OBJECTIVES: Sugammadex significantly reduces time and variability of recovery from neuromuscular blockade (NMB) compared to neostigmine. We explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex versus neostigmine in Canada. METHODS: A discrete event simulation (DES) model was developed to compare ORs using neostigmine and sugammadex for NMB reversal, for the same simulated schedule of procedures. Selected inputs included OR procedure and turnover times, hospital policies with respect to paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use.  Trials have shown that sugammadex’s impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four [TOF] ratio ≥0.9) is verified prior to extubation in the OR.  Two scenarios were therefore evaluated; when full recovery is verified prior to extubation and when it is not.  RESULTS: In the modeled scenario where full neuromuscular recovery was verified prior to extubation (92 procedures performed over one month with sugammadex), the use of sugammadex versus neostigmine over one month avoided 5.5 procedural cancellations and 9.3 hours of paid overtime, while saving an average of 61 minutes per OR day. No difference was observed between comparators for these endpoints in the modeled scenario when full neuromuscular recovery was not verified prior to extubation, however, the per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 48 cases prevented over one month), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (21 cases avoided).  CONCLUSIONS: The impact of sugammadex was found to vary according to practices for neuromuscular recovery and extubation.  Use of sugammadex can improve the current trade-off between OR efficiency and occurrence of RNMB when utilizing neostigmine.