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

Table 1 Study selection criteria using the population, intervention, comparison, outcomes and study approach

Category	Inclusion criteria	Exclusion criteria
Population	Adults (≥ 18 years) undergoing ECT for psychiatric disorders	Pediatric populations
Intervention	Rocuronium (any dose) with sugammadex reversal	Other NMBA agents (e.g., atracurium and vecuronium) or reversal without sugammadex
Comparator	Succinylcholine (any dose)	Studies without a direct succinylcholine comparison group
Outcomes	Motor/EEG seizure duration, recovery time, adverse events	Studies not reporting relevant outcomes or with insufficient data for extraction
Study design	RCTs and observational studies (cohort, case-control study and case series) with comparator arms	Case reports, reviews, editorials, conference abstracts without full data and animal studies
Language	No restriction

ECT: Electroconvulsive therapy; EEG: Electroencephalography; RCT: Randomized controlled trial; NMBA: Neuromuscular blocking agent.

Table 2 Study description

Ref.	Study design	Patients/ECT sessions	R dose	SG dose	SCC dose	Induction agent	Key outcomes measured
Hoshi et al[11]	Small observational case series, non-blinded muscle relaxant selection	5 patients (every patient 3 with SCC and 4 with R + SCC)	0.6 mg/kg	16 mg/kg	1 mg/kg	Propofol 1.0 mg/kg	T1 10% and 90% recovery, time to first spontaneous breath, eye opening, seizure duration, adverse effects
Kadoi et al[12]	Clinical study, lottery system for sugammadex dose (non-blinded sugammadex administration)	17 patients(3 session with different dose of SG and 4 sessions of SCC)	0.6 mg/kg	16 mg/kg, 8 mg/kg, or 4 mg/kg	1 mg/kg	Propofol 1.0 mg/kg	T1 10% and 90% recovery, seizure duration, time to first spontaneous breath, adverse effects
Saricicek et al[13]	Randomized	45 patients	0.3 mg/kg	4 mg/kg	1 mg/kg	Propofol 1 mg/kg	Myalgia VAS, headache VAS, time to T1, T2, motor seizure duration
Koksal et al[14]	Randomized, double-blind (for drug preparation)	16 patients	0.6 mg/kg	4 mg/kg	1 mg/kg	Propofol 2 mg/kg	Spontaneous breathing time, eye opening time, time for obeying instructions, motor seizure duration, MAS and MAS 9 timing, T1 0% and T1 90% times, vital signs, side effects
Oflezer et al[15]	Single-center retrospective observational study	134 patients	0.3 mg/kg	2 mg/kg	0.5 mg/kg	Propofol 1 mg/kg	EEG seizure duration, motor seizure modification, CGI-I score, adverse effects, vital signs
Moutaoukil et al[16]	Small observational case series (prospectively collected)	4 patients	0.3 mg/kg	4 mg/kg	0.5 mg/kg	Propofol 1-1.5 mg/kg	Motor seizure modification, time to spontaneous breathing, time to eye opening, agitation, myalgia, headache, nausea/vomiting, EEG seizure duration
Karaca Bent et al[17]	Single-center observational cohort study (prospective collection, retrospective analysis)	100 adult patients	0.4 mg/kg	2 mg/kg	1 mg/kg	Propofol 1 mg/kg	Spontaneous breathing time, spontaneous eye opening, seizure duration, vital signs (BP, HR, SpO2)

ECT: Electroconvulsive therapy; SCC: Succinylcholine; R: Rocuronium; SG: Sugammadex; T1: Time to spontaneous respiration; T2: Time to eye-opening; VAS: Visual Analogue Scale; MAS: Modified Ashworth Scale; CGI-I: Global Impression Improvement; EEG: Electroencephalography; BP: Blood pressure; HR: Heart rate.

Table 3 Study findings

Ref.	Main findings	Conclusion/recommendation
Hoshi et al[11]	Recovery: Time to spontaneous respiration 10% and 90% recovery tended to be shorter in the RS group, but the difference was not statistically significant; seizure duration: RS longer (39 seconds vs 33 seconds)	It shows potential benefits as an alternative to succinylcholine for muscle relaxation; side effects: No adverse effects were reported with either muscle relaxants
Kadoi et al[12]	Efficacy as an alternative to SCC; sugammadex (8 mg/kg) produces equally rapid recovery as SCC for 0.6 mg/kg of rocuronium	Sugammadex (8 mg/kg) produces equally rapid recovery as SCC; side effects: No adverse effects were reported
Saricicek et al[13]	Recovery: Group RS is significantly shorter for spontaneous respiration and eye-opening across all sessions; side effects: Myalgia and headache VAS scores were significantly lower in the RS group; seizure duration: No statistically significant difference was observed	It also causes reduced myalgia and headache, and faster recovery compared to succinylcholine
Koksal et al[14]	Recovery: Rocuronium + succinylcholine was significantly shorter for Modified Alderete Score 9 (7.26 minutes vs 11.26 minutes), Spontaneous eye opening (6.64 minutes vs 9.67 minutes), obeying instructions (8.10 minutes vs 11.72 minutes), spontaneous breathing (5.93 minutes vs 8.14 minutes), and time to spontaneous respiration 90% (4.87 minutes vs 9.95 minutes); onset: Group RS longer (149.40 seconds vs 111.53 seconds); seizure duration: Group RS longer (23.28 seconds vs 15.62 seconds)	Sufficient muscle relaxation and early recovery. It can be used as an alternative to succinylcholine
Oflezer et al[15]	EEG/motor seizure duration: Rocuronium + succinylcholine longer than succinylcholine (36.61 seconds vs 33.15 seconds; P = 0.002, P < 0.001 respectively); adverse effects: No major complications or deaths were reported in either group; CGI-I score: No significant difference	Similar results in terms of seizure variables and clinical outcomes can be a suitable alternative.
Moutaoukil et al[16]	Recovery: Rocuronium + succinylcholine was significantly shorter for spontaneous respiration (219 seconds vs 296 seconds) and eye opening (402 seconds vs 467 seconds); motor seizure modification: RS had a significantly higher (better) score (3.6 vs 3.0); side effects: Agitation (0% vs 16%) and myalgia (4% vs 33%) were significantly lower in the RS group; seizure duration: Comparable (40 seconds vs 38 seconds)	Efficacious alternative to succinylcholine, leading to faster recovery with less myalgia and agitation
Karaca Bent et al[17]	Recovery: RS was notably shorter for spontaneous breathing time (88.82 seconds vs 111.78 seconds), spontaneous eye opening (173.12 seconds vs 211.42 seconds), and Modified Alderete Score 9 (410.54 seconds vs 542.60 seconds); seizure duration: No significant difference	Sugammadex is an ideal alternative agent when succinylcholine is contraindicated, or anticholinesterases are not suitable; it shortens recovery time and spontaneous respiration

RS: Rocuronium-sugammadex; SCC: Succinylcholine; VAS: Visual Analogue Scale; EEG: Electroencephalography; CGI-I: Global Impression Improvement.