mkdir -p /home/daytona/workspace/nmb-ppt && ls /home/daytona/workspace/nmb-ppt/

~/nmb-ppt/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Neuromuscular Blockade in Anaesthesia";
pres.author = "Anaesthesia Teaching Series";

// ─── Colour palette ────────────────────────────────────────────────────────
// Dominant dark navy, supporting steel-blue, accent amber/gold
const C = {
  navy:       "0D1B2A",   // dominant dark bg
  navyMid:    "1A3550",   // lighter navy
  steel:      "1F6B9A",   // steel blue accent band
  steelLight: "3B8CC6",   // lighter steel
  amber:      "F4A225",   // accent / highlight
  white:      "FFFFFF",
  offwhite:   "E8EDF2",
  light:      "C9D8E7",
  muted:      "8BA5BE",
  dark:       "0A1520",
};

// ─── Helpers ───────────────────────────────────────────────────────────────
function addSlide(dark = false) {
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 10, h: 5.625,
    fill: { color: dark ? C.navy : C.offwhite },
    line: { color: dark ? C.navy : C.offwhite }
  });
  return s;
}

function titleSlide(s, title, subtitle = "") {
  // Top accent bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.07, fill: { color: C.amber }, line: { color: C.amber } });
  // Bottom accent bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.555, w: 10, h: 0.07, fill: { color: C.steel }, line: { color: C.steel } });
  // Left gutter
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: C.amber }, line: { color: C.amber } });

  s.addText(title, {
    x: 0.5, y: 1.2, w: 9, h: 1.8,
    fontSize: 40, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", valign: "middle", margin: 0
  });
  if (subtitle) {
    s.addText(subtitle, {
      x: 0.5, y: 3.1, w: 9, h: 0.9,
      fontSize: 18, color: C.light, fontFace: "Calibri",
      align: "left", valign: "top", margin: 0
    });
  }
}

function sectionHeader(s, label, title) {
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 1.15, fill: { color: C.steel }, line: { color: C.steel } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.555, w: 10, h: 0.07, fill: { color: C.amber }, line: { color: C.amber } });
  s.addText(label.toUpperCase(), {
    x: 0.4, y: 0.1, w: 9.2, h: 0.4,
    fontSize: 10, color: C.amber, bold: true, fontFace: "Calibri",
    charSpacing: 3, margin: 0
  });
  s.addText(title, {
    x: 0.4, y: 0.5, w: 9.2, h: 0.65,
    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", margin: 0
  });
}

function contentSlide(dark = false) {
  const s = addSlide(dark);
  return s;
}

function addHeader(s, section, title, dark = false) {
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.9, fill: { color: dark ? C.navyMid : C.steel }, line: { color: dark ? C.navyMid : C.steel } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.08, h: 5.625, fill: { color: C.amber }, line: { color: C.amber } });
  s.addText(section.toUpperCase(), {
    x: 0.25, y: 0.05, w: 9.5, h: 0.3,
    fontSize: 9, color: C.amber, bold: true, charSpacing: 2.5,
    fontFace: "Calibri", margin: 0
  });
  s.addText(title, {
    x: 0.25, y: 0.32, w: 9.5, h: 0.55,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri", margin: 0
  });
}

function bullets(s, items, opts = {}) {
  const {
    x = 0.25, y = 1.0, w = 9.5, h = 4.4,
    fontSize = 14.5, color = C.navy, indent = 0.3
  } = opts;
  const arr = items.map((item, i) => {
    if (typeof item === "string") {
      return { text: item, options: { bullet: { code: "25CF" }, indentLevel: 0, breakLine: i < items.length - 1 } };
    }
    return { text: item.text, options: { bullet: { code: item.sub ? "25B8" : "25CF" }, indentLevel: item.sub ? 1 : 0, breakLine: i < items.length - 1, color: item.sub ? C.steel : color } };
  });
  s.addText(arr, { x, y, w, h, fontSize, fontFace: "Calibri", color, valign: "top", paraSpaceAfter: 3 });
}

function twoCol(s, leftItems, rightItems, leftTitle = "", rightTitle = "", opts = {}) {
  const { y = 1.0, h = 4.35, fs = 13 } = opts;
  if (leftTitle) {
    s.addText(leftTitle, { x: 0.25, y, w: 4.5, h: 0.35, fontSize: 12, bold: true, color: C.amber, fontFace: "Calibri", margin: 0 });
  }
  if (rightTitle) {
    s.addText(rightTitle, { x: 5.1, y, w: 4.6, h: 0.35, fontSize: 12, bold: true, color: C.amber, fontFace: "Calibri", margin: 0 });
  }
  const ty = leftTitle ? y + 0.38 : y;
  const th = leftTitle ? h - 0.38 : h;
  const buildArr = (items) => items.map((item, i) => ({
    text: typeof item === "string" ? item : item.text,
    options: { bullet: { code: typeof item === "object" && item.sub ? "25B8" : "25CF" }, indentLevel: typeof item === "object" && item.sub ? 1 : 0, breakLine: i < items.length - 1, color: typeof item === "object" && item.sub ? C.navyMid : C.navy }
  }));
  s.addText(buildArr(leftItems), { x: 0.25, y: ty, w: 4.5, h: th, fontSize: fs, fontFace: "Calibri", color: C.navy, valign: "top", paraSpaceAfter: 3 });
  // Divider
  s.addShape(pres.shapes.RECTANGLE, { x: 4.9, y: y, w: 0.03, h: h, fill: { color: C.muted }, line: { color: C.muted } });
  s.addText(buildArr(rightItems), { x: 5.1, y: ty, w: 4.6, h: th, fontSize: fs, fontFace: "Calibri", color: C.navy, valign: "top", paraSpaceAfter: 3 });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 1 — Title
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  titleSlide(s,
    "Neuromuscular Blockade\nin Anaesthesia",
    "Advanced Pharmacology & Clinical Application  |  Anaesthesia Residency Teaching Series"
  );
  s.addText("Based on Miller's Anesthesia 10e · Barash Clinical Anesthesia 9e · Morgan & Mikhail 7e", {
    x: 0.5, y: 4.85, w: 9, h: 0.5,
    fontSize: 10, color: C.muted, fontFace: "Calibri", align: "left", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 2 — Objectives
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Introduction", "Learning Objectives");
  bullets(s, [
    "Describe the anatomy and physiology of the neuromuscular junction (NMJ)",
    "Differentiate depolarizing vs. nondepolarizing mechanisms of blockade",
    "Apply pharmacokinetic/pharmacodynamic profiles to clinical drug selection",
    "Interpret neuromuscular monitoring: TOF, PTC, DBS, and quantitative acceleromyography",
    "Manage RSI, difficult airway, and special population considerations",
    "Select appropriate reversal strategies: neostigmine vs. sugammadex",
    "Recognise and prevent residual neuromuscular blockade (RNMB)",
    "Understand drug interactions and adverse effects"
  ], { fontSize: 15, color: C.navy });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 3 — Section: NMJ Anatomy & Physiology
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  sectionHeader(s, "Section 1", "Neuromuscular Junction: Anatomy & Physiology");
  s.addText("Understanding the NMJ is essential for predicting how neuromuscular blocking drugs work.", {
    x: 0.4, y: 2.2, w: 9.2, h: 0.7, fontSize: 16, color: C.light, fontFace: "Calibri", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 4 — NMJ Anatomy
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 1 | NMJ Physiology", "Anatomy of the Neuromuscular Junction");
  twoCol(s,
    [
      "Motor nerve terminal (presynaptic)",
      { text: "Stores ACh in vesicles (~200,000 molecules each)", sub: true },
      { text: "Voltage-gated Ca²+ channels trigger exocytosis", sub: true },
      "Synaptic cleft (~50 nm wide)",
      { text: "Acetylcholinesterase (AChE) breaks down ACh", sub: true },
      "Motor end-plate (postsynaptic)",
      { text: "Nicotinic ACh receptors (nAChR): α2βδε adult / α2βδγ fetal", sub: true },
      { text: "2 α-subunits are binding sites for ACh and NMBDs", sub: true }
    ],
    [
      "Mature nAChR: α2βδε — low conductance, short open time",
      "Immature/fetal nAChR (α2βδγ): extrajunctional, high conductance, prolonged open time",
      { text: "Upregulated in: denervation, burns, immobilisation", sub: true },
      { text: "→ Risk of succinylcholine-induced hyperkalaemia", sub: true },
      "Prejunctional α3β2 nAChR: mobilisation of ACh stores",
      { text: "Blocked by nondepolarising agents → fade on TOF", sub: true }
    ],
    "Presynaptic / Synaptic", "Postsynaptic / Receptor"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 5 — ACh Synthesis & Release
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 1 | NMJ Physiology", "ACh Synthesis, Release & Signal Transduction");
  bullets(s, [
    "ACh synthesised from choline + acetyl-CoA by choline acetyltransferase in the motor nerve terminal",
    "Stored in vesicles; release triggered by action potential → Ca²+ influx via voltage-gated channels",
    "Quantal release: each vesicle liberates ~200,000 ACh molecules (one quantum)",
    "ACh binds α-subunits of postsynaptic nAChR → Na+ influx / K+ efflux → end-plate potential (EPP)",
    "EPP sufficient → action potential propagates → excitation-contraction coupling (Ca²+ release from SR)",
    "AChE at end-plate hydrolyses ACh within <1 ms → rapid termination of signal",
    "Safety margin of NMJ: >75% receptor occupancy required before measurable weakness occurs"
  ], { fontSize: 14, color: C.navy });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 6 — Section: Drug Classification
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  sectionHeader(s, "Section 2", "Classification of Neuromuscular Blocking Drugs");
  s.addText("Depolarising vs. Nondepolarising — mechanism, structure, and duration", {
    x: 0.4, y: 2.2, w: 9.2, h: 0.7, fontSize: 16, color: C.light, fontFace: "Calibri", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 7 — Depolarising vs Nondepolarising (Overview Table)
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 2 | Classification", "Depolarising vs. Nondepolarising Agents");

  const rows = [
    [
      { text: "Feature", options: { bold: true, color: C.white, fill: { color: C.steel } } },
      { text: "Depolarising (Phase I)", options: { bold: true, color: C.white, fill: { color: C.steel } } },
      { text: "Nondepolarising (Competitive)", options: { bold: true, color: C.white, fill: { color: C.steel } } }
    ],
    ["Mechanism", "ACh receptor agonist — prolonged depolarisation", "Competitive ACh antagonist — no ion channel opening"],
    ["Prototype drug", "Succinylcholine (suxamethonium)", "Rocuronium, vecuronium, cisatracurium, pancuronium"],
    ["Fasciculations", "Yes (initial)", "No"],
    ["TOF fade", "No (>0.7 TOF ratio maintained)", "Yes (fade with repeating stimuli)"],
    ["Post-tetanic potentiation", "No", "Yes"],
    ["Reversal agent", "None available (spontaneous only)", "Neostigmine / Sugammadex"],
    ["Augmented by anticholinesterases", "Block prolonged (do NOT give neostigmine)", "Block reversed"]
  ];

  s.addTable(rows, {
    x: 0.15, y: 1.0, w: 9.7, h: 4.5,
    fontSize: 11.5, fontFace: "Calibri", color: C.navy,
    border: { type: "solid", color: C.light },
    colW: [1.8, 4.0, 3.9],
    rowH: 0.47,
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 8 — Succinylcholine (Pharmacology)
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 2 | Depolarising Agent", "Succinylcholine (Suxamethonium)");
  twoCol(s,
    [
      "Structure: 2× ACh molecules linked at acetyl methyl groups",
      "ED95: 0.3 mg/kg;  Intubating dose: 1–1.5 mg/kg",
      "Onset: 60–90 sec;  Duration: 8–12 min (Phase I)",
      "Paediatric IM dose: 4 mg/kg (up to 150 mg)",
      "Metabolism: pseudocholinesterase (plasma cholinesterase)",
      { text: "NOT metabolised by AChE at NMJ", sub: true },
      "Phase II (Dual) block: large/repeated doses → resembles nondepolarising block",
      { text: "Features: fade, post-tetanic potentiation, reversible by neostigmine", sub: true }
    ],
    [
      "Absolute contraindications:",
      { text: "Hyperkalaemia risk: burns (>8h), denervation, prolonged immobility, rhabdomyolysis", sub: true },
      { text: "Personal/family history of malignant hyperthermia", sub: true },
      { text: "Myopathies (Duchenne / Becker) — K+ release → arrest", sub: true },
      "Relative contraindications:",
      { text: "Raised IOP / ICP (use high-dose rocuronium instead)", sub: true },
      { text: "Atypical pseudocholinesterase → prolonged apnoea", sub: true },
      { text: "Dibucaine number <30: severely atypical; 30–70: heterozygous", sub: true }
    ],
    "Pharmacokinetics / Dosing", "Contraindications & Adverse Effects"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 9 — Nondepolarising Agents (Table)
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 2 | Nondepolarising Agents", "Pharmacokinetic Profiles — Key Agents");

  const rows = [
    [
      { text: "Drug", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "Class", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "ED95 (mg/kg)", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "Intubating dose", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "Onset (min)", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "Duration (min)", options: { bold: true, color: C.white, fill: { color: C.navy } } },
      { text: "Elimination", options: { bold: true, color: C.white, fill: { color: C.navy } } }
    ],
    ["Rocuronium", "Aminosteroid", "0.3", "0.6–1.2 mg/kg", "1.5–3", "30–70", "70% hepatic"],
    ["Vecuronium", "Aminosteroid", "0.05", "0.1 mg/kg", "3–4", "25–50", "Hepatic/renal"],
    ["Pancuronium", "Aminosteroid", "0.07", "0.1 mg/kg", "2–4", "60–120", "60% renal"],
    ["Cisatracurium", "Benzylisoquinolin.", "0.05", "0.15–0.2 mg/kg", "3–5", "45–75", "Hofmann + ester"],
    ["Atracurium", "Benzylisoquinolin.", "0.23", "0.5 mg/kg", "2–3", "25–45", "Hofmann + ester"],
    ["Mivacurium", "Benzylisoquinolin.", "0.08", "0.15 mg/kg", "2–3", "12–20", "Pseudocholinesterase"]
  ];

  s.addTable(rows, {
    x: 0.1, y: 1.0, w: 9.8, h: 4.5,
    fontSize: 11, fontFace: "Calibri", color: C.navy,
    border: { type: "solid", color: C.light },
    colW: [1.35, 1.35, 1.1, 1.35, 1.0, 1.35, 2.3],
    rowH: 0.55,
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 10 — Mechanisms Deeper Dive
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 2 | Mechanisms", "Molecular Pharmacology of NMBDs");
  twoCol(s,
    [
      "All NMBDs are quaternary ammonium compounds",
      { text: "Positively charged N imparts nAChR affinity", sub: true },
      "Nondepolarising agents: competitive antagonists at BOTH α-subunits",
      { text: "Block occurs even if only one α-subunit occupied", sub: true },
      { text: "Also block prejunctional α3β2 receptors → ACh mobilisation impaired → fade", sub: true },
      "Open-channel block (use-dependent):",
      { text: "Some agents enter open ion channel — neostigmine may worsen this", sub: true }
    ],
    [
      "Upregulation states (denervation, burns, immobility):",
      { text: "Extrajunctional immature nAChR (γ-subunit) with prolonged open time", sub: true },
      { text: "Succinylcholine: massive K+ efflux → life-threatening hyperkalaemia", sub: true },
      { text: "Nondepolarisers: RESISTANCE (more receptors to block)", sub: true },
      "Downregulation (myasthenia gravis):",
      { text: "Resistance to succinylcholine; enhanced sensitivity to nondepolarisers", sub: true },
      "Inhaled agents, local anaesthetics, ketamine: potentiate nondepolarising block at receptor-lipid interface"
    ],
    "Core Mechanism", "Disease-State Interactions"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 11 — Section: Monitoring
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  sectionHeader(s, "Section 3", "Neuromuscular Monitoring");
  s.addText("Objective monitoring is mandatory — time and clinical signs cannot reliably exclude RNMB", {
    x: 0.4, y: 2.2, w: 9.2, h: 0.7, fontSize: 16, color: C.light, fontFace: "Calibri", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 12 — Monitoring Modalities
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 3 | Monitoring", "Peripheral Nerve Stimulation Patterns");

  const rows = [
    [
      { text: "Pattern", options: { bold: true, color: C.white, fill: { color: C.steel } } },
      { text: "Description", options: { bold: true, color: C.white, fill: { color: C.steel } } },
      { text: "Clinical Use", options: { bold: true, color: C.white, fill: { color: C.steel } } },
      { text: "Interpretation", options: { bold: true, color: C.white, fill: { color: C.steel } } }
    ],
    ["TOF (Train-of-Four)", "4 stimuli at 2 Hz; compare T4/T1 ratio", "Most widely used; ulnar nerve → adductor pollicis", "Ratio ≥0.9 = adequate recovery; <0.9 = RNMB"],
    ["Single Twitch", "Single supramaximal stimulus at 0.1–1 Hz", "Baseline establishment, post-block monitoring", "Reduction reflects % block"],
    ["Tetanic (50/100 Hz)", "Sustained 5-sec high-frequency stimulation", "Deep block assessment", "Fade = nondepolarising block present"],
    ["PTC (Post-Tetanic Count)", "50 Hz for 5s → 3s pause → single twitches at 1 Hz", "Profound/deep block when TOF = 0", "Count 1–5: deep block; >10: light block"],
    ["DBS (Double-Burst)", "2 × 3 tetanic impulses at 50 Hz separated by 750 ms", "Detect fade manually better than TOF", "Absence of fade ≠ full recovery without quantitative"]
  ];

  s.addTable(rows, {
    x: 0.1, y: 1.0, w: 9.8, h: 4.55,
    fontSize: 11, fontFace: "Calibri", color: C.navy,
    border: { type: "solid", color: C.light },
    colW: [1.9, 2.5, 2.4, 3.0],
    rowH: 0.6,
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 13 — Depth of Block / Quantitative Monitoring
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 3 | Monitoring", "Depth of Block & Quantitative Monitoring");
  twoCol(s,
    [
      "Depth-of-block classification:",
      { text: "Profound: PTC = 0 (TOF = 0, no response to tetanus)", sub: true },
      { text: "Deep: PTC 1–5 (TOF = 0)", sub: true },
      { text: "Moderate: TOF 1–3 twitches (T1-T3 present)", sub: true },
      { text: "Minimal/Shallow: TOF 4 twitches present, ratio <0.9", sub: true },
      { text: "Full recovery: TOF ratio ≥0.9 (quantitative)", sub: true },
      "Residual paralysis (RNMB): TOF ratio 0.7–0.9 → clinical weakness, hypoxic ventilatory response impaired",
      "Subjective assessment (visual/tactile) unreliable below TOF ratio 0.4"
    ],
    [
      "Quantitative (acceleromyography / mechanomyography / electromyography):",
      { text: "Only reliable method to confirm TOF ratio ≥0.9", sub: true },
      { text: "Neuromuscular management guidelines recommend mandatory use", sub: true },
      "Common monitoring site: adductor pollicis (ulnar nerve at wrist)",
      { text: "Facial nerve: overestimates recovery — avoid for decision-making", sub: true },
      "RNMB occurs in ~40% of patients if no reversal agent is used (Barash 9e)",
      "Incidence drops to <1% with sugammadex + quantitative monitoring"
    ],
    "Depth Classification", "Quantitative Monitoring"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 14 — Section: Reversal
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  sectionHeader(s, "Section 4", "Reversal of Neuromuscular Blockade");
  s.addText("Anticholinesterases (neostigmine) vs. Selective Relaxant Binding Agents (sugammadex)", {
    x: 0.4, y: 2.2, w: 9.2, h: 0.7, fontSize: 16, color: C.light, fontFace: "Calibri", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 15 — Neostigmine
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 4 | Reversal", "Neostigmine (Anticholinesterase)");
  twoCol(s,
    [
      "Mechanism: reversible AChE inhibition → ↑ ACh at NMJ → competes with NMBD",
      "Given with anticholinergic (glycopyrrolate 0.2 mg per 1 mg neostigmine OR atropine) to prevent bradycardia, bronchospasm, hypersalivation",
      "Dosing by TOF count:",
      { text: "TOF ≥4 twitches: 0.04–0.05 mg/kg (max 5 mg)", sub: true },
      { text: "TOF 1–3 twitches: 0.07 mg/kg", sub: true },
      { text: "TOF = 0 or PTC <2: do NOT give — inadequate effect, ceiling dose", sub: true },
      "Works ONLY for nondepolarising block",
      { text: "Prolongs succinylcholine (Phase I) by inhibiting pseudocholinesterase", sub: true }
    ],
    [
      "Limitations:",
      { text: "Ceiling effect: max dose may not fully reverse deep block", sub: true },
      { text: "Time to TOF ratio ≥0.9 is highly variable (Barash 9e)", sub: true },
      { text: "Paradoxical neostigmine-induced weakness at high doses (open-channel block)", sub: true },
      "Onset: 5–10 min; Duration: 60–90 min",
      "Contraindicated: bowel obstruction (muscarinic activation → increased secretions, peristalsis)",
      "Important: TOF ratio must be confirmed ≥0.9 with quantitative monitor after reversal — never extubate on neostigmine alone at deep block"
    ],
    "Mechanism & Dosing", "Limitations & Cautions"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 16 — Sugammadex
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 4 | Reversal", "Sugammadex (Selective Relaxant Binding Agent)");
  twoCol(s,
    [
      "Modified γ-cyclodextrin — encapsulates rocuronium / vecuronium in high-affinity 1:1 complex (Ka >10⁷ M⁻¹)",
      { text: "Does NOT work for benzylisoquinolinium agents (atracurium, cisatracurium)", sub: true },
      "Dosing by depth of block:",
      { text: "Moderate (TOF ≥2): 2 mg/kg", sub: true },
      { text: "Deep (PTC 1–5): 4 mg/kg", sub: true },
      { text: "Immediate reversal / RSI emergency: 16 mg/kg", sub: true },
      "Onset: TOF ratio ≥0.9 within 3 min at 16 mg/kg dose"
    ],
    [
      "Advantages over neostigmine:",
      { text: "Can reverse any depth including profound block", sub: true },
      { text: "No muscarinic side effects — no anticholinergic required", sub: true },
      { text: "Faster, more predictable reversal (RCT evidence)", sub: true },
      "Cautions:",
      { text: "Sugammadex-rocuronium complex excreted renally; avoid in severe renal impairment (CrCl <30)", sub: true },
      { text: "May reduce efficacy of toremifene and hormonal contraceptives — advise patients", sub: true },
      { text: "Re-paralysis risk if inadequate dose or too early use — re-dose if TOF falls again", sub: true },
      "Cost consideration: ~20× more expensive than neostigmine in most formularies"
    ],
    "Mechanism & Dosing", "Advantages & Cautions"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 17 — Section: Pharmacology in Special Situations
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  sectionHeader(s, "Section 5", "Special Situations & Clinical Application");
  s.addText("RSI · Difficult airway · Organ impairment · Paediatrics · Intensive care", {
    x: 0.4, y: 2.2, w: 9.2, h: 0.7, fontSize: 16, color: C.light, fontFace: "Calibri", margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 18 — RSI & Difficult Airway
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 5 | Clinical Application", "Rapid Sequence Induction (RSI)");
  twoCol(s,
    [
      "Goal: achieve intubating conditions rapidly with cricoid pressure to reduce aspiration risk",
      "Traditional agent: Succinylcholine 1.5 mg/kg",
      { text: "Fastest onset (60–90s), ultra-short duration", sub: true },
      { text: "Contraindicated: hyperkalaemia risk, MH susceptibility, myopathy", sub: true },
      "Alternative: High-dose Rocuronium 1.2 mg/kg",
      { text: "Comparable intubating conditions at 60s vs succinylcholine", sub: true },
      { text: "Reversed immediately with sugammadex 16 mg/kg if cannot intubate", sub: true },
      { text: "'Cannot intubate, cannot oxygenate' (CICO) — rocuronium + sugammadex is gold standard alternative", sub: true }
    ],
    [
      "Priming principle (rarely used now):",
      { text: "10% of intubating dose given 3 min prior → ↓ onset time of full dose", sub: true },
      { text: "Risk: premature paralysis, apnoea", sub: true },
      "Timing of block assessment:",
      { text: "Laryngoscopy at T1 = 0 on single twitch OR 60–90s post-drug", sub: true },
      "Modified RSI (safe to preoxy + ventilate gently in paediatrics / obesity):",
      { text: "Lower aspiration risk population — mask ventilation permitted", sub: true },
      "NEVER paralysed and failed airway: always have clear rescue plan (LMA, surgical airway)"
    ],
    "Standard RSI", "Alternatives & Key Points"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 19 — Organ Impairment & Special Populations
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 5 | Special Populations", "Drug Selection in Organ Impairment");

  const rows = [
    [
      { text: "Condition", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Impact", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Preferred Agent", options: { bold: true, color: C.white, fill: { color: C.navyMid } } },
      { text: "Agents to Avoid / Use Caution", options: { bold: true, color: C.white, fill: { color: C.navyMid } } }
    ],
    ["Renal failure", "↑ Duration of renally cleared agents", "Cisatracurium (Hofmann elimination)", "Pancuronium (60% renal), rocuronium (moderate ↑)"],
    ["Hepatic failure", "↑ Duration aminosteroids; ↓ pseudocholinesterase", "Cisatracurium, atracurium", "Vecuronium, rocuronium (significant ↑)"],
    ["Burns / Denervation", "Extrajunctional receptor upregulation", "Nondepolarising agents only", "Succinylcholine CONTRAINDICATED (hyperkalaemia)"],
    ["Myasthenia Gravis", "Fewer functional nAChR", "Reduce nondepolarising dose 50–75%", "Succinylcholine: resistance; nondepolarisers: hypersensitive"],
    ["Paediatrics", "Higher volume of distribution, faster metabolism", "Succinylcholine (RSI only), cisatracurium, atracurium", "Succinylcholine: IM for intubation only (not MH/myopathy)"],
    ["Obesity (BMI >40)", "Use IBW for NMBDs; TBW for succinylcholine", "Rocuronium (IBW dosing) + sugammadex reversal", "Avoid under-dosing — residual block risk is higher"]
  ];

  s.addTable(rows, {
    x: 0.1, y: 1.0, w: 9.8, h: 4.5,
    fontSize: 10.5, fontFace: "Calibri", color: C.navy,
    border: { type: "solid", color: C.light },
    colW: [1.6, 2.2, 2.3, 3.7],
    rowH: 0.55,
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 20 — Drug Interactions
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 5 | Pharmacology", "Drug Interactions with NMBDs");
  twoCol(s,
    [
      "POTENTIATE (enhance/prolong) nondepolarising block:",
      { text: "Volatile anaesthetics (isoflurane > desflurane > sevoflurane > nitrous oxide)", sub: true },
      { text: "Aminoglycoside antibiotics (gentamicin, tobramycin) — inhibit Ca²+ and ACh release", sub: true },
      { text: "Magnesium sulphate — inhibit Ca²+ channels and ACh release; antagonises nAChR", sub: true },
      { text: "Calcium channel blockers, local anaesthetics, lithium, loop diuretics", sub: true },
      { text: "Hypothermia — ↓ plasma clearance, Hofmann elimination slowed", sub: true },
      { text: "Acidosis — ↓ antagonism by anticholinesterases", sub: true }
    ],
    [
      "ANTAGONISE (reduce) nondepolarising block:",
      { text: "Chronic anticonvulsants (phenytoin, carbamazepine) — upregulate receptors", sub: true },
      { text: "Chronic corticosteroids — receptor upregulation", sub: true },
      { text: "Chronic theophylline — complex interaction", sub: true },
      "PROLONG succinylcholine block:",
      { text: "Organophosphates, ecothiopate eyedrops — inhibit pseudocholinesterase", sub: true },
      { text: "Cyclophosphamide, metoclopramide, pancuronium — reduce pseudocholinesterase activity", sub: true },
      { text: "Atypical pseudocholinesterase gene (dibucaine number <30)", sub: true }
    ],
    "Augment Nondepolarising Block", "Reduce or Prolong Block"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 21 — ICU Neuromuscular Blockade
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 5 | ICU Application", "NMBDs in the Intensive Care Setting");
  twoCol(s,
    [
      "Indications for ICU NMB:",
      { text: "Severe ARDS (P:F <150 mmHg): ACURASYS trial — cisatracurium 48h → ↓ mortality (note: larger ROSE trial did not confirm benefit with liberal sedation/PEEP)", sub: true },
      { text: "Refractory raised ICP", sub: true },
      { text: "Patient-ventilator dyssynchrony", sub: true },
      { text: "Status epilepticus (motor activity control)", sub: true },
      "Preferred agent: Cisatracurium",
      { text: "Organ-independent elimination: no accumulation in renal/hepatic failure", sub: true },
      { text: "Anti-inflammatory properties (direct lung-protective effect suggested in animal models)", sub: true }
    ],
    [
      "Complications of prolonged ICU NMB:",
      { text: "Critical illness myopathy / neuropathy (especially with corticosteroids)", sub: true },
      { text: "Prolonged ventilation, pressure injuries, DVT", sub: true },
      { text: "Awareness under anaesthesia (NMBDs have NO sedative/analgesic properties)", sub: true },
      "Monitoring in ICU:",
      { text: "PTC and TOF monitoring required — titrate to PTC 1–2 for deep block", sub: true },
      { text: "Daily drug holidays to assess neurological status recommended", sub: true },
      "Awareness precaution: ensure adequate sedation/analgesia BEFORE NMB",
      { text: "BIS / auditory evoked potentials to guide depth of sedation", sub: true }
    ],
    "Indications & Agent of Choice", "Complications & Monitoring"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 22 — Residual NMB & Patient Safety
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 6 | Safety", "Residual Neuromuscular Blockade (RNMB)");
  twoCol(s,
    [
      "Definition: TOF ratio <0.9 at time of extubation/PACU arrival",
      "Incidence: ~40% without pharmacological reversal; 20% after neostigmine alone",
      "Clinical consequences:",
      { text: "Pharyngeal dysfunction → aspiration risk", sub: true },
      { text: "Upper airway obstruction (tongue, pharynx)", sub: true },
      { text: "Impaired hypoxic ventilatory response (carotid body chemoreceptors very sensitive)", sub: true },
      { text: "Postoperative pulmonary complications → ↑ morbidity", sub: true },
      "Signs of RNMB: inability to sustain head lift for 5s, weak hand grip, paradoxical breathing, diplopia"
    ],
    [
      "Prevention strategy:",
      { text: "Quantitative TOF monitoring throughout case", sub: true },
      { text: "Titrate NMBD to minimum effective dose; use short-acting agents when possible", sub: true },
      { text: "Do NOT rely on time or clinical signs alone", sub: true },
      { text: "Reverse appropriately: sugammadex preferred for deep block", sub: true },
      { text: "Confirm TOF ratio ≥0.9 before extubation", sub: true },
      "RNMB in PACU: give sugammadex (2–4 mg/kg depending on TOF count)",
      "Documentation: record NMBD dose, timing, TOF values, reversal agent and dose in anaesthetic record"
    ],
    "Definition & Clinical Impact", "Prevention & Management"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 23 — Malignant Hyperthermia
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Section 6 | Adverse Events", "Malignant Hyperthermia (MH) & NMBDs");
  twoCol(s,
    [
      "Succinylcholine is a TRIGGERING AGENT for MH",
      { text: "Autosomal dominant RyR1 / DHPR mutation → uncontrolled SR Ca²+ release", sub: true },
      { text: "Masseter spasm after succinylcholine may be early warning", sub: true },
      "Volatile anaesthetic agents are the primary triggers; succinylcholine is a co-trigger",
      "MH Triad: hypercapnia, hyperthermia, muscle rigidity + metabolic acidosis, hyperkalaemia, CK elevation",
      "Incidence: ~1:10,000 (paediatric), ~1:50,000–100,000 (adult)"
    ],
    [
      "Management of MH:",
      { text: "STOP triggering agent immediately — switch to TIVA (propofol)", sub: true },
      { text: "Dantrolene sodium: 2.5 mg/kg IV bolus, repeat every 5 min up to 10 mg/kg total", sub: true },
      { text: "Cooling: cold IV fluids, ice packs, cooling blanket", sub: true },
      { text: "Correct hyperkalaemia, acidosis, arrhythmias", sub: true },
      { text: "Monitor in ICU — MH may recur for 24–48 h", sub: true },
      "NMBDs for MH-susceptible patient:",
      { text: "Use non-triggering: nondepolarising agents (rocuronium, vecuronium, cisatracurium) are SAFE", sub: true },
      { text: "TIVA with propofol + opioid + non-triggering NMBD is standard", sub: true }
    ],
    "Succinylcholine & MH Risk", "Crisis Management"
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 24 — Key Clinical Pearls
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = contentSlide(false);
  addHeader(s, "Summary", "Key Clinical Pearls for the Anaesthesia Trainee");
  bullets(s, [
    "NMBDs cause paralysis with NO sedation or analgesia — always ensure adequate depth of anaesthesia before giving",
    "Succinylcholine remains fastest onset/offset agent but carries significant risk profile — know your contraindications",
    "High-dose rocuronium (1.2 mg/kg) is the evidence-based alternative to succinylcholine in RSI — always have sugammadex 16 mg/kg drawn up",
    "Cisatracurium is the agent of choice in hepatic/renal failure and prolonged ICU use (Hofmann elimination)",
    "TOF ratio <0.9 = residual paralysis — never extubate without quantitative confirmation of ≥0.9",
    "Sugammadex reverses aminosteroid agents at ANY depth; neostigmine requires at least TOF count ≥2 twitches",
    "Drug interactions are common — volatile agents, aminoglycosides, and MgSO4 all potentiate nondepolarising block",
    "In burns/denervation: succinylcholine is absolutely contraindicated after 24–48h due to hyperkalaemia risk"
  ], { fontSize: 13.5, color: C.navy });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 25 — References & End
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = addSlide(true);
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.07, fill: { color: C.amber }, line: { color: C.amber } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: C.amber }, line: { color: C.amber } });
  s.addText("REFERENCES & FURTHER READING", {
    x: 0.4, y: 0.25, w: 9.2, h: 0.5,
    fontSize: 18, bold: true, color: C.amber, fontFace: "Calibri", margin: 0
  });
  const refs = [
    "Miller RD et al. Miller's Anesthesia, 10th ed. Elsevier, 2024. [Chapters 24, 28, 32]",
    "Barash PG et al. Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed. Wolters Kluwer, 2022. [Chapter 21]",
    "Morgan GE, Mikhail MS. Morgan & Mikhail's Clinical Anesthesiology, 7th ed. McGraw Hill, 2022. [Chapter 11]",
    "Brunton LL et al. Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. McGraw Hill, 2023. [Chapter 13]",
    "Murphy GS et al. Residual neuromuscular blockade. Anesth Analg. 2010;111:693–713.",
    "Aarons L. Sugammadex: a new neostigmine alternative. Br J Anaesth. 2007;99:461–468.",
    "Papazian L et al. (ACURASYS). NEJM. 2010;363:1107–1116. | Moss M et al. (ROSE). NEJM. 2019;380:1997–2008.",
    "Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring. Anesthesiology. 2017;126:173–190."
  ];
  const refArr = refs.map((r, i) => ({
    text: r,
    options: { breakLine: i < refs.length - 1, bullet: { code: "25CF" } }
  }));
  s.addText(refArr, {
    x: 0.4, y: 0.85, w: 9.3, h: 4.5,
    fontSize: 11.5, color: C.light, fontFace: "Calibri",
    valign: "top", paraSpaceAfter: 4
  });
}

// ─── Write file ────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/nmb-ppt/Neuromuscular_Blockade_Anaesthesia.pptx" })
  .then(() => console.log("DONE"))
  .catch(e => { console.error(e); process.exit(1); });

cd /home/daytona/workspace/nmb-ppt && node build.js 2>&1

ls -lh /home/daytona/workspace/nmb-ppt/Neuromuscular_Blockade_Anaesthesia.pptx