OBJECTIVES: To estimate the budget impact of sugammadex within a typical US hospital. METHODS: A model was developed to evaluate budget impact of using sugammadex instead of neostigmine or spontaneous reversal in a subset of hospital procedures.  Sugammadex utilization was projected to be highest in procedures with deep neuromuscular block (NMB) throughout, and patients at elevated risk of post-operative respiratory complications.  Inputs included costs of NMB and reversal agents, operating room (OR) procedure time, value of OR time, risks and costs of residual neuromuscular blockade (RNMB) and associated complications, and reductions in RNMB with sugammadex use.  Because trials have shown 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 modeled, evaluating when recovery to TOF ≥0.9 is verified prior to extubation and when it is not. RESULTS: When all patients are verified to have full neuromuscular recovery (TOF ≥ 0.9, no RNMB) prior to extubation, sugammadex saved an average of 24 minutes in the OR per procedure, with a net cost savings provided at least 10% of OR time saved can be converted to increased throughput.  When no patients are verified to have full recovery prior to extubation, sugammadex saved 1 minute in the OR per procedure; while reducing the risk of RNMB from 47% to 3%.  The incidence of post-operative aspiration, hypoxemia, muscle weakness or upper airway obstruction was reduced from 86 per 100 procedures, to 36 per 100 among patients receiving sugammadex, at an average incremental cost of $66 per procedure.    CONCLUSIONS: Budget impact of sugammadex was found to vary according to practices for neuromuscular monitoring and extubation.  Use of sugammadex can ameliorate the current trade-off between OR efficiency and occurrence of RNMB when utilizing neostigmine or spontaneous reversal.