const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE";
pres.title = "Hydrocephalus & Raised ICP – Anesthesia Management";
pres.author = "MD Anesthesia";

// ── COLOR PALETTE ──────────────────────────────────────────────
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const ACCENT2   = "F4A261";   // amber      (highlight/warning)
const WHITE     = "FFFFFF";
const LIGHT_GRY = "D6E4F0";
const SUBTEXT   = "A8C7E8";

// ── HELPER: slide background ─────────────────────────────────
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// ═══════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════
let s = pres.addSlide();
addBg(s);

// decorative circles
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s.addShape(pres.ShapeType.ellipse, {
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s.addText("HYDROCEPHALUS &", {
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s.addText("RAISED INTRACRANIAL PRESSURE", {
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s.addText("Sources: Miller's Anesthesia (10e)  •  Morgan & Mikhail (7e)", {
  x: 0.5, y: 6.7, w: 11, h: 0.35,
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});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 2 — OVERVIEW / CONTENTS
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Overview", "Topics covered in this presentation");

const topics = [
  ["01", "Anatomy of ICP — Monroe-Kellie Doctrine"],
  ["02", "Hydrocephalus — Types, Pathophysiology & Causes"],
  ["03", "Signs, Symptoms & Diagnosis of Raised ICP"],
  ["04", "Cerebral Blood Flow, CPP & Autoregulation"],
  ["05", "Anesthetic Agents & their Effects on ICP"],
  ["06", "Preanesthetic Assessment & Premedication"],
  ["07", "Induction & Airway Management"],
  ["08", "Intraoperative Management — ICP Control"],
  ["09", "Ventilation, Osmotherapy & Positioning"],
  ["10", "Emergence, Extubation & Postoperative Care"],
  ["11", "Special Scenarios — Shunt Surgery & ETV"],
  ["12", "Key Takeaways"],
];

topics.forEach(([num, text], i) => {
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});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 3 — MONROE-KELLIE DOCTRINE
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Monroe-Kellie Doctrine", "The Rigid Cranial Vault");

s.addText("The cranial vault is a rigid structure with a FIXED total volume", {
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// 3 component boxes
const comp = [
  { label: "BRAIN", val: "80%", color: "1E4D8C", detail: "Parenchyma + Interstitial fluid" },
  { label: "BLOOD", val: "12%", color: "8B1A1A", detail: "Arterial + Venous compartments" },
  { label: "CSF",   val: "8%",  color: "1A5C4A", detail: "Produced 0.35 mL/min (~500 mL/day)" },
];
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    x, y: 1.85, w: 4.0, h: 1.6, rectRadius: 0.1,
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s.addText("Increased volume in ONE component → must be offset by decrease in ANOTHER → else ↑ ICP", {
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  fontSize: 15.5, bold: true, color: WHITE, fontFace: "Calibri"
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// Compensation points
bulletBox(s, [
  "1°  Displacement of CSF from cranial → spinal compartment",
  "2°  Increased CSF absorption at arachnoid granulations",
  "3°  Decreased CSF production",
  "4°  Reduction of cerebral blood volume (primarily venous)",
  "Once compensatory mechanisms exhausted → PRECIPITOUS rise in ICP (pressure-volume curve)"
], { x: 0.3, y: 4.1, w: 12.5, h: 2.2, fontSize: 14.5, color: LIGHT_GRY });

s.addText("Normal ICP: ≤10 mmHg  |  Raised ICP: >20 mmHg  |  Critical: >40 mmHg", {
  x: 0.3, y: 6.55, w: 12.5, h: 0.38,
  fontSize: 13.5, bold: true, color: ACCENT2, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 4 — HYDROCEPHALUS — TYPES
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT2);
addHeaderBar(s, "Hydrocephalus — Classification & Causes", "Increase in CSF volume → ↑ ICP");

infoCard(s, 0.25, 1.25, 6.0, 2.5, "OBSTRUCTIVE (NON-COMMUNICATING)",
  [
    "CSF outflow obstructed within ventricular system",
    "Aqueductal stenosis (congenital malformations)",
    "Posterior fossa tumors (70% in children)",
    "Intraventricular hemorrhage or blood clot",
    "Obstructed ventricular shunts",
    "Chiari malformation"
  ], "12263A", ACCENT2);

infoCard(s, 6.6, 1.25, 6.0, 2.5, "COMMUNICATING",
  [
    "CSF reabsorption impaired at arachnoid granulations",
    "Post-meningitis / post-SAH",
    "Leptomeningeal carcinomatosis",
    "Venous sinus thrombosis",
    "Normal Pressure Hydrocephalus (elderly triad)",
    "Overproduction — choroid plexus papilloma"
  ], "12263A", ACCENT);

infoCard(s, 0.25, 3.9, 5.8, 2.5, "NORMAL PRESSURE HYDROCEPHALUS (NPH)",
  [
    "Classic triad: Wet-Wobbly-Wacky",
    "→ Urinary incontinence",
    "→ Gait disturbance (magnetic gait)",
    "→ Dementia",
    "ICP normal (10–15 mmHg) intermittently elevated",
    "Tx: VP shunt — often reversible"
  ], "1A3A1A", ACCENT);

infoCard(s, 6.4, 3.9, 6.2, 2.5, "KEY PATHOPHYSIOLOGY",
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    "CSF: 500 mL/day produced; total volume ~150 mL",
    "Production: choroid plexus (mainly lateral ventricles)",
    "Circulation: lateral → 3rd → aqueduct → 4th → subarachnoid",
    "Absorption: arachnoid granulations → venous sinuses",
    "ICP waveforms: P1 (percussion) P2 (tidal) P3 (dicrotic)",
    "P2 > P1 → decreased compliance (critical sign)"
  ], "1A1A3A", ACCENT2);

// ═══════════════════════════════════════════════════════════════
//  SLIDE 5 — SIGNS & SYMPTOMS OF RAISED ICP
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Clinical Features of Raised ICP", "Recognition is key to timely intervention");

// Left column — symptoms
s.addShape(pres.ShapeType.roundRect, {
  x: 0.25, y: 1.25, w: 4.0, h: 5.4, rectRadius: 0.1,
  fill: { color: MID_BG }, line: { color: ACCENT, width: 1.2 }
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s.addText("SYMPTOMS", {
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  fontSize: 14, bold: true, color: ACCENT, fontFace: "Calibri", align: "center"
});
bulletBox(s, [
  "Headache (worse in morning, on coughing/Valsalva)",
  "Nausea & Vomiting (projectile)",
  "Blurred / double vision",
  "Visual field defects",
  "Altered consciousness / drowsiness",
  "Seizures",
  "Personality changes"
], { x: 0.35, y: 1.82, w: 3.7, h: 4.6, fontSize: 12.5, color: LIGHT_GRY });

// Middle column — signs
s.addShape(pres.ShapeType.roundRect, {
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  fill: { color: MID_BG }, line: { color: ACCENT2, width: 1.2 }
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s.addText("SIGNS", {
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  fontSize: 14, bold: true, color: ACCENT2, fontFace: "Calibri", align: "center"
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bulletBox(s, [
  "Papilloedema (fundoscopy — blurred disc margins)",
  "6th nerve palsy (false localizing sign)",
  "Cushing's triad: ↑BP + Bradycardia + Irregular respiration",
  "'Sunset sign' in infants (downward gaze palsy)",
  "Bulging fontanelle (infants)",
  "Dilated, poorly-reactive pupils",
  "Decorticate/decerebrate posturing",
  "Cheyne-Stokes breathing"
], { x: 4.65, y: 1.82, w: 3.7, h: 4.6, fontSize: 12.5, color: LIGHT_GRY });

// Right column — herniation
s.addShape(pres.ShapeType.roundRect, {
  x: 8.85, y: 1.25, w: 4.0, h: 5.4, rectRadius: 0.1,
  fill: { color: "3D1010" }, line: { color: "FF4444", width: 1.5 }
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s.addText("HERNIATION SYNDROMES", {
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  fontSize: 13, bold: true, color: "FF6666", fontFace: "Calibri", align: "center"
});
bulletBox(s, [
  "Transtentorial (uncal): CN III palsy, ipsilateral hemiplegia",
  "Central: rostrocaudal brainstem deterioration",
  "Subfalcine (cingulate): ACA compression",
  "Tonsillar (foramen magnum): cardiorespiratory arrest",
  "Transcalvarial: through skull defect",
  "",
  "ANESTHETIC EMERGENCY:",
  "Sudden ICP spike → herniation = Death unless immediate decompression"
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// ═══════════════════════════════════════════════════════════════
//  SLIDE 6 — CBF, CPP, AUTOREGULATION
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "CBF, CPP & Cerebral Autoregulation", "Physiological basis of neuroanesthesia");

// Equations box
s.addShape(pres.ShapeType.roundRect, {
  x: 0.25, y: 1.25, w: 12.7, h: 0.85, rectRadius: 0.08,
  fill: { color: "0A2540" }, line: { color: ACCENT, width: 2 }
});
s.addText([
  { text: "CPP = MAP − ICP    ", options: { bold: true, color: ACCENT2, fontSize: 20, fontFace: "Calibri" } },
  { text: "|   ", options: { color: ACCENT, fontSize: 20, fontFace: "Calibri" } },
  { text: "Normal CPP: 60–80 mmHg    ", options: { bold: true, color: WHITE, fontSize: 17, fontFace: "Calibri" } },
  { text: "|   ", options: { color: ACCENT, fontSize: 20, fontFace: "Calibri" } },
  { text: "Target CPP > 60 mmHg", options: { bold: true, color: ACCENT, fontSize: 17, fontFace: "Calibri" } },
], { x: 0.35, y: 1.32, w: 12.5, h: 0.65, valign: "middle" });

// Cards row
const cbfCards = [
  {
    title: "Autoregulation Range",
    lines: [
      "MAP 50–150 mmHg: CBF constant (~50 mL/100g/min)",
      "Below 50: ischemia risk ↑",
      "Above 150: breakthrough perfusion, oedema",
      "Impaired by: TBI, volatile agents, hypercapnia",
      "Preserved by: propofol, barbiturates, etomidate"
    ]
  },
  {
    title: "CO₂ Reactivity (Most Powerful Regulator)",
    lines: [
      "PaCO₂ ↑ → CBF ↑ (vasodilation) → ↑ ICP",
      "PaCO₂ ↓ → CBF ↓ (vasoconstriction) → ↓ ICP",
      "4% change in CBF per mmHg CO₂",
      "Hyperventilation target: PaCO₂ 30–35 mmHg (temporizing)",
      "Avoid PaCO₂ < 30: cerebral ischemia risk"
    ]
  },
  {
    title: "Other Determinants of CBF",
    lines: [
      "O₂: Hypoxia (PaO₂ < 50): potent vasodilation",
      "Temperature: CBF ↓ 5–7% per °C reduction",
      "Viscosity: haematocrit — optimal 30–35%",
      "Venous outflow obstruction ↑ ICP",
      "PEEP > 10 cm H₂O may ↑ ICP via CVP"
    ]
  }
];

cbfCards.forEach((card, i) => {
  infoCard(s, 0.25 + i * 4.3, 2.28, 4.1, 4.0, card.title, card.lines, MID_BG, ACCENT);
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 7 — ANESTHETIC AGENTS EFFECTS ON ICP
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT2);
addHeaderBar(s, "Anesthetic Agents & Effects on ICP / CBF / CMR", "Critical knowledge for neuroanesthesia");

// Table header
const tHdr = [
  "AGENT", "CBF", "CMR", "ICP", "NOTES"
];
const tRows = [
  ["Propofol",   "↓↓",  "↓↓",  "↓↓",  "Agent of choice for TIVA; maintains autoregulation; dose-related BP drop → watch CPP"],
  ["Thiopentone","↓↓",  "↓↓",  "↓↓",  "Excellent for induction in raised ICP; max CMR reduction at isoelectric EEG"],
  ["Etomidate",  "↓↓",  "↓↓",  "↓↓",  "Ideal induction agent; adrenal suppression with infusion; myoclonic activity"],
  ["Ketamine",   "↑↑",  "~0",  "↑↑",  "AVOID in isolated raised ICP; safe under controlled ventilation + benzodiazepine"],
  ["Isoflurane", "↑/~", "↓↓",  "↑",   "Dose-dependent CBF increase; >1 MAC impairs autoregulation; hypocapnia blunts ↑ICP"],
  ["Sevoflurane","~",   "↓↓",  "~",   "Most cerebral-friendly volatile; autoregulation better preserved than Iso/Des"],
  ["Desflurane", "↑↑",  "↓",   "↑↑",  "Marked sympathetic activation & ICP rise during rapid increases; avoid in raised ICP"],
  ["N₂O",        "↑",   "↑",   "↑",   "Use cautiously; augments volatile ICP rise; AVOID with pneumocephalus"],
  ["Opioids",    "~",   "~",   "~",   "Minimal direct effect; indirect ↑ICP via CO₂ retention if ventilation inadequate"],
  ["Midazolam",  "↓",   "↓",   "↓",   "Less than barbiturates; BP reduction may reduce CPP; useful premedication"],
  ["Lidocaine IV","↓",  "↓",   "↓",   "Attenuates ICP rise on laryngoscopy; 1.5 mg/kg IV 3 min before intubation"],
  ["Mannitol",   "↑*",  "—",   "↓↓",  "↑CBF transiently via ↓viscosity; powerful ICP reduction; 0.25–1.5 g/kg IV bolus"],
];

const colW = [2.0, 0.8, 0.8, 0.8, 7.6];
const startX = 0.2;
const startY = 1.25;
const rowH = 0.44;

// header row
let rowY = startY;
colW.forEach((w, ci) => {
  const x = startX + colW.slice(0, ci).reduce((a, b) => a + b, 0);
  s.addShape(pres.ShapeType.rect, {
    x, y: rowY, w, h: 0.42,
    fill: { color: ACCENT }, line: { color: DARK_BG, width: 0.5 }
  });
  s.addText(tHdr[ci], {
    x: x + 0.04, y: rowY + 0.04, w: w - 0.08, h: 0.34,
    fontSize: 12, bold: true, color: DARK_BG, fontFace: "Calibri", align: "center", valign: "middle"
  });
});
rowY += 0.44;

tRows.forEach((row, ri) => {
  colW.forEach((w, ci) => {
    const x = startX + colW.slice(0, ci).reduce((a, b) => a + b, 0);
    const bgCol = ri % 2 === 0 ? "10283F" : MID_BG;
    const txtCol = ci === 1 || ci === 2 || ci === 3
      ? (row[ci].includes("↑") ? "FF7070" : row[ci].includes("↓") ? "70DDAA" : WHITE)
      : WHITE;
    s.addShape(pres.ShapeType.rect, {
      x, y: rowY, w, h: rowH,
      fill: { color: bgCol }, line: { color: "1E4060", width: 0.5 }
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    s.addText(row[ci], {
      x: x + 0.05, y: rowY + 0.02, w: w - 0.1, h: rowH - 0.04,
      fontSize: ci === 4 ? 10.5 : 12,
      bold: ci === 0 ? true : false,
      color: ci === 0 ? ACCENT2 : txtCol,
      fontFace: "Calibri", valign: "middle"
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  });
  rowY += rowH;
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 8 — PREANESTHETIC ASSESSMENT
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Preanesthetic Assessment", "Preparing the patient with raised ICP");

infoCard(s, 0.25, 1.25, 4.1, 5.5, "HISTORY",
  [
    "Duration & progression of symptoms",
    "Severity of headache, vomiting pattern",
    "Visual symptoms / field defects",
    "Seizure history",
    "Prior neurosurgical interventions",
    "Medications (steroids, anticonvulsants, diuretics)",
    "Airway history (previous difficult intubation)"
  ], MID_BG, ACCENT);

infoCard(s, 4.55, 1.25, 4.1, 5.5, "EXAMINATION",
  [
    "GCS score (document carefully)",
    "Pupillary responses (size, reactivity)",
    "Papilloedema on fundoscopy",
    "Cushing's triad assessment",
    "Focal neurological deficits",
    "Airway assessment (Mallampati, neck mobility)",
    "Cardiovascular — HR, BP, rhythm"
  ], MID_BG, ACCENT);

infoCard(s, 8.85, 1.25, 4.0, 5.5, "INVESTIGATIONS",
  [
    "CT head (contrast): mass, oedema, midline shift, herniation",
    "MRI brain: detailed tumour characterisation",
    "ICP monitoring (EVD / bolt) readings",
    "CBC, CMP, coagulation profile",
    "Serum osmolality (osmotherapy monitoring)",
    "ABG (PaCO₂, PaO₂ optimisation)",
    "Chest X-ray, ECG",
    "Blood glucose (hyperglycemia worsens outcome)"
  ], MID_BG, ACCENT2);

s.addText("PREMEDICATION:", {
  x: 0.25, y: 6.88, w: 2, h: 0.34,
  fontSize: 13, bold: true, color: ACCENT2, fontFace: "Calibri"
});
s.addText("Avoid sedatives/opioids (respiratory depression → CO₂ retention → ↑ICP)  |  Dexamethasone 8–16 mg IV for vasogenic oedema (tumour)  |  Anticonvulsants if seizure history  |  Continue antihypertensives  |  Famotidine for aspiration prophylaxis", {
  x: 2.3, y: 6.88, w: 10.5, h: 0.34,
  fontSize: 11.5, color: LIGHT_GRY, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 9 — INDUCTION & AIRWAY MANAGEMENT
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT2);
addHeaderBar(s, "Induction & Airway Management", "Goals: smooth induction, prevent ICP spikes");

s.addShape(pres.ShapeType.roundRect, {
  x: 0.25, y: 1.25, w: 12.7, h: 0.62, rectRadius: 0.06,
  fill: { color: "2A1200" }, line: { color: ACCENT2, width: 1.5 }
});
s.addText("GOALS: Hemodynamic stability | Blunt ICP response to laryngoscopy | Prevent hypoxia & hypercarbia | Rapid, predictable induction", {
  x: 0.35, y: 1.33, w: 12.5, h: 0.44,
  fontSize: 13.5, bold: true, color: ACCENT2, fontFace: "Calibri"
});

// 3-step boxes
const indSteps = [
  {
    num: "STEP 1", label: "Preoxygenation & Preparation", color: "1A3A5C",
    items: [
      "100% O₂ for 3–5 minutes",
      "Head elevated 30° (↓venous pressure → ↓ICP)",
      "Large bore IV access × 2",
      "Arterial line (continuous BP monitoring)",
      "Vasopressors drawn up (phenylephrine/noradrenaline)",
      "Video laryngoscope ready",
      "ICP monitor checked"
    ]
  },
  {
    num: "STEP 2", label: "Induction Sequence", color: "1A3A1A",
    items: [
      "Lidocaine 1.5 mg/kg IV 3 min before (blunts ICP ↑)",
      "Fentanyl 2–3 mcg/kg (blunts laryngoscopy response)",
      "Propofol 1.5–2 mg/kg (↓CMR, ↓CBF, ↓ICP)",
      "  OR Thiopentone 3–5 mg/kg (haemodynamically stable px)",
      "  OR Etomidate 0.3 mg/kg (if cardiovascular compromise)",
      "Succinylcholine 1.5 mg/kg OR Rocuronium 1.2 mg/kg",
      "Maintain BP — avoid MAP drop > 20%"
    ]
  },
  {
    num: "STEP 3", label: "Intubation & Confirmation", color: "3A1A1A",
    items: [
      "Rapid sequence or modified RSI preferred",
      "Aim: intubation in < 30s after induction",
      "Apply cricoid pressure if aspiration risk",
      "Confirm ETT position (capnography)",
      "Target ETCO₂ 30–35 mmHg immediately",
      "Secure ETT firmly (neck ties may ↑ venous pressure)",
      "Avoid succinylcholine in denervation injury (fasciculations)"
    ]
  }
];

indSteps.forEach((step, i) => {
  const x = 0.25 + i * 4.3;
  s.addShape(pres.ShapeType.roundRect, {
    x, y: 2.0, w: 4.1, h: 4.7, rectRadius: 0.08,
    fill: { color: step.color }, line: { color: ACCENT2, width: 1.2 }
  });
  s.addText(step.num, {
    x: x + 0.1, y: 2.1, w: 3.9, h: 0.35,
    fontSize: 13, bold: true, color: ACCENT2, fontFace: "Calibri"
  });
  s.addText(step.label, {
    x: x + 0.1, y: 2.46, w: 3.9, h: 0.4,
    fontSize: 12.5, bold: true, color: WHITE, fontFace: "Calibri"
  });
  const tArr = step.items.map((item, j) => ({
    text: item,
    options: {
      bullet: { indent: 14 },
      breakLine: j < step.items.length - 1,
      fontSize: 11.5,
      color: LIGHT_GRY,
      fontFace: "Calibri"
    }
  }));
  s.addText(tArr, { x: x + 0.1, y: 2.9, w: 3.9, h: 3.7, valign: "top" });
});

s.addText("⚠  Ketamine: AVOID in raised ICP unless controlled ventilation + benzodiazepine co-administration", {
  x: 0.25, y: 6.78, w: 12.7, h: 0.34,
  fontSize: 12.5, bold: true, color: "FF9090", fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 10 — INTRAOPERATIVE MANAGEMENT
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Intraoperative Management of Raised ICP", "The 'Brain-Relaxed' surgical field");

infoCard(s, 0.25, 1.25, 3.95, 5.5, "MAINTENANCE ANESTHESIA",
  [
    "TIVA preferred (Propofol + Remifentanil/Fentanyl)",
    "Propofol 4–12 mg/kg/h + Remifentanil 0.1–0.3 mcg/kg/min",
    "Sevoflurane ≤ 0.5 MAC if volatile needed",
    "Avoid N₂O (↑CBF, pneumocephalus risk)",
    "Maintain BIS 40–60",
    "NMB: adequate muscle relaxation throughout",
    "Avoid desflurane (ICP spikes)"
  ], MID_BG, ACCENT);

infoCard(s, 4.45, 1.25, 3.95, 5.5, "MONITORING (ESSENTIAL)",
  [
    "Invasive arterial BP (continuous)",
    "ICP monitor (if EVD/bolt in situ)",
    "CPP = MAP − ICP (maintain > 60 mmHg)",
    "End-tidal CO₂ (ETCO₂ 30–35 mmHg)",
    "Urine output hourly (target > 0.5 mL/kg/h)",
    "Temperature (normothermia 36–37°C)",
    "BIS / EEG (for burst suppression therapy)",
    "Jugular venous O₂ saturation (SjvO₂ > 55%)"
  ], MID_BG, ACCENT2);

infoCard(s, 8.65, 1.25, 4.2, 5.5, "POSITIONING",
  [
    "Head up 15–30° (venous drainage)",
    "Head neutral — avoid neck rotation/flexion",
    "Neck ties must not compress jugular veins",
    "Pin fixation (Mayfield): blunt response with",
    "  extra opioid or lidocaine before pinning",
    "Horseshoe position: ensure eyes not compressed",
    "Sitting position: risk of VAE (Doppler monitor)"
  ], MID_BG, ACCENT);

s.addText("ICP MANAGEMENT LADDER (Step-Up Approach):", {
  x: 0.25, y: 6.85, w: 3.5, h: 0.35,
  fontSize: 12, bold: true, color: ACCENT2, fontFace: "Calibri"
});
s.addText("Head up 30° → Normocapnia → Adequate sedation → Osmotherapy → Hyperventilation (PaCO₂ 30–35) → CSF drainage → Barbiturate coma → Decompressive craniectomy", {
  x: 3.8, y: 6.85, w: 9.1, h: 0.35,
  fontSize: 11.5, color: LIGHT_GRY, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 11 — OSMOTHERAPY & VENTILATION
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Osmotherapy & Ventilation Strategy", "Cornerstone pharmacological ICP management");

infoCard(s, 0.25, 1.25, 4.0, 5.5, "MANNITOL",
  [
    "Dose: 0.25–1.5 g/kg IV bolus (20% solution)",
    "Onset: 10–20 min; Duration: 2–6 hours",
    "Mechanism:",
    "  → Osmotic dehydration of brain (main)",
    "  → ↓ blood viscosity → ↑ CBF → reflex vasoconstriction",
    "  → ↑ CSF absorption",
    "Serum osmolality target: 300–320 mOsm/L",
    "AVOID if osmolality > 320 or renal failure",
    "Watch: rebound ICP rise if used continuously"
  ], MID_BG, ACCENT);

infoCard(s, 4.5, 1.25, 4.0, 5.5, "HYPERTONIC SALINE",
  [
    "Dose: 3% NaCl 1–2 mL/kg; 23.4% NaCl 0.5 mL/kg",
    "Mechanism: osmotic gradient → draws water out of brain",
    "Advantages over mannitol:",
    "  → No diuresis (hypovolaemia-free)",
    "  → May be superior in traumatic brain injury",
    "  → Useful in renal impairment",
    "Target serum Na: 145–155 mEq/L",
    "Rapid bolus (not slow infusion)",
    "Watch: central pontine myelinolysis (chronic hypoNa)"
  ], MID_BG, ACCENT2);

infoCard(s, 8.75, 1.25, 4.1, 5.5, "VENTILATION STRATEGY",
  [
    "Normocapnia: PaCO₂ 35–40 mmHg (routine)",
    "Mild hyperventilation: PaCO₂ 30–35 mmHg",
    "  → Temporizing only (effects diminish in 6–12h)",
    "  → Use only for acute ICP surge / herniation",
    "  → Avoid PaCO₂ < 30 → cerebral ischemia",
    "Normoxia: PaO₂ > 60 mmHg (SaO₂ > 95%)",
    "PEEP ≤ 5–8 cmH₂O (higher PEEP ↑ CVP → ↑ICP)",
    "PCV or VCV acceptable — aim for lung protection",
    "Avoid Valsalva, coughing, airway suctioning"
  ], MID_BG, ACCENT);

// Dexamethasone note
s.addShape(pres.ShapeType.roundRect, {
  x: 0.25, y: 6.88, w: 12.7, h: 0.38, rectRadius: 0.06,
  fill: { color: "1A3A1A" }, line: { color: ACCENT, width: 1 }
});
s.addText("Dexamethasone: 8–16 mg IV → effective for VASOGENIC oedema (tumour/abscess).  NOT effective in cytotoxic oedema (TBI, stroke).  Steroids are CONTRAINDICATED in TBI (↑ mortality – CRASH Trial).", {
  x: 0.35, y: 6.9, w: 12.5, h: 0.34,
  fontSize: 11.5, color: WHITE, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 12 — EMERGENCE & EXTUBATION
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT2);
addHeaderBar(s, "Emergence, Extubation & Postoperative Care", "Critical phase — prevent secondary brain injury");

infoCard(s, 0.25, 1.25, 4.0, 5.4, "CRITERIA FOR EXTUBATION",
  [
    "Awake, following commands",
    "GCS ≥ 13 (pre-op baseline)",
    "Protective airway reflexes present",
    "Adequate reversal of NMB",
    "Haemodynamically stable",
    "PaCO₂ and PaO₂ within normal range",
    "No significant surgical complications",
    "Seizure-free emergence"
  ], MID_BG, ACCENT);

infoCard(s, 4.5, 1.25, 4.0, 5.4, "SMOOTH EMERGENCE STRATEGIES",
  [
    "Remifentanil infusion during emergence",
    "Lidocaine 1 mg/kg before extubation",
    "Labetalol / esmolol for hypertension",
    "Adequate analgesia (prevent pain-induced ↑ICP)",
    "Anti-emetics (ondansetron) — vomiting ↑ICP",
    "KEEP head 30° elevated throughout",
    "Dexmedetomidine infusion: smooth emergence",
    "Suction gently; avoid stimulation during recovery"
  ], MID_BG, ACCENT2);

infoCard(s, 8.75, 1.25, 4.1, 5.4, "POSTOPERATIVE CONSIDERATIONS",
  [
    "ICU admission after major neurosurgery",
    "Continue ICP monitoring if EVD in situ",
    "Serial neurological assessment (GCS)",
    "Post-op CT head: rule out haematoma",
    "Seizure prophylaxis (levetiracetam/phenytoin)",
    "SIADH: within 24–48h; free water retention → ↓Na",
    "Diabetes Insipidus: after suprasellar surgery",
    "Pain: multimodal analgesia, avoid NSAIDs",
    "DVT prophylaxis: sequential compression devices"
  ], MID_BG, ACCENT);

s.addShape(pres.ShapeType.roundRect, {
  x: 0.25, y: 6.72, w: 12.7, h: 0.45, rectRadius: 0.06,
  fill: { color: "3D2000" }, line: { color: ACCENT2, width: 1.2 }
});
s.addText("⚠  DELAYED EXTUBATION INDICATIONS: Prolonged surgery, massive blood loss, cerebral oedema on closure, haemodynamic instability, GCS < pre-op baseline, bilateral posterior fossa surgery, brainstem involvement", {
  x: 0.35, y: 6.75, w: 12.5, h: 0.38,
  fontSize: 12, bold: true, color: ACCENT2, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 13 — SHUNT SURGERY (Hydrocephalus)
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Anesthesia for Hydrocephalus — Shunt Surgery & ETV", "Practical management");

infoCard(s, 0.25, 1.25, 3.9, 5.5, "VP SHUNT / REVISION",
  [
    "Most common hydrocephalus surgery",
    "Often infants / children (special considerations)",
    "Airway: LMA acceptable for non-obstructive hydro",
    "RSI if raised ICP / full stomach",
    "Monitor: temp (heat loss in infants), glucose",
    "Avoid volatile agents > 0.5 MAC",
    "Propofol + Remifentanil TIVA preferred",
    "Avoid succinylcholine (fasciculations → ↑ICP)",
    "Position: head turned away from shunt side",
    "Peritoneal end: watch for ↑intra-abdominal pressure"
  ], MID_BG, ACCENT);

infoCard(s, 4.4, 1.25, 3.9, 5.5, "ENDOSCOPIC 3RD VENTRICULOSTOMY (ETV)",
  [
    "Alternative to shunt; endoscope into ventricles",
    "Sudden CSF loss during fenestration → ↓BP (bradycardia)",
    "Autonomic instability — have atropine ready",
    "Irrigation fluid: warm Ringer's lactate",
    "Fluid absorption risk — monitor for hyponatraemia",
    "TIVA preferred (PROPOFOL based)",
    "Air embolism rare but possible — Doppler monitor",
    "Post-op: monitor for procedure failure",
    "Extubate awake with intact protective reflexes"
  ], MID_BG, ACCENT2);

infoCard(s, 8.55, 1.25, 4.3, 5.5, "NEONATAL & PAEDIATRIC PEARLS",
  [
    "Open fontanelle: ICP estimation by palpation",
    "'Sunset sign', irritability, poor feeding as signs",
    "Large head circumference measurement",
    "Gas induction acceptable if airway manageable",
    "Sevoflurane: agent of choice for paediatric induction",
    "Glucose monitoring essential (neonates)",
    "Normothermia: forced air warming vital",
    "Fluid: 0.9% NaCl preferred over hypotonic solutions",
    "Lower MAC values in neonates vs older children"
  ], MID_BG, ACCENT);

s.addText("KEY POINT: In obstructive hydrocephalus with high ICP — treat as FULL STOMACH + RAISED ICP = Modified RSI with ICP precautions", {
  x: 0.25, y: 6.85, w: 12.7, h: 0.38,
  fontSize: 13, bold: true, color: ACCENT2, fontFace: "Calibri"
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 14 — KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);
addStripe(s, ACCENT);
addHeaderBar(s, "Key Takeaways", "MD Anesthesia — High-Yield Points");

const takeaways = [
  ["Monroe-Kellie", "Brain 80% + Blood 12% + CSF 8% = fixed volume. Any ↑ must be compensated or ICP rises."],
  ["Normal ICP", "≤10 mmHg; target CPP > 60 mmHg; autoregulation MAP 50–150 mmHg."],
  ["CO₂ is King", "PaCO₂ is the most powerful CBF regulator. Hyperventilate only as temporizing measure (PaCO₂ 30–35)."],
  ["Agent Choice", "Propofol/Thiopentone/Etomidate ↓ICP. Ketamine ↑ICP (avoid). Sevoflurane < 0.5 MAC is safest volatile."],
  ["Induction", "Lidocaine + Fentanyl + Propofol/Thiopentone + NMB. Avoid hemodynamic swings. Head up 30°."],
  ["Osmotherapy", "Mannitol 0.25–1.5 g/kg bolus OR Hypertonic saline. Serum Osm target 300–320. Never prophylactic."],
  ["Steroids", "Dexamethasone for VASOGENIC oedema (tumour) ONLY. CONTRAINDICATED in TBI."],
  ["Extubation", "Only when awake, GCS at baseline, haemodynamically stable. Smooth emergence paramount."],
  ["Hydrocephalus", "RSI with ICP precautions if obstructive. ETV: watch bradycardia, fluid absorption, air embolism."],
  ["Monitoring", "Arterial line, ICP monitor, ETCO₂, BIS, temperature, hourly UO mandatory in all major neuro cases."],
];

takeaways.forEach(([kw, text], i) => {
  const col = i < 5 ? 0 : 1;
  const row = i % 5;
  const x = 0.25 + col * 6.45;
  const y = 1.25 + row * 1.05;
  s.addShape(pres.ShapeType.roundRect, {
    x, y, w: 6.2, h: 0.95, rectRadius: 0.08,
    fill: { color: i % 2 === 0 ? MID_BG : "12263A" },
    line: { color: ACCENT, width: 0.8 }
  });
  s.addText(kw + ":", {
    x: x + 0.12, y: y + 0.07, w: 1.6, h: 0.75,
    fontSize: 12, bold: true, color: ACCENT2, fontFace: "Calibri", valign: "middle"
  });
  s.addText(text, {
    x: x + 1.75, y: y + 0.07, w: 4.3, h: 0.75,
    fontSize: 12, color: LIGHT_GRY, fontFace: "Calibri", valign: "middle"
  });
});

// ═══════════════════════════════════════════════════════════════
//  SLIDE 15 — THANK YOU
// ═══════════════════════════════════════════════════════════════
s = pres.addSlide();
addBg(s);

s.addShape(pres.ShapeType.ellipse, {
  x: 4.5, y: 1.5, w: 4.3, h: 4.3,
  fill: { color: MID_BG }, line: { color: ACCENT, width: 2 }
});
s.addShape(pres.ShapeType.rect, {
  x: 0, y: 6.5, w: "100%", h: 0.08,
  fill: { color: ACCENT }, line: { type: "none" }
});

s.addText("THANK YOU", {
  x: 1, y: 2.45, w: 11.3, h: 1.1,
  fontSize: 54, bold: true, color: WHITE, fontFace: "Calibri",
  align: "center", charSpacing: 6
});
s.addText("Hydrocephalus & Raised ICP — Anesthesia Management", {
  x: 1, y: 3.6, w: 11.3, h: 0.6,
  fontSize: 20, color: ACCENT, fontFace: "Calibri",
  align: "center", italic: true
});
s.addText("Miller's Anesthesia 10e  •  Morgan & Mikhail 7e  •  Brain Trauma Foundation Guidelines", {
  x: 1, y: 6.6, w: 11.3, h: 0.4,
  fontSize: 12, color: SUBTEXT, fontFace: "Calibri", align: "center"
});

// ───────── WRITE FILE ──────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/hydrocephalus-icp-ppt/Hydrocephalus_RaisedICP_Anesthesia.pptx" })
  .then(() => console.log("PPT created successfully!"))
  .catch(e => { console.error(e); process.exit(1); });