[TIVA or Volatile Anaesthesia: Pros and Cons in Thoracic Surgery]

Thoracic surgical procedures present specific challenges in anaesthesiology. One lung ventilation (OLV) regularly required in this context does improve surgical exposure, but leads to characteristic pathophysiological changes: the right-to-left shunt increases, dead space ventilation rises, and hypoxic pulmonary vasoconstriction (HPV) elevates pulmonary vascular resistance. These mechanisms have a direct impact on gas exchange and haemodynamics and demand a differentiated anaesthesiological strategy. A comparison between the performance of total intravenous anaesthesia (TIVA) and balanced general anaesthesia shows that both techniques exhibit specific advantages and disadvantages, which must be carefully weighed under the conditions of OLV, as well as with consideration of individual patient factors. While TIVA may offer benefits through less influence on HPV and reduced environmental burden, volatile anaesthesia, combining volatile inhalational anaesthetics such as desflurane or sevoflurane with intravenously administered drugs (opioids, muscle relaxants, hypnotics), enables more precise pharmacological monitoring. In addition, volatile inhalational anaesthetics can be advantageous, particularly in patients with impaired cardiocirculatory function. Furthermore, operating theatres contribute significantly to the CO₂ emissions of the healthcare system, with desflurane, and to a lesser extent sevoflurane, accounting for a relevant share. Low-flow techniques can reduce emissions, yet intravenous or regional anaesthesia are considered more ecologically favourable. Moreover, there are burdens from the high consumption of disposable materials as well as the considerable energy demand of the infrastructure. The current evidence in this regard is, however, heterogeneous, so further systematic investigations are required. The choice of anaesthetic technique is therefore not only a medical, but increasingly also an ecological decision. The aim of the present work is to systematically analyse and compare the available evidence from randomised controlled trials and systematic reviews on TIVA and balanced general anaesthesia in thoracic surgery. In addition to clinical endpoints, ecological, inflammatory, and patient-specific aspects are also considered, in order to provide a sound basis for future decision-making processes.