medicine, Manipal Tata Medical College, Jamshedpur 831017, Jhārkhand, India
Co-first authors: Rishi Anand and Deb Sanjay Nag.
Author contributions: Anand R, Nag DS, Gope RL, Sahoo MK, Bhushan P, Pal BD, Patel R, Shivani S, Bharadwaj MK, and Ansari MA contributed to the writing and editing the manuscript and review of literature; Anand R, Nag DS, and Ansari MA contributed to statistical analysis of the research; Gope RL, Sahoo MK, Bhushan P, Pal BD, Patel R, Shivani S, and Bharadwaj MK contributed to the discussion and design of the manuscript; Anand R and Nag DS contributed equally to this manuscript and are co-first authors. All author approval the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Deb Sanjay Nag, Consultant, Department of Anaesthesiology, Tata Main Hospital, C Road West, Northern Town, Bistupur, Jamshedpur 831001, Jhārkhand, India.
ds.nag@tatasteel.com
Received: July 28, 2025
Revised: August 20, 2025
Accepted: November 4, 2025
Published online: February 19, 2026
Processing time: 186 Days and 1.6 Hours
BACKGROUND
Electroconvulsive therapy (ECT) requires optimal muscle relaxation, which is conventionally achieved with succinylcholine (SCC) despite its adverse effects. In this context, rocuronium-sugammadex (RS) has emerged as a potential alternative, but its comparative efficacy remains uncertain. Hence, this meta-analysis evaluated the recovery times, seizure duration, and safety of these agents in ECT.
AIM
To compare the recovery times, seizure duration, and side effect profiles of RS and SCC in ECT.
METHODS
PubMed, EMBASE, and Cochrane Library (from inception to June 2025) were systematically searched for randomized and observational studies comparing RS with SCC in ECT. The primary outcomes were seizure duration (motor/electroencephalogram) and recovery time, and the secondary outcomes included adverse events (e.g., myalgia). Pooled standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models.
RESULTS
This meta-analysis included 7 studies involving 250 observations of patients who received RS and 282 sessions in which patients received SCC. Regarding seizure duration required for effective ECT, RS was associated with a longer duration (SMD: 0.43, 95%CI: 0.15-0.70, P < 0.05). However, this effect became nonsignificant in analyses limited to randomized controlled trials (SMD: 0.54, 95%CI: -0.17 to 1.25, P > 0.05). No significant difference was found between the groups in the recovery time (SMD: -0.51, 95%CI: -1.57 to 0.56, P = 0.277), despite trends favoring RS in three out of six studies. Qualitatively, the RS combination was associated with fewer adverse events, such as myalgia, although the reporting was inconsistent across studies. Substantial heterogeneity (I2 = 89%-93%) was a key finding for recovery outcomes, likely stemming from variability in the dosing and procedural protocols.
CONCLUSION
RS is a feasible alternative to SCC for ECT, with acceptable recovery and fewer side effects without affecting the seizure duration. However, larger high-quality randomized controlled trials are necessary to statistically substantiate these findings and assess the long-term outcomes.
Core Tip: Based on the meta-analysis, rocuronium-sugammadex (RS) may be associated with a statistically longer seizure duration in the overall analyses, although this effect was not significant in randomized studies. No significant difference was found in recovery time compared to succinylcholine, despite some trends favoring the use of RS. Qualitatively, RS appears to have a better safety profile, with fewer adverse events such as myalgia. However, the high heterogeneity in recovery outcomes emphasizes the need for more standardized research protocols to yield more consistent and definitive conclusions.
