What are the guidelines for anesthesia management according to Miller's Anesthesia textbook?

I understand you're looking for information from Miller's Anesthesia, Stoelting's, and Barash textbooks. However, the evidence provided does not contain content from these specific textbooks. Instead, I have access to current anesthesia guidelines from professional societies and FDA drug labels that can address general anesthesia management principles.

General Anesthesia Management Guidelines

Core Monitoring Requirements

All patients undergoing general anesthesia require continuous monitoring of airway patency, respiratory rate, oxygen saturation (SpO₂), pulse, blood pressure, and electrocardiographic monitoring during emergence and recovery. 1

Essential Monitoring Parameters

• Airway and Respiratory Monitoring: Periodic assessment of airway patency, respiratory rate, and SpO₂ must be performed during emergence and recovery, with particular attention to oxygenation and ventilation 1
• Cardiovascular Monitoring: Routine pulse and blood pressure monitoring should be continuous during emergence and recovery, with electrocardiographic monitors immediately available 1
• Neuromuscular Function: Assessment is mandatory for patients who received nondepolarizing neuromuscular blocking agents or have medical conditions associated with neuromuscular dysfunction 1
• Capnography: Should be used in all patients whenever there is loss or likelihood of loss of normal response to verbal contact 1

Anesthetic Agent Selection and Dosing

Propofol remains the preferred induction agent for most adult patients, requiring 2-2.5 mg/kg for ASA-PS I or II patients under 55 years when unpremedicated. 2

Induction Dosing by Patient Population

• Standard Adult Patients (ASA-PS I-II, <55 years): 2-2.5 mg/kg propofol, titrated at approximately 40 mg every 10 seconds until clinical signs show onset of anesthesia 2
• Elderly/Debilitated/ASA-PS III-IV Patients: Reduced dose of 1-1.5 mg/kg (approximately 20 mg every 10 seconds), avoiding rapid bolus to prevent cardiorespiratory depression including hypotension, apnea, and oxygen desaturation 2
• Pediatric Patients (3-16 years, ASA-PS I-II): 2.5-3.5 mg/kg propofol when unpremedicated, with younger children requiring higher doses than older children 2

Maintenance Strategy

• Infusion Rates: Maintenance rates of 50-100 mcg/kg/min in adults optimize recovery times 2
• Multimodal Approach: Combining agents that act at different targets in the nociceptive system controls intraception intraoperatively and pain postoperatively while reducing doses of hypnotics needed for unconsciousness 3

Difficult Airway Management

For anticipated difficult airways, awake tracheal intubation is the recommended approach, with preoxygenation for 3-5 minutes at tidal volume with FiO₂ = 1.0 to reach an end-tidal oxygen concentration ≥0.90. 1

Preoxygenation Protocols

• Standard Method: 3-5 minutes of oxygen at tidal volume with FiO₂ = 1.0 1
• Alternative Method: 1 minute at tidal volume with FiO₂ = 1.0 1
• Target: Achieve end-tidal oxygen concentration ≥0.90 (EtO₂ ≥ 0.9) 1
• Delivery Methods: Oxygen via nasal cannulae, facemask (including humidified nasal cannula and continuous positive airway pressure), or supraglottic airway insufflation 1

Airway Assessment Components

• Facial Features: Mouth opening, nose slope, neck slope, ratio of brow to nose to chin, presence of full beard 1
• Clinical Tests: Upper lip bite test 1
• Anatomical Measurements: Mallampati/modified Mallampati, neck circumference, neck mobility (including radiation changes), prognathism, thyromental distance, sternomental distance, temporomandibular distance 1

Special Positioning Considerations

For beach chair positioning, elevate the head of bed 30° before induction to optimize respiratory mechanics, and use non-invasive positive pressure ventilation (NIPPV) or CPAP before loss of spontaneous ventilation. 4

Beach Chair Position Management

• Pre-induction Positioning: Position patient with head of bed elevated 30° to optimize respiratory mechanics 4
• Ventilation Support: Apply NIPPV or CPAP before loss of spontaneous ventilation to attenuate anesthesia-induced respiratory changes 4
• Ventilator Settings: Deliver tidal volumes of 6-8 ml/kg predicted body weight with PEEP of 5 cm H₂O; zero end-expiratory pressure (ZEEP) is not recommended 4
• Staffing Requirements: Minimum of three staff members plus the anesthetist for patients weighing >50 kg 4
• Pressure Point Monitoring: Essential attention to pressure areas to prevent nerve injuries and pressure ulcers during prolonged procedures 4

Regional Anesthesia Ergonomics

When performing regional anesthesia, maintain the same minimum monitoring standards as for general anesthesia, with the patient level adjusted so the anaesthetist's neck is not flexed >60°. 1

Procedural Ergonomic Principles

Environment Requirements:

• Sufficient space with quiet, distraction-free area 1
• Ambient temperature ≥21°C 1
• Adjustable lighting with dimmer switch 1

Patient Positioning:

• Comfortable on trolley/bed/operating table with stable, secure positioning 1
• Unobstructed access without impeding objects 1
• Patient level adjusted to prevent anaesthetist neck flexion >60° 1

Equipment Setup:

• All equipment checked before use 1
• Adjustable height trolley/bed/operating table and stool/chair 1
• Equipment trolley on operator's dominant side to minimize torso torsion 1
• Ultrasound machine fully adjustable, opposite operator with screen at eye level 1

Operator Position:

• Standing position: optimal height within 5 cm above to 10 cm below elbow 1
• Minimize flexion of neck, lower back, and knees 1
• Maintain aseptic technique without leaning on or over patient 1

Central Neuraxial Blockade

• Optimal Table Height: For spinal anaesthesia in standing position, raise table to level of nipple or xiphoid process of anaesthetist for optimal needle entry angle and comfort 1
• Monitoring Duration: After regional anaesthetic for analgesia (e.g., rib or femur fracture), maintain minimum 30 minutes monitoring for local anaesthetic systemic toxicity, which can peak 30-90 minutes post-injection 1

Obesity-Specific Considerations

For obese patients, use ramped or sitting position for induction and recovery, dose drugs based on lean body weight titrated to effect, and always use neuromuscular monitoring when neuromuscular blocking drugs are administered. 1

Obese Patient Management

• Positioning: Ramped or sitting position aids induction and recovery 1
• Drug Dosing: Base on lean body weight and titrate to effect rather than total body weight 1
• Opioid/Sedative Use: Exercise caution with long-acting agents 1
• Neuromuscular Monitoring: Mandatory whenever neuromuscular blocking drugs are used 1
• Depth of Anaesthesia Monitoring: Consider especially when using total intravenous anaesthesia with neuromuscular blocking drugs 1
• Airway Strategy: Plan robust airway strategy as desaturation occurs quickly and airway management can be difficult 1
• Regional Anaesthesia: Desirable but often technically difficult or impossible 1

MRI Environment Anesthesia

For anesthesia in MRI units, only MR Safe vaporizers and gas cylinders should be used within the scanning room, with MR Conditional anaesthetic machines and ventilators positioned as determined by the individual magnet field. 1

MRI-Specific Requirements

• Equipment: Only MR Safe vaporizers and gas cylinders within scanning room; standard equipment may cause serious accidents 1
• Infusion Pumps: Standard pumps must not enter MR environment; use MR Conditional or MR Safe pumps, or place within RF shield enclosure (Faraday cage), or position outside scanning room 1
• Airway Devices: When using laryngeal mask or non-armoured tracheal tube, secure pilot balloon away from scan area to prevent image distortion from internal ferromagnetic spring 1
• Monitoring: According to national guidelines with awareness of potential airway complications and time required for assistance to arrive 1
• Induction Location: Dedicated area with appropriately trained anaesthetic assistant 1

Maintenance Options in MRI

• Inhalational Agents: Using MR Conditional machines with MR Safe vaporizers 1
• Total Intravenous Anaesthesia: Requires high index of suspicion for infusion problems as IV cannula not visible; failure to hear pump alarms due to ear plugs or anaesthetist position; long infusion lines risk misconnection or high pressure preventing agent delivery 1
• Infusion Line Management: Ensure appropriate combination of lines, pumps, and settings to prevent infusion stoppage due to excessive resistance or high-pressure alarm cut-out 1

Propofol Handling and Safety

Propofol must be prepared for single-patient use only with strict aseptic technique, administered within 12 hours of vial opening, and all unused portions discarded at 12 hours or end of procedure, whichever occurs sooner. 2

Critical Safety Requirements

• Aseptic Technique: Strict maintenance mandatory; disinfect vial rubber stopper with 70% isopropyl alcohol 2
• Single-Patient Use: Vials never to be accessed more than once or used on more than one person 2
• Time Limits: Administration must commence promptly and be completed within 12 hours after vial opening 2
• Disposal: Discard unused drug product, reservoirs, dedicated administration tubing, and solutions containing propofol at end of procedure or 12 hours, whichever occurs sooner 2
• IV Line Management: Flush every 12 hours and at end of procedure to remove residual propofol 2
• Dilution: If necessary, only dilute with 5% Dextrose Injection, USP, to concentration not less than 2 mg/mL 2

Contamination Risks

• Microbial Growth: Despite benzyl alcohol 1.5 mg/mL and sodium benzoate 0.7 mg/mL inhibiting growth up to 12 hours, propofol can still support microorganism growth 2
• Reported Complications: Failure to use aseptic technique associated with microbial contamination, fever, infection/sepsis, life-threatening illness, and death 2
• Bloodborne Pathogen Transmission: Reports of Hepatitis B, Hepatitis C, and HIV transmission from unsafe injection practices and use of single-use vials on multiple persons 2