Anesthesia management for patients with a history of stem cell transplant poses unique clinical challenges due to the complex interplay of immunosuppression, systemic toxicity, and organ dysfunction that are commonly observed in this patient population. These patients often have significant comorbidities as a result of their underlying hematologic malignancies or the intensive chemoradiotherapy regimens they undergo before the transplant. A comprehensive preoperative evaluation, meticulous intraoperative planning, and vigilant postoperative care are essential to optimizing outcomes and reducing complications.
The preoperative assessment should include a detailed history of the transplant process, including the conditioning regimen, the source of the graft (autologous or allogeneic), and post-transplant complications, such as graft-versus-host disease (GVHD). Pulmonary complications are common in this group and include idiopathic pneumonia syndrome, bronchiolitis obliterans, and infectious pneumonias. These complications can severely impair gas exchange and increase the risk of perioperative hypoxia (Ji et al., 2022). Thus, pulmonary function tests and imaging studies are often warranted preoperatively. Cardiovascular toxicity from chemotherapy agents such as anthracyclines may manifest as cardiomyopathy. Echocardiographic evaluation is necessary to assess ejection fraction and valvular function before anesthesia induction (Mahadeo et al., 2021).
The hematologic status of patients with stem cell transplant needing surgery is crucial for anesthesia and surgery planning. Profound cytopenias, including thrombocytopenia, may be present and increase the risk of perioperative bleeding. Platelet transfusions are frequently required and must be timed appropriately to ensure hemostatic efficacy during invasive procedures (Russell et al., 2024). Additionally, neutropenia increases the risk of perioperative infections, necessitating strict aseptic techniques and potentially prophylactic antibiotics.
Anesthesia medications must be carefully selected in patients with stem cell transplant. Hepatic and renal dysfunction, which are not uncommon due to previous chemotherapy or GVHD-related organ damage, can alter drug metabolism and excretion. Agents such as propofol, which have a short, context-sensitive half-life and have relatively predictable kinetics, are often preferred. However, volatile anesthetics may exacerbate hepatic injury and require cautious use. Neuromuscular blockers that do not rely on hepatic or renal clearance, such as cisatracurium, are preferred in patients with end-organ impairment (Alodhaib et al., 2025).
Intraoperative monitoring should be comprehensive. Arterial lines should be considered for hemodynamic monitoring and blood gas analysis in any patients with cardiovascular instability or respiratory compromise. Temperature regulation is critical due to the patients’ immunocompromised state; even mild hypothermia can predispose them to infections and coagulopathy. Furthermore, fluid management must be judicious, especially in cases of capillary leak syndrome or hypoalbuminemia, both of which may occur post-transplant (Mahadeo et al., 2021).
Postoperative care includes aggressive pain management while minimizing the immunosuppressive and respiratory depressive effects of opioids. Regional anesthesia techniques can provide superior analgesia and reduce systemic opioid use when not contraindicated by thrombocytopenia or coagulopathy. However, the risks of bleeding must be weighed against the benefits of invasive blocks, especially in patients with platelet counts below 50,000/µL (Russell et al., 2024). Additionally, anesthesiologists must be alert to potential complications, such as septic shock or acute respiratory distress syndrome (ARDS), which can occur even during the immediate postoperative period. Due to the complex physiology of SCT recipients, even minor procedures require careful planning and execution.
Patients with stem cell transplants are at high risk for anesthesia complications due to multisystem involvement, immunosuppression, and the potential for rapid decompensation. Tailored anesthetic strategies that consider the transplant timeline and associated complications are critical for safe and effective perioperative care.
References
- Liang J, Chen Y, Zhou J, et al. Lung transplantation for bronchiolitis obliterans after hematopoietic stem cell transplantation: a retrospective single-center study. Ann Transl Med. 2022;10(12):659. doi:10.21037/atm-22-2517
- Ragoonanan D, Khazal SJ, Abdel-Azim H, et al. Diagnosis, grading and management of toxicities from immunotherapies in children, adolescents and young adults with cancer. Nat Rev Clin Oncol. 2021;18(7):435-453. doi:10.1038/s41571-021-00474-4
- Anthon CT, Pène F, Perner A, et al. Platelet transfusions in adult ICU patients with thrombocytopenia: A sub-study of the PLOT-ICU inception cohort study. Acta Anaesthesiol Scand. 2024;68(8):1018-1030. doi:10.1111/aas.14467
- Khan MA, Abu Esba LC, Yousef CC, et al. Practical challenges and considerations in adopting biosimilars in oncology clinical practice within a large healthcare system. Expert Rev Clin Pharmacol. 2025;18(6):323-331. doi:10.1080/17512433.2025.2492063
- Anthon CT, Pène F, Perner A, et al. Platelet transfusions and thrombocytopenia in intensive care units: Protocol for an international inception cohort study (PLOT-ICU). Acta Anaesthesiol Scand. 2022;66(9):1146-1155. doi:10.1111/aas.14124