Precision Anesthesia in 2025: What CRNAs Need to Know About Genetics & Biomarkers
Recent advances in pharmacogenomics, microRNA science, and central nervous system (CNS) biomarkers have reshaped anesthesia practice. Between 2023 and 2025, expanded genomic profiling, sex-based pharmacogenetic insights, and novel biomarkers predicting postoperative cognitive dysfunction (POCD) have emerged as essential tools for individualized perioperative care. This manuscript summarizes current evidence relevant to Certified Registered Nurse Anesthetists (CRNAs), focusing on actionable genetic variants, emerging biomarkers, and their clinical implications for anesthetic management, patient safety, and recovery.
Introduction
Precision medicine continues to influence perioperative practice, particularly through rapid advances in genetics and molecular biomarkers. As anesthetic agents interact with a wide range of metabolic, neurologic, and inflammatory pathways, understanding a patient’s genetic and biochemical profile can substantially improve safety and therapeutic outcomes. Recent studies from 2023 to 2025 highlight significant variability in anesthetic response driven by pharmacogenomic variation, microRNA expression, sex-specific genetic interactions, and CNS biomarkers
Pharmacogenomics in Anesthetic Drug Response
Genetic variation in key metabolic pathways affects patient responses to opioids, sedatives, volatile agents, and neuromuscular blockers. CYP450 polymorphisms—particularly CYP2D6, CYP2C9, CYP3A4, CYP2B6, and CYP2C19—alter metabolism of opioids, NSAIDs, benzodiazepines, and propofol. Whole-exome sequencing (WES) data from 2023 revealed more than 100 anesthesia-relevant variants across diverse populations. BCHE gene mutations continue to represent the primary cause of prolonged succinylcholine-induced paralysis, while updated findings show these variants are more common than previously recognized.
MicroRNAs as Emerging Predictive Biomarkers
MicroRNAs (miRNAs) are rapidly becoming central to precision anesthesia. Recent findings demonstrate that miR-21, miR-34a, and miR-155 modulate neuroinflammatory pathways and may predict delayed emergence, opioid sensitivity, and risk of postoperative delirium. Their stability in serum and CSF makes them promising candidates for perioperative biomarker assays.
Central Nervous System Injury Biomarkers
Novel biomarkers including glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1 (UCH-L1), Tau proteins, neuron-specific enolase (NSE), and S100β have been validated for detecting neuronal injury and predicting POCD. These markers provide insight into anesthetic neurotoxicity, blood–brain barrier function, and cerebral stress during surgery.
Quick Reference: genetic Testing in Anesthesia
Available and Emerging Tests for Anesthetic Sensitivity
| Category |
Gene/Test |
Clinical Use | Availability | CRNA Notes |
| MH susceptibility | RYR1, CACNA1S | Reaction to volatiles/succinylcholine | Routine targeted testing | Use TIVA, stock dantrolene |
| Pseudocholinesterase deficiency | BCHE, dibucaine assay | Prolonged paralysis after SCh/mivacu | Routine |
Avoid depolarizers |
| Opioid sensitivity | CYP2D6, OPRM1, COMT, ABCB1 | Analgesic variability/toxicity | PGx panels | Useful for postop pain plans |
| Propofol metabolism | CYP2B6, UGT1A9 | Altered clearance/emergence | Research | Monitor depth/recovery |
| NSAID metabolism | CYP2C9 | Bleeding/renal risk | Available | Adjust NSAID strategy |
| Volatile anesthetic response | GABRA2, KCNJ6 | Depth/emergence variability | Research | Not yet actionable |
| Local anesthetic sensitivity | SCN5A | Possible cardiac sensitivity | Research | Monitor ECG |
Conclusion
Advancements in genetics and molecular biomarkers are redefining anesthesia practice. For CRNAs, incorporating pharmacogenomic data, miRNA insights, and CNS biomarkers into clinical decision-making enhances patient safety and supports individualized anesthetic care. Ongoing research and expanding clinical adoption will continue to advance precision anesthesia throughout the next decade.
References
- Pharmacogenomics in Anesthesiology: Personalized Approaches to Pain Management. Hilaris Publishing, 2023.
- Whole-Exome Sequencing Identifies Novel Variants in AnesthesiaPharmacogenes. Frontiers in Pharmacology, 2023.
- Emerging Trends in Pharmacogenomics: Comprehensive Genomic Profiling. Human Genomics, 2023.
- Personalized Anesthesia: Genetic and AI Predictive Tools. Frontiers in Medicine, 2024.
- Role of microRNAs in Anesthesia and Pain. Springer Nature, 2025.
- Genetic Variation and Sex-Based Differences in Anesthesia Outcomes. MDPI Genes, 2024.