Perioperative considerations for patients with multiple myeloma

Multiple myeloma is an incurable cancer characterised by clonal plasma-cell proliferation, arising predominantly in the bone marrow but producing widespread systemic complications. Additionally, this cancer usually presents in elderly patients who are often frail and suffering from multiple comorbidities. The global prevalence of multiple myeloma is steadily increasing, with therapeutic advances contributing to improved survival. There are several complications of multiple myeloma that the anaesthetist needs to be aware of arising from the disease itself, specific and supportive treatments adverse effects, as well as underlying patient complexities. The preoperative period demands a comprehensive, systematic assessment that identifies and optimises disease- and treatment-related complications, quantifies frailty, addresses anaemia through patient blood management principles, and stratifies thrombotic risk. Intraoperative management requires careful individualisation of anaesthetic technique in the absence of multiple myeloma-specific evidence-based guidelines, with particular vigilance directed at airway complexity, haemodynamic instability, heightened bleeding risk, and challenging pain management. Postoperative care must sustain these principles, with early attention to renal function, pain control, thromboprophylaxis, and the prompt recognition of the infectious complications to which this population is disproportionately vulnerable. Unfortunately, the literature on anaesthesia in the context of multiple myeloma is sparse, largely limited to isolated case reports. As a consequence, this article's predominantly PubMed-based search strategy (included in supplementary materials) required a wide search to allow for perioperative recommendations that are necessarily extrapolated from broader oncological, haematological, and surgical evidence. As such, this article offers a comprehensive review of anaesthetic considerations in multiple myeloma, addressing an important gap in current practice guidance.