Rocuronium-sugammadex as an alternative muscle relaxant to succinylcholine in electroconvulsive therapy: A meta-analysis

Abstract

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.

Keywords: Electroconvulsive therapy; Succinylcholine; Rocuronium; Sugammadex; Neuromuscular blockade; Meta-analysis

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.