OBJECTIVES: To assess the cost-effectiveness of sugammadex compared with neostigmine + glycopyrrolate as a reversal agent for moderate and deep rocuronium or vecuronium-induced neuromuscular blockade (NMB) in the elective setting in England and Wales, when extubation occurs at a train-of-four (TOF) ratio of 0.9. METHODS: A decision tree comparing the cost-effectiveness of sugammadex versus neostigmine + glycopyrrolate when reversing moderate or deep NMB induced by commonly used neuromuscular blocking agents (NMBAs) (atracurium/rocuronium/vecuronium) was developed.  Extubation was modelled to occur at a TOF ratio of 0.9, as may happen when using objective NMB monitoring to determine when to safely extubate.  Time to recovery was used to calculate the cost of patients recovering in theatre based on both the average cost per minute of theatre time, and operating room (OR) staff costs per minute. Effectiveness was measured by the number of prolonged paralysis cases prevented by each treatment regimen. RESULTS: Reversal of moderate NMB: when considering average cost per minute of theatre time, results show that sugammadex strategies are dominant compared with all assessed comparators. When considering OR staff cost per minute, results show that rocuronium with sugammadex is dominant over all assessed comparators, with the exception of atracurium with neostigmine + glycopyrrolate (ICER