Pharmacology of thoracic anesthesia

Purpose of review Thoracic anesthesia is one of the most demanding subspecialties, requiring the integration of surgical conditions with patient safety. Procedures such as lung resections, video-assisted thoracic surgery, robotic surgery, and transplantation impose unique physiologic stress, particularly during one-lung ventilation, which challenges gas exchange and cardiovascular stability. This review summarizes current evidence on anesthetic strategies in thoracic surgery, including induction and maintenance techniques, opioid use, neuromuscular blockade, and hemodynamic management. Recent findings Thoracic anesthesia present ongoing debates. No consensus exists on whether total intravenous anesthesia or volatile anesthesia is superior: propofol may provide long-term oncologic benefit, whereas volatiles offer pulmonary protection but raise concerns about tumor progression and impaired hypoxic pulmonary vasoconstriction. Opioids remain effective but carry risks of respiratory depression, delirium, hyperalgesia, immune suppression, and persistent use, fueling opioid-sparing but not opioid-free strategies. Neuromuscular blockade improves surgical conditions, yet optimal depth outside robotic surgery and the need for routine reversal remain debated. Hemodynamic management balances euvolemia against hypovolemia. Summary Modern thoracic anesthesia pharmacology combines novel agents with established drug classes, integrating current evidence to improve intraoperative stability, reduce complications, and promote recovery.