THORACIC ANESTHESIA: Edited by Tjorvi E. PerryHow, when and why to establish preoperative surgical risk in thoracic surgeryColeman, John R.a; Hanson, Neil A.b Author Information aDepartment of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia bDepartment of Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA Correspondence to John R. Coleman, VCU Department of Anesthesiology, P.O. Box 980695 Richmond, VA 23298-0695, USA. Tel: +1 804 828 9160; e-mail: [email protected] Current Opinion in Anaesthesiology 36(1):p 68-73, February 2023. | DOI: 10.1097/ACO.0000000000001215 Buy Metrics Abstract Purpose of review Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management. Recent findings Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients. Summary Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.