Clinical bottom line
Patients with myelodysplastic syndromes (MDS) present unique anesthetic challenges due to their underlying hematologic dysfunction, cytopenias, and frequent comorbidities. Current evidence suggests that careful preoperative evaluation, optimization of hematologic parameters, and tailored intraoperative management can mitigate perioperative risks. However, data on anesthetic outcomes in MDS remain limited and largely extrapolated from hematologic and transplant literature. Anesthesiologists should maintain heightened vigilance for bleeding, infection, and organ dysfunction, and collaborate closely with hematology specialists to optimize perioperative care.
What the evidence shows
Myelodysplastic syndromes are a heterogeneous group of clonal hematopoietic disorders characterized by ineffective hematopoiesis, peripheral cytopenias, and risk of progression to acute myeloid leukemia (Bowen et al., 2006). The clinical course and prognosis vary widely, influenced by cytogenetic abnormalities, marrow blast percentage, and patient factors (Greenberg et al., 2008; Greenberg et al., 2002).
Perioperative management considerations stem from the underlying pathophysiology and treatment-related complications. Patients often exhibit anemia, thrombocytopenia, and neutropenia, increasing risks of bleeding, infection, and impaired wound healing. These hematologic abnormalities necessitate preoperative optimization, including transfusion support and infection prophylaxis when indicated (Bowen et al., 2006).
Outcomes data specific to anesthesia in MDS are sparse. However, insights can be drawn from studies on hematopoietic stem cell transplantation (HSCT) for MDS, where perioperative morbidity and mortality are influenced by disease status, comorbidities, and conditioning regimens (Shigematsu et al., 2025). In this context, meticulous anesthetic planning, including avoidance of agents that exacerbate marrow suppression or organ toxicity, is emphasized.
Prognostic scoring systems such as the Revised International Prognostic Scoring System (IPSS-R) aid in risk stratification and guide therapeutic decisions, which indirectly impact anesthetic risk assessment (Greenberg et al., 2008; Greenberg et al., 2002). Multidisciplinary coordination is essential to balance the urgency of surgery against hematologic stability and treatment timing (Bowen et al., 2006).
Caveats and uncertainty
The evidence base for anesthetic management in MDS is limited by a lack of prospective, anesthesia-focused studies. Most recommendations derive from hematology and transplant literature, which may not fully capture perioperative anesthetic nuances. Variability in disease severity, treatment regimens, and comorbidities complicates generalizability.
Data on specific anesthetic agents and techniques in MDS patients are lacking, and the impact of newer therapies such as hypomethylating agents on perioperative outcomes remains underexplored. Furthermore, the risk-benefit balance of invasive monitoring or regional anesthesia in thrombocytopenic patients requires individualized assessment.
Given the heterogeneity of MDS, prognostic tools should be integrated cautiously with clinical judgment. The timing of surgery relative to disease status and treatment cycles is critical but not well defined in the literature.
How this may change practice
Anesthesiologists should incorporate hematologic risk stratification into preoperative evaluation for patients with MDS, utilizing prognostic scoring systems in collaboration with hematology. Optimization of blood counts and infection control measures should be prioritized before elective procedures.
Intraoperative management should focus on minimizing bleeding risk, maintaining hemodynamic stability, and avoiding nephrotoxic or marrow-suppressive agents. Regional anesthesia may be considered cautiously with platelet thresholds in mind.
Postoperative vigilance for infection, bleeding, and delayed wound healing is warranted. Enhanced communication with hematology and oncology teams can facilitate perioperative planning and improve outcomes.
Future research targeting anesthetic pharmacology, monitoring strategies, and perioperative protocols specific to MDS will be valuable to refine practice.