Sarcopenia as a Risk Factor in Anesthesia: Impact on Perioperative Morbidity and Mortality

 Corresponding author: Daniela Consumi Cordero Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Sarcopenia as a Risk Factor in Anesthesia: Impact on Perioperative Morbidity and Mortality Ivonne Consumi Flores 1, María Rebeca Sánchez Calderón 2, Carmen Andrea Soto Rojas 1, María Orozco Arguedas 3, María José Solís Marín 4 and Daniela Consumi Cordero 5, * 1 Medical Doctor, Independent Researcher, San José, Costa Rica. 2 Medical Doctor, at Maximiliano Peralta Jiménez Hospital, Cartago, Costa Rica. 3 Medical Doctor, Independent Researcher, Heredia, Costa Rica. 4 Medical Doctor at Tony Facio Castro Hospital, Limón, Costa Rica. 5 Medical Doctor, Independent Researcher, Alajuela, Costa Rica. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 Publication history: Received on 20 September 2025; revised on 26 October 2025; accepted on 29 October 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.24.1.0932 Abstract Sarcopenia is a progressive condition characterized by the loss of skeletal muscle mass, strength, and function, representing a critical risk factor in anesthesia and perioperative outcomes, particularly among older adults. Its pathophysiology involves complex cellular and metabolic mechanisms, including mitochondrial dysfunction, insulin resistance, chronic inflammation, oxidative stress, and hormonal imbalance, all of which contribute to impaired muscle regeneration and increased protein degradation. Nutritional deficiencies, especially low protein and vitamin D intake, further accelerate muscle deterioration and functional decline. The prevalence of sarcopenia among surgical patients ranges from thirty to seventy-four percent, varying by age, sex, and diagnostic criteria. Accurate identification requires the combined evaluation of muscle mass, strength, and physical performance through techniques such as computed tomography, dual-energy X-ray absorptiometry, bioelectrical impedance, handgrip strength testing, and gait speed analysis. In the anesthetic context, reduced muscle mass and altered body composition modify drug distribution and clearance, increasing the risk of overdose, prolonged recovery, and postoperative delirium. Sarcopenic patients also have diminished cardiopulmonary reserve and thermoregulatory capacity, heightening their susceptibility to intraoperative instability and postoperative complications. Sarcopenia independently predicts increased postoperative morbidity, mortality, prolonged mechanical ventilation, and extended hospital stays. Comprehensive management requires early screening, nutritional optimization, and prehabilitation programs combining resistance and aerobic exercise. During surgery, individualized anesthetic dosing and multimodal analgesia improve safety, while early mobilization and physiotherapy enhance recovery. Multidisciplinary collaboration among anesthesiologists, surgeons, nutritionists, and physiotherapists is essential to minimize complications, support functional rehabilitation, and improve survival and quality of life in patients affected by sarcopenia. Keywords: Muscle Loss; Inflammation; Metabolism; Frailty; Rehabilitation; Mortality 1. Introduction Sarcopenia, defined as the progressive loss of skeletal muscle mass and function, has emerged as a significant risk factor affecting anesthesia and surgical outcomes, particularly in older adults. According to international consensus groups World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 434 such as the European Working Group on Sarcopenia in Older People (EWGSOP), the condition involves both reduced muscle mass and diminished function, with recent updates emphasizing muscle weakness as the principal diagnostic criterion (1; 2). Its relevance in perioperative medicine is increasingly evident due to its strong association with adverse outcomes, including higher morbidity and mortality rates, especially in the context of an aging population and the rising volume of surgical procedures among elderly patients (3; 4). The EWGSOP defines sarcopenia as a condition characterized by low muscle mass and reduced muscle strength, where muscle weakness serves as the most sensitive and early marker of disease progression (1). This condition is linked to several negative health outcomes, such as impaired mobility, prolonged recovery, and increased perioperative risk, making it a critical factor in anesthetic and surgical decision-making (2). From an epidemiological standpoint, sarcopenia affects approximately 10% to 16% of the global elderly population, with an even higher prevalence among individuals with chronic illnesses or reduced physical activity. The demographic shift toward older populations and the growing demand for surgical interventions highlight the need for early detection and management of sarcopenia in perioperative care (3). For anesthesiologists and perioperative teams, sarcopenia represents an independent predictor of postoperative complications, delayed recovery, and increased mortality. Therefore, integrating preoperative assessment tools to identify sarcopenia and implementing targeted interventions such as nutritional support and resistance training can significantly improve perioperative outcomes and enhance postoperative recovery in this high-risk group (5). The objective of this article is to analyze the role of sarcopenia as an independent risk factor in anesthesia and perioperative outcomes, emphasizing its impact on morbidity and mortality in surgical patients. 2. Methodology For the development of this review on sarcopenia as a risk factor in anesthesia and its impact on perioperative morbidity and mortality, a comprehensive literature analysis was conducted with the objective of examining the clinical relevance, pathophysiological mechanisms, diagnostic approaches, and perioperative implications of sarcopenia in surgical patients. Special attention was given to the association between sarcopenia and adverse postoperative outcomes, anesthetic considerations, and strategies for preoperative assessment and optimization aimed at improving surgical safety and recovery. The review was based on the consultation of established scientific databases, including PubMed, Scopus, and Web of Science, selected for their relevance in anesthesiology, perioperative medicine, and geriatric surgery. Rigorous inclusion and exclusion criteria were applied to ensure the quality and pertinence of the selected studies. Articles published between 2020 and 2025, in English or Spanish, were included if they addressed key aspects such as the definition and diagnosis of sarcopenia, its epidemiology, pathophysiological basis, impact on perioperative morbidity and mortality, and management strategies before, during, and after anesthesia. Studies lacking peer review, with incomplete data, or presenting duplicated information were excluded. The main keywords used in the search strategy included: Muscle loss, inflammation, metabolism, frailty, rehabilitation, mortality. The initial search identified 32 relevant sources, including original research articles, systematic reviews, meta-analyses, and clinical guidelines published by recognized societies of anesthesiology, geriatrics, and perioperative medicine. These sources were critically analyzed to extract data regarding diagnostic criteria, anesthetic implications, postoperative complications, and evidence-based interventions to optimize outcomes in sarcopenic patients. Additionally, artificial intelligence tools were employed as complementary aids for information synthesis, thematic categorization, and the identification of conceptual relationships between studies. The use of these tools enhanced the efficiency of data organization and contributed to maintaining coherence and clarity throughout the structure of the review. The analysis followed a qualitative and comparative approach, with thematic categorization of findings to identify the main clinical challenges, risk factors, and current management strategies related to sarcopenia in the perioperative setting. This approach provided an evidence-based overview of the current state of knowledge and underscored the importance of early diagnosis, individualized anesthetic planning, and multidisciplinary interventions to reduce perioperative morbidity and mortality in sarcopenic patients. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 435 3. Pathophysiology of Sarcopenia Sarcopenia is characterized by complex cellular and metabolic alterations that compromise muscle mass, regeneration, and function. These changes affect the skeletal muscle microenvironment, leading to impaired activity of satellite cells, which are essential for muscle repair and growth (6). Mitochondrial dysfunction and insulin resistance play key roles in this process by altering energy metabolism and promoting a negative protein balance in which muscle protein degradation exceeds synthesis (7). Chronic inflammation and oxidative stress are central mechanisms in the pathogenesis of sarcopenia. Persistent lowgrade inflammation activates catabolic pathways that accelerate muscle protein breakdown, while oxidative stress damages cellular structures and impairs mitochondrial function, further limiting muscle regeneration. The infiltration of inflammatory cells and the accumulation of reactive oxygen species exacerbate muscle atrophy and functional decline, reinforcing the progressive nature of the condition (7). Hormonal and nutritional dysregulation also contribute significantly to sarcopenia. Age-related decreases in anabolic hormones such as testosterone and growth hormone are associated with reduced muscle mass, diminished strength, and slower recovery from injury. Nutritional deficiencies, particularly inadequate intake of protein and vitamin D, further aggravate muscle loss and weakness. Proper nutrition, including sufficient protein and antioxidant nutrients, is essential to counteract catabolic processes and preserve muscle integrity (8). Sarcopenia is closely linked to physical frailty, a clinical state marked by reduced strength, endurance, and physiological reserve. This association increases the risk of falls, disability, and dependence on long-term care. In the surgical context, sarcopenia leads to reduced tolerance to physiological stress, delayed postoperative recovery, and a higher incidence of complications, highlighting its importance as a predictor of poor perioperative outcomes in the elderly (7). 4. Epidemiology and Diagnosis The prevalence of sarcopenia in surgical populations varies widely, ranging from 30% to 74%, with higher rates observed among older adults and individuals undergoing major orthopedic procedures such as total knee or hip replacements (9). Gender differences have been reported depending on the diagnostic framework used: men tend to show a higher prevalence under the EWGSOP2 criteria, whereas women demonstrate a higher prevalence when evaluated using the International Working Group on Sarcopenia guidelines (10). The prevalence also increases progressively with age and displays notable variability across regions and ethnic groups, reflecting the influence of demographic and methodological factors (10; 11). Accurate diagnosis of sarcopenia relies on the evaluation of muscle mass, strength, and physical performance. Muscle mass assessment is typically performed through imaging or bioelectrical methods, including computed tomography (CT), dual-energy X-ray absorptiometry (DXA), and bioelectrical impedance analysis (BIA), each differing in precision, cost, and accessibility (Petermann-Rocha et al., 2021; Voulgaridou et al., 2024). Muscle strength is most commonly measured using handgrip dynamometry, a simple and reliable tool that correlates strongly with frailty and predicts adverse surgical outcomes. Physical performance is evaluated through tests such as gait speed and the Short Physical Performance Battery (SPPB), both of which are valuable predictors of postoperative complications and recovery potential (12). Despite these tools, current diagnostic approaches present limitations. Considerable heterogeneity exists among diagnostic criteria, leading to inconsistencies in prevalence estimates and difficulties in comparing studies across populations (10; 13). Moreover, existing definitions may not adequately capture the multifactorial and dynamic nature of sarcopenia, particularly in the perioperative setting, where acute stress and inflammation can accelerate muscle loss (11). The EWGSOP2 diagnostic framework addresses these challenges by integrating measurements of muscle mass, muscle strength, and physical performance to enhance diagnostic accuracy and clinical applicability (13). 5. Anesthetic Implications of Sarcopenia Sarcopenia profoundly influences anesthetic management through pharmacokinetic and pharmacodynamic alterations that modify drug behavior and patient response. Reduced muscle mass and an increased proportion of body fat alter drug distribution, particularly affecting lipophilic agents such as propofol. These changes reduce the volume of distribution for hydrophilic drugs while increasing retention of lipophilic compounds, leading to delayed clearance and World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 436 prolonged drug effects (14). Additionally, age-related pharmacodynamic changes, including heightened sensitivity to anesthetics, require careful dose adjustments in older adults to prevent excessive sedation and adverse effects (15). Sarcopenic patients are at greater risk of anesthetic overdose and prolonged recovery. Older adults frequently receive higher-than-needed doses of propofol, resulting in extended sedation and delayed emergence from anesthesia (16). Evidence indicates that elderly patients generally require lower doses of propofol to achieve the same anesthetic depth, underscoring the importance of individualized dosing to avoid complications such as hypotension, respiratory depression, and delayed awakening (15). Beyond pharmacologic factors, sarcopenia also contributes to physiological vulnerability during anesthesia. Decreased cardiopulmonary reserve predisposes patients to intraoperative hypotension, hypoxia, and respiratory compromise. Altered body composition impairs thermoregulation, increasing susceptibility to perioperative hypothermia, which can further influence drug metabolism and delay postoperative recovery (17). Furthermore, sarcopenic patients exhibit an increased risk of postoperative delirium and cognitive dysfunction, likely due to altered drug kinetics, increased central nervous system sensitivity, and reduced cerebral perfusion (18). These neurocognitive complications significantly affect recovery and long-term outcomes. To minimize risks, individualized anesthetic dosing and vigilant intraoperative monitoring are essential. The use of multimodal monitoring techniques, including entropy or BI spectral index analysis, enables precise control of anesthetic depth and promotes safer, more tailored perioperative care (15; 18). 6. Sarcopenia and Perioperative Outcomes Sarcopenia is strongly associated with an increased incidence of postoperative complications across multiple surgical specialties. Patients with sarcopenia exhibit higher rates of infections, respiratory failure, and pressure ulcers, reflecting their diminished physiological reserve and impaired healing capacity. In emergency laparotomy, sarcopenic individuals present a significantly elevated risk of postoperative complications compared with non-sarcopenic patients (odds ratio = 1.78) (15). Similarly, in cardiac surgery, sarcopenia has been linked to a higher incidence of renal failure, stroke, and other major complications (19). In gastrointestinal and hepato-pancreatico-biliary cancer surgeries, it independently predicts severe postoperative morbidity, confirming its role as a systemic risk factor for adverse outcomes (20). Sarcopenia also contributes to prolonged mechanical ventilation and delayed weaning in the postoperative period. In cardiac surgical patients, reduced respiratory muscle strength results in longer intubation times and extended dependence on mechanical ventilation, which can further delay recovery and increase susceptibility to secondary complications (21). The impact of sarcopenia extends to length of hospital stay. Patients with this condition often require prolonged intensive care unit (ICU) and hospital admissions. For instance, in emergency laparotomy, sarcopenic patients experience significantly longer ICU stays (mean difference = 0.55 days) and total hospitalization (mean difference = 2.33 days) compared with their non-sarcopenic counterparts (Yang et al., 2022). This pattern has also been documented in cardiac and breast reconstruction surgeries, highlighting the broad clinical and economic burden of sarcopenia (21; 22). Moreover, sarcopenia is a robust predictor of shortand long-term mortality. Following emergency laparotomy, sarcopenic patients face a markedly higher 30-day mortality risk (odds ratio = 2.42) (15), while in cardiac surgery, both early and late mortality rates are significantly increased (21). Elevated mortality persists up to 90 days after surgery, underscoring the sustained impact of reduced muscle mass and function on survival (19). Finally, sarcopenia adversely affects postoperative functional recovery and rehabilitation. Patients often experience delayed mobility, reduced strength, and poor participation in rehabilitation programs, leading to prolonged dependence and higher readmission rates (21). Its close association with frailty compounds these challenges, further impairing recovery potential and emphasizing the need for early identification and multidisciplinary management (23). 7. Preoperative Assessment and Optimization Sarcopenia remains frequently underdiagnosed in the preoperative setting, despite its significant implications for surgical risk assessment and outcomes. Screening and risk stratification tools are essential to identify sarcopenic patients who may not be recognized through conventional measures such as body mass index. Techniques like multifrequency bioimpedance analysis provide valuable insights into body composition, allowing for the detection of World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 437 reduced muscle mass and early identification of patients at higher perioperative risk (24). Accurate preoperative risk stratification enables tailored surgical and anesthetic planning, optimizing the risk–benefit balance and improving overall patient safety (25). Nutritional optimization plays a central role in the management of sarcopenia. Interventions that include protein supplementation, vitamin D, and omega-3 fatty acids have demonstrated efficacy in enhancing muscle mass and strength, thereby reducing postoperative complications. These measures are particularly important in elderly patients undergoing orthopedic surgeries, where the prevalence of sarcopenia is high and recovery heavily depends on nutritional and functional status (26). Prehabilitation, incorporating both resistance and aerobic exercise before surgery, has emerged as an effective strategy to improve muscular strength and cardiorespiratory fitness, thus enhancing resilience to surgical stress. This proactive approach, often compared to training for a marathon, focuses on conditioning patients to better tolerate the physiological demands of anesthesia and surgery (27). Finally, correction of comorbidities and systemic inflammation is fundamental in optimizing surgical outcomes among sarcopenic individuals. Chronic conditions such as diabetes, cardiovascular disease, and inflammatory disorders exacerbate muscle loss and increase perioperative risk. Addressing these factors through careful medical management before surgery contributes to improved postoperative recovery and reduced mortality (28). 8. Anesthetic and Intraoperative Management Strategies Drug selection and dosing considerations are critical in the anesthetic management of sarcopenic patients due to altered pharmacokinetics and pharmacodynamics. Reduced skeletal muscle mass affects the volume of distribution, metabolism, and clearance of many anesthetic agents, increasing the risk of accumulation and prolonged sedation. Consequently, lower doses or alternative medications may be required to achieve the desired anesthetic effect while minimizing toxicity and delayed recovery (25). Maintaining hemodynamic and metabolic stability during surgery is equally important, as sarcopenic patients are more prone to fluid imbalances and thermoregulatory disturbances. Fluid therapy must be carefully titrated to avoid both dehydration and fluid overload, either of which can exacerbate cardiovascular stress and postoperative complications (20). Active warming techniques, such as forced-air warming systems, should be implemented to maintain normothermia and reduce the risk of hypothermia-related metabolic derangements and delayed anesthetic recovery (30). The choice between regional and general anesthesia requires careful consideration. Regional anesthesia offers several advantages, including reduced systemic drug exposure, lower risk of respiratory complications, and faster postoperative recovery. However, sarcopenic patients may still experience a higher incidence of chronic postsurgical pain and prolonged analgesic use, even with neuraxial techniques (19). Therefore, anesthetic modality should be individualized based on patient comorbidities, procedure type, and overall physiological reserve (25). Multimodal analgesia represents a cornerstone of perioperative pain management in sarcopenic individuals. Combining non-opioid analgesics, regional blocks, and adjunctive agents helps minimize opioid requirements and reduce adverse effects such as respiratory depression, gastrointestinal dysfunction, and dependency. Implementing opioid-sparing strategies not only enhances pain control but also decreases the likelihood of prolonged postoperative pain and functional decline, thereby supporting faster recovery and rehabilitation (19). 9. Postoperative Care and Recovery Early mobilization and physiotherapy play a central role in the postoperative management of sarcopenic patients, as they are key to preventing additional muscle loss and functional decline. Early ambulation and structured physiotherapy programs help preserve muscle strength, improve respiratory function, and reduce the incidence of complications such as pneumonia and deep vein thrombosis (19; 31). Tailored exercise regimens that combine resistance and aerobic training have been shown to accelerate recovery and enhance overall functional outcomes in the postoperative period (32). Nutritional and metabolic support is equally essential to promote healing and muscle regeneration. Adequate protein intake and supplementation with essential nutrients are vital to counteract the catabolic effects of surgery and maintain World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 433-440 438 muscle mass (25). Personalized dietary plans that address caloric and metabolic needs contribute to optimal energy balance, improved wound healing, and reduced postoperative fatigue, thereby facilitating faster rehabilitation (31). Close monitoring for complications is necessary, as sarcopenic patients exhibit increased vulnerability to respiratory, cardiovascular, and cognitive events after surgery. Regular postoperative assessments allow for early detection of adverse events and timely intervention, which can significantly improve survival and reduce hospital readmission rates (19; 32). The role of multidisciplinary teams is fundamental in achieving optimal outcomes for sarcopenic patients. Coordinated care involving surgeons, anesthesiologists, nutritionists, physiotherapists, and rehabilitation specialists ensures a comprehensive approach that addresses all aspects of perioperative risk and recovery (32). Such collaborative care models facilitate individualized treatment plans, enhance adherence to rehabilitation protocols, and ultimately improve both shortand long-term postoperative outcomes (31). 10. Conclusion Sarcopenia results from complex cellular, metabolic, hormonal, and nutritional disturbances that impair muscle mass, regeneration, and function. Its pathogenesis is driven by chronic inflammation, oxidative stress, and mitochondrial dysfunction, which together accelerate muscle degradation and reduce physiological reserve. Accurate diagnosis requires an integrated evaluation of muscle mass, strength, and physical performance; however, heterogeneity among diagnostic criteria continues to limit consistency in prevalence estimates and clinical application, especially in the perioperative setting. Sarcopenia significantly affects anesthetic management and perioperative outcomes by altering drug pharmacokinetics and pharmacodynamics, reducing cardiopulmonary reserve, and impairing thermoregulation. These physiological changes increase the risk of intraoperative instability, delayed recovery, postoperative delirium, and respiratory complications. Furthermore, sarcopenia independently predicts higher rates of postoperative morbidity, prolonged mechanical ventilation, extended intensive care and hospital stays, and elevated shortand long-term mortality, highlighting the need for early recognition and individualized anesthetic strategies. Effective perioperative management of sarcopenic patients requires a multidisciplinary and proactive approach. Preoperative interventions including nutritional optimization, resistance exercise–based prehabilitation, and correction of comorbidities can enhance muscle strength and improve surgical resilience. Intraoperatively, individualized dosing, meticulous hemodynamic control, and multimodal analgesia reduce anesthetic-related risks. Postoperatively, early mobilization, physiotherapy, and nutritional support are essential for functional recovery. Collaborative care among anesthesiologists, surgeons, nutritionists, and physiotherapists is crucial to minimize complications, shorten recovery time, and improve overall survival and quality of life. Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. References [1] Matsuguma H, Hasumi K, Wakamatsu I, Nakahara R. 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