arteriovenous fistula cannulation hemodialysis needle direction criteria

PMID: 37609532

AV fistula new cannulation criteria maturation needle direction antegrade retrograde guidelines KDOQI

https://www.midwestkidneynetwork.org/sites/default/files/rev…

ls -la /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

mkdir -p /home/daytona/workspace/fistula-cannulation && python3 -c "from reportl…

~/fistula-cannulation/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import HRFlowable
from reportlab.graphics.shapes import Drawing, Rect, String, Line, Circle, Polygon
from reportlab.graphics import renderPDF
from reportlab.graphics.charts.lineplots import LinePlot
from reportlab.graphics.widgets.markers import makeMarker
import os

OUTPUT = "/home/daytona/workspace/fistula-cannulation/AV_Fistula_Cannulation_Protocol.pdf"

# ── Colour palette ───────────────────────────────────────────────────────────
NAVY       = colors.HexColor("#1A3A5C")
TEAL       = colors.HexColor("#0D7377")
TEAL_LIGHT = colors.HexColor("#E8F7F7")
AMBER      = colors.HexColor("#E07B00")
AMBER_LITE = colors.HexColor("#FFF4E0")
RED        = colors.HexColor("#C0392B")
RED_LITE   = colors.HexColor("#FDECEA")
GREEN      = colors.HexColor("#1B7A4A")
GREEN_LITE = colors.HexColor("#E8F5EE")
GREY       = colors.HexColor("#5A5A5A")
LGREY      = colors.HexColor("#F4F6F8")
WHITE      = colors.white
BLACK      = colors.black

W, H = A4
MARGIN = 1.8 * cm

# ── Style helpers ─────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    base = styles.get(name) if name in styles else styles["Normal"]
    return ParagraphStyle(name + "_custom", parent=base, **kw)

cover_title  = S("Title",  fontSize=26, textColor=WHITE, leading=32, alignment=TA_CENTER, fontName="Helvetica-Bold")
cover_sub    = S("Normal", fontSize=13, textColor=colors.HexColor("#CCE8EC"), leading=18, alignment=TA_CENTER)
cover_note   = S("Normal", fontSize=9,  textColor=colors.HexColor("#A0C4CC"), alignment=TA_CENTER)

h1 = S("Heading1", fontSize=14, textColor=WHITE,     leading=18, fontName="Helvetica-Bold", spaceAfter=2)
h2 = S("Heading2", fontSize=12, textColor=NAVY,      leading=16, fontName="Helvetica-Bold", spaceBefore=10, spaceAfter=4)
h3 = S("Heading3", fontSize=10, textColor=TEAL,      leading=14, fontName="Helvetica-Bold", spaceBefore=6, spaceAfter=2)
body = S("Normal",  fontSize=9,  textColor=GREY,      leading=13, spaceAfter=4, alignment=TA_JUSTIFY)
body_b = S("Normal", fontSize=9, textColor=BLACK,     leading=13, spaceAfter=3, fontName="Helvetica-Bold")
small = S("Normal", fontSize=8,  textColor=GREY,      leading=11)
ref   = S("Normal", fontSize=7.5,textColor=GREY,      leading=10, spaceAfter=2)
bullet= S("Normal", fontSize=9,  textColor=GREY,      leading=13, leftIndent=14, spaceAfter=3,
           bulletIndent=4, bulletFontName="Helvetica", bulletFontSize=10)

# ── Reusable builders ─────────────────────────────────────────────────────────
def section_header(text, bg=NAVY):
    tbl = Table([[Paragraph(text, h1)]], colWidths=[W - 2*MARGIN])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS", (0,0), (-1,-1), [4,4,4,4]),
    ]))
    return tbl

def info_box(text, bg=TEAL_LIGHT, border=TEAL):
    tbl = Table([[Paragraph(text, body)]], colWidths=[W - 2*MARGIN])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("LEFTPADDING",   (0,0), (-1,-1), 12),
        ("RIGHTPADDING",  (0,0), (-1,-1), 8),
        ("BOX",           (0,0), (-1,-1), 1.5, border),
    ]))
    return tbl

def warn_box(text):
    return info_box(text, bg=AMBER_LITE, border=AMBER)

def danger_box(text):
    return info_box(text, bg=RED_LITE, border=RED)

def bullet_para(text):
    return Paragraph(f"• {text}", bullet)

def sp(h=4):
    return Spacer(1, h * mm)

# ── Cover page ────────────────────────────────────────────────────────────────
def cover_page():
    # Full-bleed header block built as a tall table
    header_data = [[
        Paragraph("AV FISTULA CANNULATION", cover_title),
    ],[
        Paragraph("REFERENCE PROTOCOL", cover_title),
    ],[
        Spacer(1, 6*mm),
    ],[
        Paragraph("Criteria for New Fistula Use  •  Needle Direction Guidelines<br/>"
                  "Gauge-to-Flow Charts  •  Week-by-Week Progression  •  Cannulation Techniques", cover_sub),
    ],[
        Spacer(1, 4*mm),
    ],[
        Paragraph("Based on KDOQI 2019 Vascular Access Guidelines | UK VASBI 2018 | Karkhah et al. 2023 Systematic Review", cover_note),
    ]]
    tbl = Table(header_data, colWidths=[W - 2*MARGIN])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), NAVY),
        ("TOPPADDING",    (0,0), (-1,-1), 10),
        ("BOTTOMPADDING", (0,0), (-1,-1), 10),
        ("LEFTPADDING",   (0,0), (-1,-1), 16),
        ("RIGHTPADDING",  (0,0), (-1,-1), 16),
    ]))
    return [sp(4), tbl, sp(6)]

# ── Needle direction diagram (Drawing) ────────────────────────────────────────
def needle_direction_diagram():
    d = Drawing(W - 2*MARGIN, 95)
    dw = W - 2*MARGIN
    
    # Background
    d.add(Rect(0, 0, dw, 95, fillColor=LGREY, strokeColor=None))
    
    # Title
    d.add(String(dw/2, 80, "NEEDLE DIRECTION IN STANDARD (REGULAR FLOW) AVF",
                 textAnchor='middle', fontName='Helvetica-Bold', fontSize=9, fillColor=NAVY))
    
    # Vein tube
    vein_y = 44
    vein_x1 = 50
    vein_x2 = dw - 50
    d.add(Rect(vein_x1, vein_y - 8, vein_x2 - vein_x1, 16,
               fillColor=colors.HexColor("#ADE8F4"), strokeColor=TEAL, strokeWidth=1.5))
    
    # Anastomosis circle (left)
    d.add(Circle(vein_x1, vein_y, 10, fillColor=colors.HexColor("#F9A825"),
                 strokeColor=AMBER, strokeWidth=2))
    d.add(String(vein_x1, vein_y - 3, "A", textAnchor='middle',
                 fontName='Helvetica-Bold', fontSize=8, fillColor=NAVY))
    
    # Blood flow arrow in vein (left to right)
    mid = (vein_x1 + vein_x2) / 2
    flow_y = vein_y
    for x in [mid - 40, mid, mid + 40]:
        d.add(Line(x, flow_y, x + 18, flow_y,
                   strokeColor=TEAL, strokeWidth=1.5))
        # arrowhead
        d.add(Polygon([x+18, flow_y, x+12, flow_y+4, x+12, flow_y-4],
                      fillColor=TEAL, strokeColor=None))
    d.add(String(mid, flow_y + 13, "Blood flow direction ->  ->  ->",
                 textAnchor='middle', fontName='Helvetica', fontSize=7.5, fillColor=TEAL))
    
    # Arterial needle (retrograde, pointing LEFT toward anastomosis)
    art_x = vein_x1 + 75
    d.add(Line(art_x, vein_y + 30, art_x - 8, vein_y + 8,
               strokeColor=RED, strokeWidth=2.5))
    # needle tip arrow pointing left
    d.add(Polygon([art_x - 8, vein_y + 8, art_x - 2, vein_y + 16, art_x + 4, vein_y + 12],
                  fillColor=RED, strokeColor=None))
    d.add(String(art_x, vein_y + 36, "ARTERIAL NEEDLE",
                 textAnchor='middle', fontName='Helvetica-Bold', fontSize=8, fillColor=RED))
    d.add(String(art_x, vein_y + 27, "RETROGRADE",
                 textAnchor='middle', fontName='Helvetica', fontSize=7, fillColor=RED))
    d.add(String(art_x, vein_y + 20, "(toward anastomosis)",
                 textAnchor='middle', fontName='Helvetica', fontSize=6.5, fillColor=GREY))
    
    # Venous needle (antegrade, pointing RIGHT toward heart)
    ven_x = vein_x2 - 75
    d.add(Line(ven_x, vein_y + 30, ven_x + 8, vein_y + 8,
               strokeColor=GREEN, strokeWidth=2.5))
    # needle tip arrow pointing right
    d.add(Polygon([ven_x + 8, vein_y + 8, ven_x + 2, vein_y + 16, ven_x - 4, vein_y + 12],
                  fillColor=GREEN, strokeColor=None))
    d.add(String(ven_x, vein_y + 36, "VENOUS NEEDLE",
                 textAnchor='middle', fontName='Helvetica-Bold', fontSize=8, fillColor=GREEN))
    d.add(String(ven_x, vein_y + 27, "ANTEGRADE",
                 textAnchor='middle', fontName='Helvetica', fontSize=7, fillColor=GREEN))
    d.add(String(ven_x, vein_y + 20, "(toward heart)",
                 textAnchor='middle', fontName='Helvetica', fontSize=6.5, fillColor=GREY))
    
    # Heart symbol (right)
    d.add(String(dw - 42, vein_y - 3, "HEART",
                 textAnchor='middle', fontName='Helvetica-Bold', fontSize=7, fillColor=NAVY))
    d.add(String(dw - 42, vein_y + 6, ">>>", textAnchor='middle',
                 fontName='Helvetica', fontSize=9, fillColor=NAVY))
    
    # Minimum distance label
    dist_x = vein_x1 + 10
    d.add(Line(vein_x1 + 10, vein_y - 14, art_x, vein_y - 14,
               strokeColor=AMBER, strokeWidth=1, strokeDashArray=[3, 2]))
    d.add(String((vein_x1 + 10 + art_x) / 2, vein_y - 22, "min 1.5-2 inches from anastomosis",
                 textAnchor='middle', fontName='Helvetica-Oblique', fontSize=6.5, fillColor=AMBER))
    
    return d

# ── Main content builder ──────────────────────────────────────────────────────
def build_story():
    story = []
    
    # ── COVER ─────────────────────────────────────────────────────────────────
    story += cover_page()
    story.append(sp(8))
    
    # ── SECTION 1: MATURATION CRITERIA ────────────────────────────────────────
    story.append(section_header("1.  CRITERIA FOR CANNULATING A NEW AV FISTULA"))
    story.append(sp(3))
    
    story.append(Paragraph("Before attempting the first cannulation, ALL of the following maturation criteria should be met "
                            "(minimum 8-12 weeks post-creation, with physician order):", body))
    story.append(sp(2))
    
    # Rule of 6s table
    rule6_data = [
        [Paragraph("<b>Parameter</b>", body_b), Paragraph("<b>Threshold</b>", body_b),
         Paragraph("<b>Notes</b>", body_b)],
        ["Vein Diameter",   "≥ 6 mm",            "Measured by ultrasound or clinical palpation"],
        ["Blood Flow Rate", "≥ 600 mL/min",       "NIH Fistula Maturation Study target"],
        ["Depth Below Skin","≤ 6 mm (ideally ≤2 mm)","Greater depth = poorer cannulation outcomes"],
        ["Maturation Time", "8 – 12 weeks",       "Never rush without surgeon/nephrologist order"],
        ["Vessel Length",   "≥ 6 cm usable segment","For two-needle placement with spacing"],
    ]
    rule6_tbl = Table(rule6_data, colWidths=[4.5*cm, 4.5*cm, 9.2*cm])
    rule6_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 9),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, LGREY]),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#D0D8E0")),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 7),
        ("RIGHTPADDING",  (0,0), (-1,-1), 7),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ]))
    story.append(rule6_tbl)
    story.append(sp(2))
    
    story.append(warn_box(
        "<b>KDOQI 2019 Update:</b> The NIH Fistula Maturation Study found that using criteria of flow ≥600 mL/min, "
        "diameter ≥6 mm, and depth ≤2 mm, successful maturation occurred in only ~50% of cases. "
        "Cannulation readiness requires physician judgment beyond the Rule of 6s alone."
    ))
    story.append(sp(3))
    
    # Functional maturity definition
    story.append(Paragraph("KDOQI 2019 – Functional Maturity Definition:", h3))
    story.append(info_box(
        "A fistula is <b>functionally mature</b> when it can provide prescribed dialysis consistently "
        "with <b>2 needles for >2/3 of dialysis sessions within 4 consecutive weeks</b>."
    ))
    story.append(sp(3))
    
    # Pre-cannulation checklist
    story.append(Paragraph("Pre-Cannulation Assessment Checklist (Every New Cannulation):", h3))
    checks = [
        "Obtain written physician/surgeon order before first cannulation attempt",
        "Only experienced, trained dialysis nurses should cannulate new fistulas",
        "LOOK: Inspect for hematoma, infiltration, infection, skin changes",
        "FEEL: Continuous thrill along the entire fistula length (strong = good flow)",
        "LISTEN: Low-pitched machinery bruit (high-pitched = stenosis)",
        "ARM ELEVATION TEST: Fistula partially collapses on elevation (rules out outflow stenosis)",
        "Measure usable vein length; mark cannulation zones",
        "Confirm no new swelling or tenderness since last session",
        "Document access assessment findings before each treatment",
    ]
    for c in checks:
        story.append(bullet_para(c))
    story.append(sp(2))
    
    story.append(danger_box(
        "<b>CONTRAINDICATIONS to cannulation:</b> Active infection/cellulitis over access, "
        "unresolved hematoma, pulsatile (not thrill) access suggesting stenosis, "
        "skin breakdown, or patient/surgeon refusal."
    ))
    story.append(sp(4))
    
    # ── SECTION 2: NEEDLE DIRECTION ───────────────────────────────────────────
    story.append(section_header("2.  NEEDLE DIRECTION: ANTEGRADE vs. RETROGRADE"))
    story.append(sp(3))
    
    story.append(Paragraph(
        "Correct needle orientation reduces access recirculation, optimizes dialysis adequacy (Kt/V), "
        "and protects the fistula from early damage.", body))
    story.append(sp(3))
    
    # Direction diagram
    story.append(needle_direction_diagram())
    story.append(sp(4))
    
    # Needle direction table
    nd_data = [
        [Paragraph("<b>Needle</b>", body_b),
         Paragraph("<b>Direction</b>", body_b),
         Paragraph("<b>Tip Orientation</b>", body_b),
         Paragraph("<b>Rationale</b>", body_b)],
        [Paragraph("<b>ARTERIAL</b>\n(blood leaving patient)", body_b),
         Paragraph("<font color='#C0392B'><b>RETROGRADE</b></font>", body_b),
         "Points TOWARD anastomosis\n(against blood flow)",
         "Draws from high-pressure inflow zone;\nreduces access recirculation (AR)"],
        [Paragraph("<b>VENOUS</b>\n(blood returning to patient)", body_b),
         Paragraph("<font color='#1B7A4A'><b>ANTEGRADE</b></font>", body_b),
         "Points AWAY from anastomosis\n(with blood flow, toward heart)",
         "Returns blood in direction of venous\noutflow; minimizes turbulence"],
    ]
    nd_tbl = Table(nd_data, colWidths=[3.8*cm, 3.2*cm, 5.5*cm, 5.7*cm])
    nd_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), TEAL),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 9),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [colors.HexColor("#FFF0F0"), colors.HexColor("#F0FFF4")]),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#D0D8E0")),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 7),
        ("RIGHTPADDING",  (0,0), (-1,-1), 7),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ]))
    story.append(nd_tbl)
    story.append(sp(3))
    
    story.append(info_box(
        "<b>UK VASBI 2018 Recommendation B:</b> \"Ideally both needles should be inserted in an antegrade direction "
        "(needle pointing away from the anastomosis / with the flow of blood). If required, the arterial needle "
        "can be inserted in a retrograde direction (needle facing towards the anastomosis / against the flow of blood). "
        "This decision requires clinical judgement.\""
    ))
    story.append(sp(2))
    
    # Reverse flow note
    story.append(Paragraph("Reverse Flow AVF (e.g., Proximal Radial Artery AVF):", h3))
    story.append(bullet_para("Blood flow direction dictates needle placement (opposite to standard AVF)"))
    story.append(bullet_para("Venous needle in forearm: RETROGRADE toward the hand (direction of venous flow)"))
    story.append(bullet_para("Venous needle in upper arm: ANTEGRADE toward the shoulder/heart"))
    story.append(sp(2))
    
    # Evidence note
    story.append(warn_box(
        "<b>Evidence note (Karkhah et al. 2023 – Systematic Review & Meta-Analysis):</b> "
        "Analysis of 3 RCTs and 4 non-RCTs found <b>uncertainty</b> about the effect of needle direction "
        "on Kt/V and access recirculation. Non-RCT data suggested retrograde arterial needle decreases Kt/V; "
        "antegrade arterial reduces AR. RCT data was inconclusive. "
        "Institutional protocol and clinical judgment remain the standard."
    ))
    story.append(sp(3))
    
    # ── SECTION 3: NEEDLE GAUGE AND BFR CHART ─────────────────────────────────
    story.append(section_header("3.  NEEDLE GAUGE – BLOOD FLOW RATE CHART"))
    story.append(sp(3))
    
    story.append(Paragraph(
        "Match needle gauge to the prescribed blood flow rate (BFR). Larger needles reduce "
        "pre-pump arterial pressure and improve delivered blood flow.", body))
    story.append(sp(3))
    
    gauge_data = [
        [Paragraph("<b>Blood Flow Rate (BFR)</b>", body_b),
         Paragraph("<b>Minimum Needle Gauge</b>", body_b),
         Paragraph("<b>Notes</b>", body_b)],
        ["< 300 mL/min",    "17 Gauge",  "First week / very new fragile fistulas; initial cannulation"],
        ["300 – 350 mL/min","16 Gauge",  "Week 2 progression; standard mid-range access"],
        ["350 – 450 mL/min","15 Gauge",  "Week 3+ after successful progression"],
        ["> 450 mL/min",    "14 Gauge",  "Established fistula; high-efficiency dialysis needs"],
    ]
    
    gauge_tbl = Table(gauge_data, colWidths=[5.5*cm, 4.5*cm, 8.2*cm])
    
    # Row colors with gauge highlighting
    gauge_colors = [NAVY, colors.HexColor("#EDF7EF"), colors.HexColor("#D5EFDA"),
                    colors.HexColor("#B8E2BF"), colors.HexColor("#90CF9A")]
    gauge_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 9),
        ("BACKGROUND",    (0,1), (-1,1), colors.HexColor("#EDF7EF")),
        ("BACKGROUND",    (0,2), (-1,2), colors.HexColor("#D5EFDA")),
        ("BACKGROUND",    (0,3), (-1,3), colors.HexColor("#B8E2BF")),
        ("BACKGROUND",    (0,4), (-1,4), colors.HexColor("#90CF9A")),
        ("FONTNAME",      (1,1), (1,-1), "Helvetica-Bold"),
        ("FONTSIZE",      (1,1), (1,-1), 11),
        ("TEXTCOLOR",     (1,1), (1,-1), GREEN),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#C0D8C0")),
        ("TOPPADDING",    (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 7),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",         (1,0), (1,-1), "CENTER"),
    ]))
    story.append(gauge_tbl)
    story.append(sp(2))
    story.append(info_box(
        "<b>Note:</b> These are <i>minimum</i> recommended gauges. Larger needles (when feasible) "
        "further reduce pre-pump arterial pressure and optimize delivered blood flow. "
        "Needle gauge must be matched to the actual achieved BFR, not just the prescribed rate."
    ))
    story.append(sp(4))
    
    # ── SECTION 4: WEEK-BY-WEEK PROGRESSION ───────────────────────────────────
    story.append(section_header("4.  WEEK-BY-WEEK CANNULATION PROGRESSION PROTOCOL"))
    story.append(sp(3))
    
    story.append(Paragraph(
        "Progress new fistula cannulation gradually. Do NOT advance faster than these guidelines "
        "without a physician order. Staff must document each session outcome.", body))
    story.append(sp(2))
    
    week_data = [
        [Paragraph("<b>Week</b>", body_b), Paragraph("<b>Gauge</b>", body_b),
         Paragraph("<b>Blood Flow Rate</b>", body_b), Paragraph("<b>Key Actions</b>", body_b)],
        ["Week 1", "17G",
         "200 – 250 mL/min",
         "• Reduced heparin (50% of ordered dose)\n• If no other access: two 17G needles\n"
         "• If CVC present: 17G arterial + CVC venous\n• Angle 25° insertion, chevron taping\n"
         "• Patient must NOT move access arm\n• Stay ≥1.5–2 inches from anastomosis"],
        ["Week 2", "16G",
         "300 mL/min",
         "• Only if Week 1 was fully successful\n• Rotate cannulation sites\n"
         "• Continue careful monitoring for infiltration"],
        ["Week 3+", "15G → 14G",
         "350 – 450+ mL/min",
         "• Progress toward prescribed BFR and gauge\n• Match gauge to BFR per chart (Section 3)\n"
         "• Continue site rotation (rope-ladder technique)\n• Regular heparin dosing"],
    ]
    
    week_tbl = Table(week_data, colWidths=[2.0*cm, 1.8*cm, 3.5*cm, 10.9*cm])
    week_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), TEAL),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 8.5),
        ("BACKGROUND",    (0,1), (-1,1), colors.HexColor("#FFF8E1")),
        ("BACKGROUND",    (0,2), (-1,2), colors.HexColor("#E8F5E9")),
        ("BACKGROUND",    (0,3), (-1,3), colors.HexColor("#E3F2FD")),
        ("FONTNAME",      (0,1), (0,-1), "Helvetica-Bold"),
        ("TEXTCOLOR",     (0,1), (0,-1), NAVY),
        ("FONTNAME",      (1,1), (1,-1), "Helvetica-Bold"),
        ("FONTSIZE",      (1,1), (1,-1), 11),
        ("TEXTCOLOR",     (1,1), (1,-1), TEAL),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#D0D8E0")),
        ("TOPPADDING",    (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("ALIGN",         (0,1), (1,-1), "CENTER"),
    ]))
    story.append(week_tbl)
    story.append(sp(3))
    
    story.append(danger_box(
        "<b>CATHETER REMOVAL RULE:</b> The central venous catheter (CVC) must NOT be removed until "
        "the patient has had <b>6 CONSECUTIVE SUCCESSFUL</b> arterial/venous needle cannulations "
        "at the prescribed BFR and needle gauge."
    ))
    story.append(sp(3))
    
    # Infiltration protocol
    story.append(Paragraph("Infiltration Management Protocol:", h3))
    infilt_data = [
        [Paragraph("<b>Occurrence</b>", body_b), Paragraph("<b>Action</b>", body_b)],
        ["1st Infiltration", "Rest fistula for 1 week, restart with smaller gauge needles. Notify nephrologist."],
        ["2nd Infiltration", "Rest fistula for 2 weeks, restart with smaller gauge needles. Notify nephrologist."],
        ["3rd Infiltration", "Notify BOTH surgeon and nephrologist. Do not attempt further cannulation."],
    ]
    infilt_tbl = Table(infilt_data, colWidths=[4*cm, 14.2*cm])
    infilt_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), RED),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 9),
        ("BACKGROUND",    (0,1), (-1,1), colors.HexColor("#FFF3CD")),
        ("BACKGROUND",    (0,2), (-1,2), colors.HexColor("#FDDCCA")),
        ("BACKGROUND",    (0,3), (-1,3), RED_LITE),
        ("FONTNAME",      (0,1), (0,-1), "Helvetica-Bold"),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#E0C0C0")),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ]))
    story.append(infilt_tbl)
    story.append(sp(4))
    
    # ── SECTION 5: CANNULATION TECHNIQUES ─────────────────────────────────────
    story.append(section_header("5.  CANNULATION TECHNIQUES (LONG-TERM AVF)"))
    story.append(sp(3))
    
    tech_data = [
        [Paragraph("<b>Technique</b>", body_b),
         Paragraph("<b>Description</b>", body_b),
         Paragraph("<b>Advantages</b>", body_b),
         Paragraph("<b>Disadvantages / Cautions</b>", body_b)],
        [Paragraph("<b>ROPE LADDER</b>\n(RECOMMENDED)", body_b),
         "Cannulation sites rotate along entire length of fistula",
         "Distributes trauma; allows vessel wall recovery; prevents aneurysm formation; most widely recommended",
         "Requires longer usable vein segment; needs staff training in site rotation"],
        [Paragraph("<b>BUTTONHOLE</b>\n(Constant-site)", body_b),
         "Same needle tract used every session; collagen track forms; blunt needle inserted",
         "Reduced pain; less hematoma for suitable patients; good for self-cannulation",
         "HIGH INFECTION RISK (esp. S. aureus); strict asepsis essential; guidelines now more cautious; not suitable for everyone"],
        [Paragraph("<b>AREA PUNCTURE</b>\n(NOT recommended)", body_b),
         "Repeated cannulation in same small zone without a formal buttonhole track",
         "None",
         "HIGH RISK: pseudoaneurysm, stenosis, aneurysm, skin breakdown. Refer to vascular team if identified."],
    ]
    tech_tbl = Table(tech_data, colWidths=[3.5*cm, 4.5*cm, 4.5*cm, 5.7*cm])
    tech_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 8.5),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [GREEN_LITE, AMBER_LITE, RED_LITE]),
        ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#D0D8E0")),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 7),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("BACKGROUND",    (0,1), (0,1), colors.HexColor("#C6EFD0")),
        ("BACKGROUND",    (0,2), (0,2), colors.HexColor("#FFEFD0")),
        ("BACKGROUND",    (0,3), (0,3), colors.HexColor("#FDDCDC")),
    ]))
    story.append(tech_tbl)
    story.append(sp(3))
    
    # ── SECTION 6: SINGLE-NEEDLE / SINGLE-POINT DIALYSIS ──────────────────────
    story.append(section_header("6.  SINGLE-NEEDLE DIALYSIS (LIMITED ACCESS SESSIONS)"))
    story.append(sp(3))
    
    story.append(Paragraph(
        "When a new fistula is too fragile, short, or narrow for two-needle placement, single-needle "
        "dialysis may be used as a bridge during early maturation.", body))
    story.append(sp(2))
    
    sn_points = [
        "Blood is alternately withdrawn and returned through a single needle using a double-pump system or Y-connector",
        "Accepted as a TEMPORARY bridge only - not suitable for ongoing long-term use",
        "Kt/V delivery is REDUCED due to increased access recirculation (less efficient than 2-needle)",
        "Must be physician-ordered and documented",
        "Central venous catheter should remain in place as backup during this period",
        "Progress to 2-needle cannulation as soon as fistula matures sufficiently",
        "Monitor Kt/V each session; increase treatment time to compensate for reduced efficiency if needed",
    ]
    for p in sn_points:
        story.append(bullet_para(p))
    story.append(sp(3))
    
    # ── SECTION 7: GENERAL NEEDLING PRINCIPLES ─────────────────────────────────
    story.append(section_header("7.  GENERAL NEEDLING TECHNIQUE PRINCIPLES"))
    story.append(sp(3))
    
    principles = [
        ("<b>Bevel UP:</b>", "Always insert needle with bevel facing upward"),
        ("<b>Insertion Angle:</b>", "Minimum angle needed to reach vessel depth; aim for needle tip to sit in CENTER of vessel (typically 25-35°)"),
        ("<b>Minimum Distance:</b>", "Always stay ≥1.5 to 2 inches (3.8-5 cm) from the arteriovenous anastomosis"),
        ("<b>Needle Spacing:</b>", "Arterial and venous needles should be ≥5 cm apart to minimize access recirculation"),
        ("<b>No Rotation:</b>", "Do NOT rotate the needle once inserted - causes vessel wall damage ('coring')"),
        ("<b>Securing:</b>", "Secure with chevron or 'H' taping technique; secure tubing separately"),
        ("<b>Tourniquet:</b>", "Apply tourniquet for AVF cannulation; do NOT apply for AV graft"),
        ("<b>Flush:</b>", "Flush needle after insertion to confirm patency and adequate flow before connecting"),
        ("<b>Removal:</b>", "Remove needle at the same angle as insertion; do NOT apply pressure before needle is fully out"),
        ("<b>Pressure:</b>", "Apply pressure for minimum 10 minutes after removal; do not 'peek' during this time"),
        ("<b>Asepsis:</b>", "Strict aseptic technique for all cannulations; cleanse site per local policy"),
    ]
    
    for bold_part, detail in principles:
        story.append(bullet_para(f"{bold_part} {detail}"))
    story.append(sp(3))
    
    # ── SECTION 8: REFERENCES ─────────────────────────────────────────────────
    story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#D0D8E0")))
    story.append(sp(2))
    story.append(Paragraph("REFERENCES & GUIDELINES", h2))
    
    refs = [
        "1. KDOQI 2019 Clinical Practice Guideline for Vascular Access. Am J Kidney Dis. 2019;75(4 Suppl 2):S1–S164.",
        "2. UK VASBI 2018 Clinical Practice Recommendations for Needling of Arteriovenous Fistulae and Grafts for Haemodialysis. "
           "Vascular Access Society of Britain and Ireland, 2018. Available: vasbi.org.uk",
        "3. Karkhah S, Pourshaikhian M, Ghorbani Vajargah P, et al. Needle Direction and Distance of Arteriovenous Fistula "
           "Cannulation in Hemodialysis Adequacy: A Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2023. PMID: 37609532.",
        "4. Midwest Kidney Network. Cannulation of New Fistula – Policy and Procedure (Sample). midwestkidneynetwork.org.",
        "5. Lok CE, Huber TS, Lee T, et al. KDOQI Vascular Access Guideline Work Group. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–S164.",
        "6. Brenner & Rector's The Kidney, 2-Volume Set. Chapter 63: Hemodialysis. Elsevier.",
        "7. Comprehensive Clinical Nephrology, 7th Edition. Chapter: Vascular Access for Hemodialysis. Elsevier.",
        "8. NIH Hemodialysis Fistula Maturation (HFM) Study Group. JAMA. 2016;316(19):1985–1994.",
    ]
    for r in refs:
        story.append(Paragraph(r, ref))
    
    story.append(sp(4))
    story.append(info_box(
        "<b>Disclaimer:</b> This document is a clinical reference summary for educational purposes. "
        "It does not replace institutional protocols, local policies, or individual physician judgment. "
        "Always follow your facility's specific procedures and obtain appropriate physician orders before cannulating any vascular access."
    ))
    
    return story

# ── Page template with header/footer ─────────────────────────────────────────
def on_first_page(canvas, doc):
    pass  # cover handles itself

def on_later_pages(canvas, doc):
    canvas.saveState()
    # Header
    canvas.setFillColor(NAVY)
    canvas.rect(MARGIN, H - 1.4*cm, W - 2*MARGIN, 0.7*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 8)
    canvas.drawString(MARGIN + 5, H - 1.05*cm, "AV FISTULA CANNULATION PROTOCOL")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(W - MARGIN - 5, H - 1.05*cm, "Clinical Reference | KDOQI 2019 | VASBI 2018")
    # Footer
    canvas.setFillColor(LGREY)
    canvas.rect(MARGIN, 0.6*cm, W - 2*MARGIN, 0.5*cm, fill=1, stroke=0)
    canvas.setFillColor(GREY)
    canvas.setFont("Helvetica", 7.5)
    canvas.drawString(MARGIN + 5, 0.78*cm, "For educational use only. Follow institutional protocols.")
    canvas.drawRightString(W - MARGIN - 5, 0.78*cm, f"Page {doc.page}")
    canvas.restoreState()

def on_first_page_template(canvas, doc):
    canvas.saveState()
    # First page footer only
    canvas.setFillColor(LGREY)
    canvas.rect(MARGIN, 0.6*cm, W - 2*MARGIN, 0.5*cm, fill=1, stroke=0)
    canvas.setFillColor(GREY)
    canvas.setFont("Helvetica", 7.5)
    canvas.drawString(MARGIN + 5, 0.78*cm, "For educational use only. Follow institutional protocols.")
    canvas.drawRightString(W - MARGIN - 5, 0.78*cm, "Page 1")
    canvas.restoreState()

# ── Build PDF ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=MARGIN, rightMargin=MARGIN,
    topMargin=1.8*cm, bottomMargin=1.5*cm,
    title="AV Fistula Cannulation Protocol",
    author="Orris Clinical Reference",
    subject="Hemodialysis Vascular Access – Cannulation Guidelines",
)

story = build_story()
doc.build(story, onFirstPage=on_first_page_template, onLaterPages=on_later_pages)
print(f"PDF generated: {OUTPUT}")

cd /home/daytona/workspace/fistula-cannulation && python3 generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/fistula-cannulation/AV_Fistula_Cannulation_Protoc…

mkdir -p /home/daytona/workspace/fistula-pptx && node -e "require('pptxgenjs'); …

~/fistula-pptx/build.js

"use strict";
const pptxgen = require("pptxgenjs");
const path = require("path");

const OUT = "/home/daytona/workspace/fistula-pptx/AV_Fistula_Maturation_Troubleshooting.pptx";

// ── Palette ────────────────────────────────────────────────────────────────
const C = {
  navy:       "1A3A5C",
  teal:       "0D7377",
  tealLight:  "14A085",
  tealPale:   "D6F0EE",
  amber:      "E07B00",
  amberPale:  "FFF4E0",
  red:        "C0392B",
  redPale:    "FDECEA",
  green:      "1B7A4A",
  greenPale:  "E8F5EE",
  purple:     "6C3483",
  purplePale: "F3E8FA",
  white:      "FFFFFF",
  offwhite:   "F4F8FA",
  lgrey:      "E8EDF2",
  grey:       "5A5A5A",
  darkgrey:   "2C3E50",
};

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "AV Fistula Maturation Timeline & Troubleshooting";
pres.author = "Orris Clinical Reference";
pres.subject = "Hemodialysis Vascular Access";

// ── Helper: full dark background ─────────────────────────────────────────
function darkBg(slide, color = C.navy) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color }, line: { color, width: 0 } });
}

// ── Helper: section label pill ────────────────────────────────────────────
function pill(slide, text, x, y, w = 2, color = C.teal) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h: 0.28, fill: { color }, line: { color, width: 0 }, rectRadius: 0.04 });
  slide.addText(text, { x, y: y + 0.01, w, h: 0.26, fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
}

// ── Helper: card (rounded rect with optional accent bar) ─────────────────
function card(slide, x, y, w, h, fillColor = C.white, accentColor = null, shadow = true) {
  slide.addShape(pres.shapes.RECTANGLE, {
    x, y, w, h,
    fill: { color: fillColor },
    line: { color: "D4DEE8", width: 0.5 },
    shadow: shadow ? { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.12 } : undefined,
  });
  if (accentColor) {
    slide.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.06, h, fill: { color: accentColor }, line: { color: accentColor, width: 0 } });
  }
}

// ── Helper: horizontal divider line ──────────────────────────────────────
function hline(slide, x, y, w, color = C.lgrey) {
  slide.addShape(pres.shapes.LINE, { x, y, w, h: 0, line: { color, width: 0.8 } });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s, C.navy);

  // Decorative teal band left
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.55, h: 5.625, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });

  // Accent arc — simulated with semi-transparent circle
  s.addShape(pres.shapes.OVAL, { x: 6.5, y: -1.2, w: 5, h: 5, fill: { color: C.teal, transparency: 85 }, line: { color: C.teal, width: 0 } });
  s.addShape(pres.shapes.OVAL, { x: 7.2, y: -0.4, w: 3.5, h: 3.5, fill: { color: C.tealLight, transparency: 90 }, line: { color: C.tealLight, width: 0 } });

  // Eyebrow
  pill(s, "HEMODIALYSIS VASCULAR ACCESS", 0.8, 0.85, 3.5, C.teal);

  // Main title
  s.addText("AV Fistula Maturation", { x: 0.8, y: 1.22, w: 8.2, h: 0.85, fontSize: 38, bold: true, color: C.white, fontFace: "Calibri", margin: 0 });
  s.addText("Timeline & Troubleshooting", { x: 0.8, y: 1.98, w: 8.2, h: 0.72, fontSize: 38, bold: true, color: "7ECFD6", fontFace: "Calibri", margin: 0 });

  hline(s, 0.8, 2.82, 4.5, C.tealLight);

  s.addText("A comprehensive clinical reference for nephrology teams\nKDOQI 2019  |  VASBI 2018  |  NIH HFM Study", {
    x: 0.8, y: 2.95, w: 6.5, h: 0.6, fontSize: 11.5, color: "9DC8CC", italics: true, margin: 0, lineSpacingMultiple: 1.3
  });

  // Bottom stat cards
  const stats = [
    { val: "25%", label: "Primary failure\nrate" },
    { val: "8–12 wks", label: "Minimum\nmaturation time" },
    { val: "6 mm", label: "Target vein\ndiameter" },
    { val: "600 mL/min", label: "Target blood\nflow rate" },
  ];
  stats.forEach((st, i) => {
    const cx = 0.8 + i * 2.3;
    card(s, cx, 4.0, 2.1, 1.2, "1E4A6A", null, false);
    s.addText(st.val, { x: cx, y: 4.08, w: 2.1, h: 0.45, fontSize: 18, bold: true, color: "7ECFD6", align: "center", margin: 0 });
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  // Slide number
  s.addText("1", { x: 9.6, y: 5.2, w: 0.3, h: 0.2, fontSize: 8, color: "4A7080", align: "right", margin: 0 });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 2 — AGENDA / OVERVIEW
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offwhite }, line: { color: C.offwhite, width: 0 } });

  // Header bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.navy }, line: { color: C.navy, width: 0 } });
  s.addText("PRESENTATION OVERVIEW", { x: 0.35, y: 0, w: 9, h: 0.75, fontSize: 14, bold: true, color: C.white, valign: "middle", margin: 0, charSpacing: 2 });
  s.addText("2", { x: 9.6, y: 0.25, w: 0.3, h: 0.2, fontSize: 8, color: "8AACB8", align: "right", margin: 0 });

  const sections = [
    { num: "01", title: "Fistula Maturation Timeline",   sub: "Week-by-week physiological changes and clinical milestones",  color: C.teal },
    { num: "02", title: "Maturation Criteria",           sub: "Rule of 6s, KDOQI 2019 updates, readiness assessment",       color: C.navy },
    { num: "03", title: "Cannulation Progression",       sub: "First cannulation protocol, needle gauge, BFR matching",     color: C.tealLight },
    { num: "04", title: "Troubleshooting: Failure to Mature", sub: "Causes, assessment, and intervention strategies",        color: C.amber },
    { num: "05", title: "Access Complications",          sub: "Stenosis, thrombosis, aneurysm, infection — recognition & management", color: C.red },
    { num: "06", title: "Monitoring & Surveillance",     sub: "Physical exam, flow monitoring, warning signs",               color: C.green },
    { num: "07", title: "Key References",                sub: "KDOQI 2019, VASBI 2018, NIH HFM Study, Karkhah 2023",       color: C.grey },
  ];

  sections.forEach((sec, i) => {
    const row = Math.floor(i / 2);
    const col = i % 2;
    // last item spans full width
    const isLast = i === sections.length - 1;
    const cx = isLast ? 0.3 : 0.3 + col * 4.85;
    const cy = 0.95 + row * 1.05;
    const cw = isLast ? 9.4 : 4.6;

    card(s, cx, cy, cw, 0.85, C.white, sec.color);
    s.addText(sec.num, { x: cx + 0.15, y: cy + 0.05, w: 0.55, h: 0.35, fontSize: 16, bold: true, color: sec.color, margin: 0 });
    s.addText(sec.title, { x: cx + 0.72, y: cy + 0.04, w: cw - 0.85, h: 0.35, fontSize: 11, bold: true, color: C.darkgrey, margin: 0 });
    s.addText(sec.sub,   { x: cx + 0.72, y: cy + 0.41, w: cw - 0.85, h: 0.3,  fontSize: 8.5, color: C.grey, margin: 0 });
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 3 — MATURATION TIMELINE (visual)
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s, "0F2233");

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
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  s.addText("3", { x: 9.6, y: 0.25, w: 0.3, h: 0.2, fontSize: 8, color: "4A8090", align: "right", margin: 0 });

  // Timeline spine line
  s.addShape(pres.shapes.LINE, { x: 0.55, y: 3.12, w: 8.9, h: 0, line: { color: C.teal, width: 2 } });

  // Milestone nodes
  const milestones = [
    { x: 0.55, week: "Day 0\nSurgery",    color: C.amber,
      top: ["Arteriovenous\nanastomosis created", "Immediate\narterialization\nbegins"],
      bot: ["Radial/brachial\nartery → cephalic/\nbasilic vein", "DO NOT cannulate"] },
    { x: 2.4,  week: "Wk 1–2",    color: C.tealLight,
      top: ["Venous wall\nthickening begins", "Lumen diameter\nstarts expanding"],
      bot: ["Vein must adapt\nto arterial pressure", "Observe only"] },
    { x: 4.25, week: "Wk 3–4",    color: C.tealLight,
      top: ["Visible vein\ncordification", "Blood flow\n↑ 5–10×"],
      bot: ["Physical exam\nshows thrill + bruit", "Assess maturation"] },
    { x: 6.1,  week: "Wk 6–8",    color: C.green,
      top: ["Vein wall\nfully muscularized", "Diameter ≥6 mm\nin many patients"],
      bot: ["Earliest possible\nfirst cannulation", "Only with MD order"] },
    { x: 7.95, week: "Wk 8–12",   color: C.green,
      top: ["Optimal maturation\nwindow", "Flow ≥600 mL/min\nexpected"],
      bot: ["Standard first\ncannulation target", "Start 17G, 200 mL/min"] },
  ];

  milestones.forEach((m) => {
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    });

    // Bottom content (below week label)
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    });
  });

  // Arrow at end of timeline
  s.addShape(pres.shapes.RIGHT_ARROW, { x: 9.45, y: 3.0, w: 0.42, h: 0.28, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });

  // Footer note
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.27, w: 10, h: 0.36, fill: { color: "0A1A2A" }, line: { color: "0A1A2A", width: 0 } });
  s.addText("⚠  Early cannulation (<6 weeks) is associated with higher failure rates. Never cannulate without surgeon/nephrologist approval.", {
    x: 0.3, y: 5.27, w: 9.4, h: 0.36, fontSize: 8, color: "F0A830", valign: "middle", italics: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 4 — MATURATION CRITERIA
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offwhite }, line: { color: C.offwhite, width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.navy }, line: { color: C.navy, width: 0 } });
  s.addText("MATURATION CRITERIA", { x: 0.35, y: 0, w: 8, h: 0.72, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  pill(s, "SECTION 02", 8.5, 0.22, 1.2, C.teal);
  s.addText("4", { x: 9.6, y: 0.5, w: 0.3, h: 0.2, fontSize: 8, color: "8AACB8", align: "right", margin: 0 });

  // Left column — Rule of 6s
  card(s, 0.3, 0.88, 4.5, 3.2, C.white, C.teal);
  s.addText("CLASSIC RULE OF 6s", { x: 0.5, y: 0.96, w: 4.1, h: 0.34, fontSize: 11, bold: true, color: C.teal, margin: 0 });

  const rule6 = [
    { icon: "⌀", label: "Vein Diameter",    val: "≥ 6 mm",          note: "Ultrasound measurement" },
    { icon: "💧", label: "Blood Flow Rate",  val: "≥ 600 mL/min",    note: "NIH HFM Study target" },
    { icon: "↕", label: "Depth Below Skin", val: "≤ 6 mm",           note: "Ideally ≤ 2 mm" },
    { icon: "⏱", label: "Maturation Time",  val: "≥ 6 weeks",        note: "8–12 weeks preferred" },
    { icon: "↔", label: "Usable Length",    val: "≥ 6 cm",           note: "For two-needle placement" },
  ];
  rule6.forEach((r, i) => {
    const ry = 1.42 + i * 0.5;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.5, y: ry, w: 4.1, h: 0.42, fill: { color: i % 2 === 0 ? C.tealPale : C.white }, line: { color: "D4E8E6", width: 0.3 } });
    s.addText(r.label, { x: 0.62, y: ry + 0.04, w: 1.8, h: 0.18, fontSize: 8.5, bold: true, color: C.darkgrey, margin: 0 });
    s.addText(r.note,  { x: 0.62, y: ry + 0.22, w: 1.8, h: 0.16, fontSize: 7,   color: C.grey, margin: 0, italics: true });
    s.addText(r.val,   { x: 2.5,  y: ry + 0.07, w: 2.0, h: 0.28, fontSize: 11,  bold: true, color: C.teal, align: "right", margin: 0 });
  });

  // Right column — KDOQI 2019 update + Functional maturity
  card(s, 5.1, 0.88, 4.6, 1.48, C.amberPale, C.amber);
  s.addText("KDOQI 2019 UPDATE", { x: 5.3, y: 0.96, w: 4.2, h: 0.3, fontSize: 11, bold: true, color: C.amber, margin: 0 });
  s.addText([
    { text: "The NIH HFM Study found that meeting the Rule of 6s\nproduces successful maturation in only ", options: {} },
    { text: "~50% of cases.", options: { bold: true, color: C.red } },
    { text: "\nGreater depth (>2 mm) significantly worsens outcomes.\nCannulation readiness requires physician judgment\nbeyond the Rule of 6s alone.", options: {} }
  ], { x: 5.3, y: 1.32, w: 4.2, h: 1.0, fontSize: 8.5, color: C.darkgrey, margin: 0, lineSpacingMultiple: 1.35 });

  card(s, 5.1, 2.5, 4.6, 1.1, C.tealPale, C.teal);
  s.addText("FUNCTIONAL MATURITY (KDOQI 2019)", { x: 5.3, y: 2.58, w: 4.2, h: 0.3, fontSize: 10, bold: true, color: C.teal, margin: 0 });
  s.addText("Fistula provides prescribed dialysis consistently\nwith 2 needles for >2/3 of sessions\nwithin 4 consecutive weeks.", {
    x: 5.3, y: 2.92, w: 4.2, h: 0.65, fontSize: 9, color: C.darkgrey, margin: 0, lineSpacingMultiple: 1.4
  });

  card(s, 5.1, 3.75, 4.6, 0.98, C.greenPale, C.green);
  s.addText("AV GRAFT — DIFFERENT TIMELINE", { x: 5.3, y: 3.82, w: 4.2, h: 0.28, fontSize: 10, bold: true, color: C.green, margin: 0 });
  s.addText("Standard graft: 2–4 weeks post-insertion\nEarly cannulation graft: within 24 hours\n(per manufacturer instructions)", {
    x: 5.3, y: 4.12, w: 4.2, h: 0.57, fontSize: 8.5, color: C.darkgrey, margin: 0, lineSpacingMultiple: 1.35
  });

  // Pre-cannulation exam bottom
  card(s, 0.3, 4.15, 4.5, 1.1, C.white, C.navy);
  s.addText("PRE-CANNULATION PHYSICAL EXAM", { x: 0.5, y: 4.22, w: 4.1, h: 0.28, fontSize: 9.5, bold: true, color: C.navy, margin: 0 });
  const exam = ["LOOK: hematoma, infection, skin changes", "FEEL: continuous soft thrill along fistula", "LISTEN: low-pitched machinery bruit", "ARM ELEVATION: partial collapse = good outflow"];
  exam.forEach((e, i) => {
    s.addText("• " + e, { x: 0.55, y: 4.54 + i * 0.16, w: 4.0, h: 0.17, fontSize: 7.8, color: C.grey, margin: 0 });
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 5 — CANNULATION PROGRESSION + GAUGE CHART
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "0C1E2E" }, line: { color: "0C1E2E", width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.68, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
  s.addText("CANNULATION PROGRESSION PROTOCOL", { x: 0.35, y: 0, w: 8.5, h: 0.68, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  pill(s, "SECTION 03", 8.5, 0.2, 1.2, C.navy);
  s.addText("5", { x: 9.6, y: 0.48, w: 0.3, h: 0.2, fontSize: 8, color: "4A8090", align: "right", margin: 0 });

  // Week progression steps (left side)
  const weeks = [
    { wk: "WK 1",  g: "17G",  bfr: "200–250 mL/min", color: C.amber,
      notes: ["50% heparin dose (prevent hematoma)", "Two 17G if no other access; CVC as venous if available", "Stay ≥1.5–2 inches from anastomosis, 25° angle", "Chevron taping; no arm movement during treatment"] },
    { wk: "WK 2",  g: "16G",  bfr: "300 mL/min",      color: C.tealLight,
      notes: ["Only if Week 1 fully successful (no infiltration)", "Begin rotating cannulation sites (rope ladder)", "Continue monitoring for hematoma, pain, swelling"] },
    { wk: "WK 3+", g: "15–14G", bfr: "350–450+ mL/min", color: C.green,
      notes: ["Progress toward prescribed gauge and BFR", "Full heparin dosing", "Transition to 2-needle only when consistent success"] },
  ];

  weeks.forEach((w, i) => {
    const wy = 0.88 + i * 1.48;
    card(s, 0.3, wy, 5.9, 1.32, "122435", null, false);
    s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: wy, w: 0.06, h: 1.32, fill: { color: w.color }, line: { color: w.color, width: 0 } });

    // Week badge
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.5, y: wy + 0.1, w: 0.7, h: 0.3, fill: { color: w.color }, line: { color: w.color, width: 0 }, rectRadius: 0.04 });
    s.addText(w.wk, { x: 0.5, y: wy + 0.1, w: 0.7, h: 0.3, fontSize: 8, bold: true, color: "0C1E2E", align: "center", valign: "middle", margin: 0 });

    // Gauge
    s.addText(w.g, { x: 1.28, y: wy + 0.06, w: 1.1, h: 0.44, fontSize: 20, bold: true, color: w.color, margin: 0 });
    s.addText(w.bfr, { x: 2.45, y: wy + 0.12, w: 2.6, h: 0.34, fontSize: 10, color: "9DC8CC", bold: true, margin: 0 });

    w.notes.forEach((n, ni) => {
      s.addText("• " + n, { x: 0.5, y: wy + 0.56 + ni * 0.185, w: 5.55, h: 0.19, fontSize: 7.8, color: "8AACB8", margin: 0 });
    });
  });

  // Right: Gauge-BFR chart
  card(s, 6.45, 0.88, 3.25, 3.45, "122435", null, false);
  s.addShape(pres.shapes.RECTANGLE, { x: 6.45, y: 0.88, w: 3.25, h: 0.36, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
  s.addText("NEEDLE GAUGE vs BFR", { x: 6.55, y: 0.88, w: 3.05, h: 0.36, fontSize: 9.5, bold: true, color: C.white, valign: "middle", margin: 0, charSpacing: 1 });

  const gaugeRows = [
    { bfr: "< 300 mL/min",    g: "17G", bar: 1.5, color: C.amber },
    { bfr: "300–350 mL/min",  g: "16G", bar: 2.0, color: C.tealLight },
    { bfr: "350–450 mL/min",  g: "15G", bar: 2.5, color: C.green },
    { bfr: "> 450 mL/min",    g: "14G", bar: 3.0, color: "8B5CF6" },
  ];
  gaugeRows.forEach((gr, i) => {
    const gy = 1.35 + i * 0.74;
    s.addText(gr.bfr, { x: 6.55, y: gy, w: 2.8, h: 0.22, fontSize: 8, color: "9DC8CC", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 6.55, y: gy + 0.25, w: gr.bar, h: 0.26, fill: { color: gr.color }, line: { color: gr.color, width: 0 } });
    s.addText(gr.g, { x: 6.55 + gr.bar + 0.08, y: gy + 0.26, w: 0.55, h: 0.24, fontSize: 12, bold: true, color: gr.color, margin: 0 });
  });

  // CVC removal rule
  s.addShape(pres.shapes.RECTANGLE, { x: 6.45, y: 4.5, w: 3.25, h: 0.83, fill: { color: C.redPale }, line: { color: C.red, width: 1 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 6.45, y: 4.5, w: 0.06, h: 0.83, fill: { color: C.red }, line: { color: C.red, width: 0 } });
  s.addText("CATHETER REMOVAL RULE", { x: 6.6, y: 4.54, w: 3.0, h: 0.24, fontSize: 9, bold: true, color: C.red, margin: 0 });
  s.addText("Do NOT remove CVC until patient has had\n6 CONSECUTIVE SUCCESSFUL cannulations\nat prescribed BFR and needle gauge.", {
    x: 6.6, y: 4.78, w: 3.0, h: 0.5, fontSize: 7.8, color: C.darkgrey, margin: 0, lineSpacingMultiple: 1.3
  });

  // Infiltration rule bottom-left
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 4.5, w: 5.9, h: 0.83, fill: { color: "122435" }, line: { color: C.amber, width: 0.75 } });
  s.addText("INFILTRATION ESCALATION", { x: 0.48, y: 4.54, w: 2.5, h: 0.24, fontSize: 9, bold: true, color: C.amber, margin: 0 });
  const infilt = ["1st: Rest 1 week → restart with smaller gauge", "2nd: Rest 2 weeks → restart with smaller gauge", "3rd: Notify surgeon + nephrologist — STOP cannulation"];
  infilt.forEach((inf, ii) => {
    s.addText(`${ii + 1}. ${inf}`, { x: 0.48, y: 4.78 + ii * 0.17, w: 5.6, h: 0.18, fontSize: 7.8, color: ii === 2 ? C.red : "9DC8CC", margin: 0 });
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 6 — FAILURE TO MATURE: CAUSES & INTERVENTIONS
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offwhite }, line: { color: C.offwhite, width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: C.amber }, line: { color: C.amber, width: 0 } });
  s.addText("TROUBLESHOOTING: FAILURE TO MATURE", { x: 0.35, y: 0, w: 8.5, h: 0.7, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  pill(s, "SECTION 04", 8.5, 0.21, 1.2, C.navy);
  s.addText("6", { x: 9.6, y: 0.48, w: 0.3, h: 0.2, fontSize: 8, color: "8AACB8", align: "right", margin: 0 });

  // Stat callouts at top
  const ftmStats = [
    { val: "25%", desc: "Primary non-maturation\nrate overall" },
    { val: "+25%", desc: "Need intervention to\nfacilitate maturation" },
    { val: "4–6 wks", desc: "Assess if no change\non physical exam" },
  ];
  ftmStats.forEach((st, i) => {
    card(s, 0.3 + i * 3.15, 0.82, 2.95, 0.92, C.white, C.amber);
    s.addText(st.val, { x: 0.5 + i * 3.15, y: 0.88, w: 2.55, h: 0.4, fontSize: 22, bold: true, color: C.amber, align: "center", margin: 0 });
    s.addText(st.desc, { x: 0.5 + i * 3.15, y: 1.26, w: 2.55, h: 0.38, fontSize: 8, color: C.grey, align: "center", margin: 0, lineSpacingMultiple: 1.2 });
  });

  // Left: Causes
  card(s, 0.3, 1.86, 4.45, 3.44, C.white, C.red);
  s.addText("CAUSES OF NON-MATURATION", { x: 0.5, y: 1.93, w: 4.05, h: 0.3, fontSize: 10.5, bold: true, color: C.red, margin: 0 });

  const causes = [
    { cat: "Inflow Problem",  items: ["Arterial inflow stenosis (most common)", "Kinking at anastomosis", "Low-output cardiac state"] },
    { cat: "Outflow Problem", items: ["Accessory/competing veins (blood steal)", "Central venous stenosis (prior CVC)", "Early venous stenosis/stricture"] },
    { cat: "Vein Issues",     items: ["Small caliber vein (<2 mm pre-op)", "Scarred or previously accessed vein", "Deep vein (>6 mm depth)"] },
    { cat: "Patient Factors", items: ["Diabetes / peripheral vascular disease", "Female sex, obesity, older age", "Prior ipsilateral CVC placement"] },
  ];
  let cy2 = 2.3;
  causes.forEach((c) => {
    s.addText(c.cat, { x: 0.5, y: cy2, w: 4.05, h: 0.22, fontSize: 8.5, bold: true, color: C.darkgrey, margin: 0 });
    cy2 += 0.23;
    c.items.forEach((item) => {
      s.addText("– " + item, { x: 0.65, y: cy2, w: 3.9, h: 0.19, fontSize: 8, color: C.grey, margin: 0 });
      cy2 += 0.2;
    });
    cy2 += 0.07;
  });

  // Right: Assessment + Intervention
  card(s, 4.95, 1.86, 4.75, 1.6, C.white, C.teal);
  s.addText("ASSESSMENT", { x: 5.15, y: 1.93, w: 4.35, h: 0.28, fontSize: 10.5, bold: true, color: C.teal, margin: 0 });
  const assess = [
    "Physical exam at 4–6 weeks post-creation",
    "Duplex ultrasound: flow, diameter, depth, stenosis",
    "Fistulography (gold standard for anatomical detail)",
    "Identify inflow vs outflow problem",
    "Check for accessory veins (competing outflow)",
  ];
  assess.forEach((a, ai) => {
    s.addText("• " + a, { x: 5.15, y: 2.26 + ai * 0.2, w: 4.35, h: 0.2, fontSize: 8, color: C.grey, margin: 0 });
  });

  card(s, 4.95, 3.6, 4.75, 1.7, C.white, C.green);
  s.addText("INTERVENTIONS", { x: 5.15, y: 3.68, w: 4.35, h: 0.28, fontSize: 10.5, bold: true, color: C.green, margin: 0 });
  const interventions = [
    { item: "Accessory vein ligation",     detail: "Redirects flow to main fistula vein" },
    { item: "Percutaneous balloon angioplasty", detail: "For inflow/outflow stenosis" },
    { item: "Surgical revision",           detail: "Anastomosis revision or jump graft" },
    { item: "Superficialization",          detail: "For deep veins (>6 mm depth)" },
    { item: "Maturation assist devices",   detail: "External banding for high-flow fistulas" },
  ];
  interventions.forEach((inv, ii) => {
    s.addText(inv.item, { x: 5.15, y: 4.02 + ii * 0.24, w: 2.4, h: 0.22, fontSize: 8, bold: true, color: C.darkgrey, margin: 0 });
    s.addText(inv.detail, { x: 7.55, y: 4.02 + ii * 0.24, w: 2.05, h: 0.22, fontSize: 7.5, color: C.grey, margin: 0, italics: true });
  });

  // KDOQI 1-2-3 rule
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 5.28, w: 9.4, h: 0.25, fill: { color: C.amberPale }, line: { color: C.amber, width: 0.75 } });
  s.addText("KDOQI 2019  \"1-2-3\" Rule:  For each 1 AV access creation → ≤2 interventions to facilitate use → ≤3 interventions to maintain use per year", {
    x: 0.5, y: 5.28, w: 9.2, h: 0.25, fontSize: 7.8, color: C.amber, valign: "middle", margin: 0, bold: true
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 7 — ACCESS COMPLICATIONS
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s, "0C1625");

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: C.red }, line: { color: C.red, width: 0 } });
  s.addText("ACCESS COMPLICATIONS: RECOGNITION & MANAGEMENT", { x: 0.35, y: 0, w: 8.5, h: 0.7, fontSize: 13, bold: true, color: C.white, valign: "middle", charSpacing: 1.5, margin: 0 });
  pill(s, "SECTION 05", 8.5, 0.21, 1.2, C.navy);
  s.addText("7", { x: 9.6, y: 0.48, w: 0.3, h: 0.2, fontSize: 8, color: "4A5060", align: "right", margin: 0 });

  const complications = [
    {
      title: "STENOSIS", color: C.red,
      sx: ["Weak/discontinuous thrill", "High-pitched bruit", "Swelling of arm/hand", "Prolonged bleeding post-needling"],
      mx: ["Duplex US first-line", "Fistulography for confirmation", "Percutaneous angioplasty", "Surgical revision if recurrent"]
    },
    {
      title: "THROMBOSIS", color: C.amber,
      sx: ["Loss of thrill/bruit", "Pulsatile (not thrill)", "Pain/tenderness", "No blood on needling"],
      mx: ["Urgent referral (<24h)", "Thrombectomy/thrombolysis", "Treat underlying stenosis", "New access if not salvageable"]
    },
    {
      title: "ANEURYSM", color: C.purple,
      sx: ["Focal bulging/pulsatile mass", "Skin thinning/discoloration", "Area puncture pattern", "Rapid expansion"],
      mx: ["Avoid further cannulation in area", "Monitor with US", "Surgical repair if skin breaking down", "Switch to rope ladder technique"]
    },
    {
      title: "INFECTION", color: C.green,
      sx: ["Redness, warmth, swelling", "Purulent discharge", "Fever, bacteremia", "Tenderness at cannulation site"],
      mx: ["Blood cultures first", "IV antibiotics (anti-staph)", "Avoid buttonhole technique", "Surgical debridement if abscess"]
    },
  ];

  const cols = [
    { x: 0.3, y: 0.85 },
    { x: 5.15, y: 0.85 },
    { x: 0.3, y: 3.2 },
    { x: 5.15, y: 3.2 },
  ];

  complications.forEach((comp, i) => {
    const { x, y } = cols[i];
    const cw = 4.65;
    const ch = 2.15;

    card(s, x, y, cw, ch, "162030", null, false);
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: cw, h: 0.36, fill: { color: comp.color }, line: { color: comp.color, width: 0 } });
    s.addText(comp.title, { x: x + 0.12, y, w: cw - 0.2, h: 0.36, fontSize: 11, bold: true, color: C.white, valign: "middle", charSpacing: 1.5, margin: 0 });

    s.addText("SIGNS", { x: x + 0.12, y: y + 0.44, w: 2.0, h: 0.22, fontSize: 8.5, bold: true, color: comp.color, margin: 0 });
    comp.sx.forEach((sx, si) => {
      s.addText("• " + sx, { x: x + 0.12, y: y + 0.66 + si * 0.19, w: 2.1, h: 0.19, fontSize: 7.8, color: "9DB5C8", margin: 0 });
    });

    s.addShape(pres.shapes.LINE, { x: x + 2.38, y: y + 0.44, w: 0, h: ch - 0.56, line: { color: "2A3A4A", width: 0.5 } });

    s.addText("MANAGEMENT", { x: x + 2.52, y: y + 0.44, w: 2.0, h: 0.22, fontSize: 8.5, bold: true, color: C.teal, margin: 0 });
    comp.mx.forEach((mx, mi) => {
      s.addText("→ " + mx, { x: x + 2.52, y: y + 0.66 + mi * 0.19, w: 2.02, h: 0.19, fontSize: 7.8, color: "9DC8CC", margin: 0 });
    });
  });

  // Footer
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.33, w: 10, h: 0.3, fill: { color: "080E18" }, line: { color: "080E18", width: 0 } });
  s.addText("Steal syndrome (ischemic hand): Pain/pallor/pulselessness distal to fistula — urgent vascular referral required.", {
    x: 0.3, y: 5.33, w: 9.4, h: 0.3, fontSize: 8, color: C.red, valign: "middle", italics: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 8 — MONITORING & SURVEILLANCE
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offwhite }, line: { color: C.offwhite, width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: C.green }, line: { color: C.green, width: 0 } });
  s.addText("MONITORING & SURVEILLANCE", { x: 0.35, y: 0, w: 8.5, h: 0.7, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  pill(s, "SECTION 06", 8.5, 0.21, 1.2, C.teal);
  s.addText("8", { x: 9.6, y: 0.48, w: 0.3, h: 0.2, fontSize: 8, color: "8AACB8", align: "right", margin: 0 });

  // Physical exam column
  card(s, 0.3, 0.85, 4.5, 4.42, C.white, C.green);
  s.addText("PRE-DIALYSIS PHYSICAL EXAM", { x: 0.5, y: 0.93, w: 4.1, h: 0.3, fontSize: 10.5, bold: true, color: C.green, margin: 0 });
  s.addText("Perform at every session before cannulation", { x: 0.5, y: 1.26, w: 4.1, h: 0.22, fontSize: 8, italics: true, color: C.grey, margin: 0 });

  const examSteps = [
    { step: "LOOK",   detail: "Skin integrity, bruising, redness, swelling, wound or discharge, aneurysmal dilation, skin thinning" },
    { step: "FEEL",   detail: "Continuous soft thrill over entire fistula (absence = thrombosis or severe stenosis). Check pulse augmentation." },
    { step: "LISTEN", detail: "Low-pitched continuous machinery bruit. High-pitched or systolic-only = stenosis upstream from stethoscope." },
    { step: "ELEVATE",detail: "Raise arm above heart level. Normal fistula partially collapses. Failure to collapse = outflow obstruction." },
    { step: "AUGMENT",detail: "Compress fistula proximally. Increased bounce distally = good arterial inflow. Absent = inflow stenosis." },
  ];
  examSteps.forEach((e, i) => {
    const ey = 1.56 + i * 0.7;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.5, y: ey, w: 0.85, h: 0.26, fill: { color: C.green }, line: { color: C.green, width: 0 }, rectRadius: 0.04 });
    s.addText(e.step, { x: 0.5, y: ey, w: 0.85, h: 0.26, fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    s.addText(e.detail, { x: 1.45, y: ey - 0.04, w: 3.25, h: 0.52, fontSize: 7.8, color: C.grey, margin: 0, lineSpacingMultiple: 1.25 });
  });

  // Right: surveillance + warning signs
  card(s, 5.1, 0.85, 4.6, 2.18, C.white, C.teal);
  s.addText("FLOW SURVEILLANCE (KDOQI 2019)", { x: 5.3, y: 0.93, w: 4.2, h: 0.3, fontSize: 10.5, bold: true, color: C.teal, margin: 0 });
  s.addText("Kt/V and URR at least monthly (minimum Kt/V ≥1.2 per session)", { x: 5.3, y: 1.28, w: 4.2, h: 0.22, fontSize: 8.5, color: C.grey, margin: 0 });
  const surveillance = [
    "Access flow measurement (Qa) at regular intervals",
    "Qa <600 mL/min or >25% decrease: refer for imaging",
    "Static venous pressure >0.5 of mean arterial pressure: stenosis likely",
    "Pre-pump arterial pressure increasingly negative: inflow problem",
    "Clinical exam is primary; flow-based surveillance supplements it",
  ];
  surveillance.forEach((sv, si) => {
    s.addText("• " + sv, { x: 5.3, y: 1.54 + si * 0.265, w: 4.2, h: 0.25, fontSize: 8, color: C.grey, margin: 0 });
  });

  card(s, 5.1, 3.18, 4.6, 2.09, C.white, C.red);
  s.addText("WARNING SIGNS — ACT IMMEDIATELY", { x: 5.3, y: 3.26, w: 4.2, h: 0.3, fontSize: 10, bold: true, color: C.red, margin: 0 });
  const warnings = [
    ["Loss of thrill or bruit", "→ thrombosis until proven otherwise"],
    ["Sudden arm swelling",     "→ central venous stenosis / thrombosis"],
    ["Hand pain/pallor/cold",   "→ steal syndrome — urgent referral"],
    ["Fever + access tenderness","→ infected access — blood cultures now"],
    ["Skin necrosis over access","→ stop cannulation, vascular referral"],
  ];
  warnings.forEach((w, wi) => {
    s.addText("⚠ " + w[0], { x: 5.3, y: 3.62 + wi * 0.32, w: 2.4, h: 0.28, fontSize: 7.8, bold: true, color: C.red, margin: 0 });
    s.addText(w[1],         { x: 7.7, y: 3.62 + wi * 0.32, w: 1.85, h: 0.28, fontSize: 7.5, color: C.grey, margin: 0, italics: true });
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 9 — CANNULATION TECHNIQUES COMPARISON
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "0C1625" }, line: { color: "0C1625", width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
  s.addText("CANNULATION TECHNIQUES", { x: 0.35, y: 0, w: 8.5, h: 0.7, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  s.addText("9", { x: 9.6, y: 0.48, w: 0.3, h: 0.2, fontSize: 8, color: "4A8090", align: "right", margin: 0 });

  const techniques = [
    {
      name: "ROPE LADDER", badge: "RECOMMENDED", badgeColor: C.green, color: C.green,
      desc: "Cannulation sites rotate systematically along the entire length of the fistula vein.",
      pros: ["Distributes puncture trauma evenly", "Allows vessel wall recovery between sessions", "Prevents focal aneurysm formation", "Reduces stenosis risk", "Most widely guideline-recommended"],
      cons: ["Requires longer usable vein segment (≥6 cm)", "Needs careful site mapping and rotation discipline"],
      x: 0.3,
    },
    {
      name: "BUTTONHOLE", badge: "USE WITH CAUTION", badgeColor: C.amber, color: C.amber,
      desc: "Same exact needle tract used every session. A collagen track forms; blunt needle used for ongoing cannulation.",
      pros: ["Reduced pain at cannulation sites", "Lower hematoma rate for suited patients", "Good option for self-cannulation"],
      cons: ["HIGH infection risk (esp. S. aureus / MRSA)", "Strict aseptic technique is mandatory", "Not suitable for all patients", "Guidelines increasingly cautious about routine use"],
      x: 3.55,
    },
    {
      name: "AREA PUNCTURE", badge: "AVOID", badgeColor: C.red, color: C.red,
      desc: "Repeated cannulation in the same small zone without a formal buttonhole track.",
      pros: ["None"],
      cons: ["High risk of pseudoaneurysm formation", "Leads to stenosis and aneurysm", "Skin breakdown and rupture risk", "Refer to vascular team if identified"],
      x: 6.8,
    },
  ];

  techniques.forEach((t) => {
    const cw = t.name === "AREA PUNCTURE" ? 2.9 : 3.05;
    const ch = 4.55;

    card(s, t.x, 0.85, cw, ch, "142030", null, false);
    s.addShape(pres.shapes.RECTANGLE, { x: t.x, y: 0.85, w: cw, h: 0.06, fill: { color: t.color }, line: { color: t.color, width: 0 } });

    // Badge
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: t.x + 0.1, y: 0.97, w: cw - 0.2, h: 0.28, fill: { color: t.badgeColor }, line: { color: t.badgeColor, width: 0 }, rectRadius: 0.04 });
    s.addText(t.badge, { x: t.x + 0.1, y: 0.97, w: cw - 0.2, h: 0.28, fontSize: 8, bold: true, color: "0C1625", align: "center", valign: "middle", margin: 0, charSpacing: 1 });

    s.addText(t.name, { x: t.x + 0.12, y: 1.34, w: cw - 0.22, h: 0.32, fontSize: 13, bold: true, color: t.color, margin: 0 });

    s.addText(t.desc, { x: t.x + 0.12, y: 1.7, w: cw - 0.22, h: 0.6, fontSize: 7.8, color: "9DB5C8", margin: 0, lineSpacingMultiple: 1.3 });

    hline(s, t.x + 0.12, 2.36, cw - 0.24, "2A3A4A");

    s.addText("✓ ADVANTAGES", { x: t.x + 0.12, y: 2.42, w: cw - 0.22, h: 0.22, fontSize: 8.5, bold: true, color: C.green, margin: 0 });
    t.pros.forEach((p, pi) => {
      s.addText("+ " + p, { x: t.x + 0.12, y: 2.66 + pi * 0.2, w: cw - 0.22, h: 0.2, fontSize: 7.5, color: C.greenPale === "E8F5EE" ? "70BF8A" : C.greenPale, margin: 0 });
    });

    const consY = 2.66 + t.pros.length * 0.2 + 0.12;
    s.addText("✗ DISADVANTAGES", { x: t.x + 0.12, y: consY, w: cw - 0.22, h: 0.22, fontSize: 8.5, bold: true, color: C.red, margin: 0 });
    t.cons.forEach((c, ci) => {
      s.addText("– " + c, { x: t.x + 0.12, y: consY + 0.24 + ci * 0.2, w: cw - 0.22, h: 0.2, fontSize: 7.5, color: "C08080", margin: 0 });
    });
  });

  // Footer
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.36, w: 10, h: 0.265, fill: { color: "070E1A" }, line: { color: "070E1A", width: 0 } });
  s.addText("Single-needle dialysis: acceptable as a bridge during early maturation only. Lower Kt/V — increase session time to compensate. Keep CVC in situ.", {
    x: 0.3, y: 5.36, w: 9.4, h: 0.265, fontSize: 7.8, color: "6A9AB0", valign: "middle", italics: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════════════
// SLIDE 10 — REFERENCES + SUMMARY
// ══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s, C.navy);

  s.addShape(pres.shapes.OVAL, { x: 7.2, y: 3.5, w: 4.5, h: 4.5, fill: { color: C.teal, transparency: 88 }, line: { color: C.teal, width: 0 } });
  s.addShape(pres.shapes.OVAL, { x: -1.5, y: -0.8, w: 4, h: 4, fill: { color: C.tealLight, transparency: 90 }, line: { color: C.tealLight, width: 0 } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.68, fill: { color: C.teal }, line: { color: C.teal, width: 0 } });
  s.addText("KEY TAKEAWAYS & REFERENCES", { x: 0.35, y: 0, w: 8.5, h: 0.68, fontSize: 14, bold: true, color: C.white, valign: "middle", charSpacing: 2, margin: 0 });
  pill(s, "SECTION 07", 8.5, 0.2, 1.2, C.navy);
  s.addText("10", { x: 9.5, y: 0.47, w: 0.35, h: 0.2, fontSize: 8, color: "4A8090", align: "right", margin: 0 });

  // Takeaways
  s.addText("KEY TAKEAWAYS", { x: 0.3, y: 0.85, w: 4.5, h: 0.3, fontSize: 11, bold: true, color: "7ECFD6", margin: 0, charSpacing: 1 });

  const takeaways = [
    "Never cannulate a new AVF without surgeon/nephrologist order and ≥8 weeks maturation",
    "Rule of 6s is a guide only — KDOQI 2019 confirms 50% success rate even when criteria met",
    "Arterial needle: retrograde (toward anastomosis). Venous needle: antegrade (toward heart)",
    "Match needle gauge to BFR: 17G → 16G → 15G → 14G. Progress weekly, only if no complications",
    "Rope ladder technique is the safest long-term strategy; avoid area puncture entirely",
    "Buttonhole technique carries high infection risk — use cautiously with strict asepsis",
    "6 consecutive successful cannulations required before removing central venous catheter",
    "Failure to mature rate is 25%; 25% more need intervention. Assess with duplex US at 4–6 weeks if no progress",
    "Thrombosis = loss of thrill → urgent referral within 24 hours. Every hour matters.",
    "Steal syndrome (hand ischemia) requires immediate vascular referral",
  ];

  takeaways.forEach((t, i) => {
    s.addText(`${i + 1}. ${t}`, { x: 0.3, y: 1.22 + i * 0.38, w: 5.6, h: 0.35, fontSize: 8, color: i < 3 ? "B0DDE2" : "8AACB8", margin: 0, lineSpacingMultiple: 1.1 });
  });

  // References
  s.addShape(pres.shapes.RECTANGLE, { x: 6.1, y: 0.85, w: 3.6, h: 4.44, fill: { color: "132033" }, line: { color: "2A3A4A", width: 0.5 } });
  s.addText("REFERENCES", { x: 6.28, y: 0.93, w: 3.2, h: 0.28, fontSize: 10, bold: true, color: "7ECFD6", margin: 0, charSpacing: 1 });
  hline(s, 6.28, 1.25, 3.2, "2A4060");

  const refs = [
    ["KDOQI 2019", "Clinical Practice Guideline for Vascular Access. Am J Kidney Dis. 2019;75(4 Suppl 2):S1–S164."],
    ["VASBI 2018", "Clinical Practice Recommendations for Needling of AV Fistulae. vasbi.org.uk"],
    ["Karkhah S et al. 2023", "Needle Direction and Distance of AVF Cannulation in HD Adequacy. Arch Acad Emerg Med. PMID: 37609532."],
    ["NIH HFM Study", "Hemodialysis Fistula Maturation Study. JAMA. 2016;316(19):1985–1994."],
    ["Brenner & Rector", "The Kidney, 2-Volume Set. Chap. 63: Hemodialysis. Elsevier."],
    ["Midwest Kidney Network", "Cannulation of New Fistula Policy & Procedure. midwestkidneynetwork.org"],
  ];
  refs.forEach((r, ri) => {
    s.addText(r[0], { x: 6.28, y: 1.34 + ri * 0.55, w: 3.2, h: 0.2, fontSize: 8, bold: true, color: C.teal, margin: 0 });
    s.addText(r[1], { x: 6.28, y: 1.54 + ri * 0.55, w: 3.2, h: 0.28, fontSize: 7.2, color: "6A8898", margin: 0, lineSpacingMultiple: 1.15 });
  });

  // Bottom disclaimer
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.3, w: 10, h: 0.325, fill: { color: "0A1520" }, line: { color: "0A1520", width: 0 } });
  s.addText("Clinical reference for educational purposes only. Does not replace institutional protocols, physician judgment, or patient-specific management. Always obtain appropriate orders.", {
    x: 0.3, y: 5.3, w: 9.4, h: 0.325, fontSize: 7.5, color: "4A6878", valign: "middle", italics: true, margin: 0, align: "center"
  });
}

// ── Write file ─────────────────────────────────────────────────────────────
pres.writeFile({ fileName: OUT })
  .then(() => console.log("PPTX generated: " + OUT))
  .catch(err => { console.error(err); process.exit(1); });

cd /home/daytona/workspace/fistula-pptx && node build.js 2>&1

ls -lh /home/daytona/workspace/fistula-pptx/AV_Fistula_Maturation_Troubleshootin…