Authors: Carr Z J et al.
Anesthesiology, February 17, 2026, 10.1097/ALN.0000000000005890
This focused review provides a practical perioperative framework for patients with sarcoidosis undergoing noncardiac surgery. Sarcoidosis is a multisystem granulomatous disorder that most commonly affects the lungs, but it can also involve the heart, nervous system, liver, kidneys, upper airway, and other organs. Because of this broad organ involvement, perioperative risk varies widely from patient to patient, and the review emphasizes structured preoperative screening rather than a one-size-fits-all approach.
The authors identify pulmonary and cardiac disease as the two most important perioperative concerns. Pulmonary sarcoidosis is common and may range from mild restrictive lung disease to advanced fibrosis, pulmonary hypertension, and chronic respiratory insufficiency. Cardiac sarcoidosis, although less common clinically, has major perioperative significance because it can cause conduction block, ventricular arrhythmias, cardiomyopathy, and sudden deterioration, sometimes in previously unrecognized disease. The review stresses that perioperative complications may arise when these silent manifestations are unmasked by anesthesia, surgery, or physiologic stress.
For preoperative assessment, the article recommends a symptom-driven but organ-focused approach. Patients with mild disease and normal pulmonary function may only need standard evaluation. Higher-risk patients should undergo further workup based on red flags such as worsening dyspnea, resting hypoxemia, declining pulmonary function tests, syncope, palpitations, conduction abnormalities, reduced ejection fraction, or known pulmonary hypertension. The authors recommend pulmonary function testing and recent chest imaging for patients with significant respiratory involvement, with echocardiography and electrocardiography playing important roles when cardiac sarcoidosis is suspected. Advanced cardiac imaging such as cardiac MRI or fluorodeoxyglucose PET is suggested when high-risk features or unexplained conduction disease are present.
The review also highlights important extrapulmonary considerations. Airway sarcoidosis can rarely produce subglottic or tracheobronchial stenosis, making airway evaluation important when hoarseness, stridor, or prior difficult intubation is present. Neurosarcoidosis may increase the risk of seizures, aspiration, autonomic instability, or postoperative ventilation needs. Renal and hepatic involvement can alter drug handling, while hypercalcemia from granulomatous vitamin D dysregulation may contribute to volume depletion, arrhythmias, and metabolic instability. Chronic inflammation, steroid exposure, and sarcopenia may further reduce physiologic reserve.
Medication management is another major theme. Patients on chronic corticosteroids may need stress-dose supplementation depending on the procedure and steroid exposure history. Methotrexate is generally considered safe to continue perioperatively, while biologic agents and some other immunosuppressants may need temporary interruption with multidisciplinary input. The review underscores the balance between maintaining disease control and minimizing infection risk.
Intraoperatively, the authors favor lung-protective ventilation and individualized ventilator management based on whether the patient has restrictive, obstructive, or mixed lung physiology. For advanced pulmonary disease, excessive airway pressures and overly aggressive recruitment maneuvers should be avoided. In patients with pulmonary hypertension or cardiac sarcoidosis, invasive hemodynamic monitoring may be warranted for major procedures. The review also discusses ICD and pacemaker management, arrhythmia preparedness, electrolyte optimization, and cautious titration of protein-bound anesthetic drugs in patients with hypoalbuminemia.
Regional anesthesia is presented as advantageous when feasible, especially because it may reduce systemic drug exposure and avoid some pulmonary complications of general anesthesia. Still, the technique must be individualized based on anticoagulation, thrombocytopenia, neurologic issues, and procedure type.
Postoperatively, the article recommends enhanced surveillance for high-risk patients, especially those with cardiac sarcoidosis, pulmonary hypertension, significant parenchymal lung disease, or perioperative arrhythmias. Telemetry or ICU monitoring may be appropriate for selected patients. Pulmonary hygiene, early mobilization, multimodal analgesia, thromboprophylaxis, and vigilance for infection are emphasized. The authors also note that surgical stress may unmask previously subclinical organ involvement, so low thresholds for postoperative subspecialty reassessment are appropriate when symptoms worsen.
Overall, this review is useful because it turns a complex multisystem disease into a practical perioperative framework. Its central message is that sarcoidosis should not be treated as simply a pulmonary disorder. Instead, anesthesiologists should actively screen for occult cardiac disease, assess pulmonary severity, recognize extrapulmonary manifestations, and tailor perioperative planning to the organs involved.
What You Should Know
This review is especially helpful because sarcoidosis is uncommon, variable, and easy to underestimate in the perioperative setting.
The most important hidden risk is cardiac sarcoidosis, which may present only as unexplained conduction disease, arrhythmia, syncope, or cardiomyopathy.
Pulmonary disease severity matters, but airway, neurologic, renal, hepatic, and metabolic involvement can also significantly affect anesthetic planning.
Patients with active disease progression, unstable cardiac findings, major pulmonary decline, severe hypercalcemia, or uncontrolled neurosarcoidosis may need surgery delayed when feasible.
The practical value of this article is its emphasis on risk stratification: mild stable sarcoidosis can often proceed routinely, while higher-risk disease requires targeted testing and closer postoperative monitoring.
Key Points
Sarcoidosis is a multisystem granulomatous disease with important perioperative implications beyond the lungs.
Pulmonary and cardiac involvement are the main determinants of perioperative risk.
Preoperative electrocardiography is important because cardiac sarcoidosis may be clinically silent until perioperative stress unmasks it.
Pulmonary function testing and recent chest imaging help identify patients with advanced pulmonary sarcoidosis or declining reserve.
Airway stenosis, neurosarcoidosis, hypercalcemia, renal dysfunction, hepatic dysfunction, and sarcopenia can all affect perioperative management.
Lung-protective ventilation, arrhythmia preparedness, thoughtful immunosuppressant management, and enhanced postoperative surveillance are key elements of care.
Thank you to Anesthesiology for allowing us to summarize this article.