hydrocortisone perioperative anaesthesia corticosteroid

ls -la /tmp/workspace/ 2>/dev/null || echo "Directory does not exist"

mkdir -p /tmp/workspace/hydrocortisone && python3 << 'EOF' from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import cm from reportlab.lib import colors from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, KeepTogether) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY doc = SimpleDocTemplate( "/tmp/workspace/hydrocortisone/Hydrocortisone_Anaesthesia.pdf", pagesize=A4, rightMargin=2*cm, leftMargin=2*cm, topMargin=2*cm, bottomMargin=2*cm ) styles = getSampleStyleSheet() # Custom styles title_style = ParagraphStyle('Title', parent=styles['Title'], fontSize=22, textColor=colors.HexColor('#1a3a5c'), spaceAfter=6, alignment=TA_CENTER, fontName='Helvetica-Bold') subtitle_style = ParagraphStyle('Subtitle', parent=styles['Normal'], fontSize=11, textColor=colors.HexColor('#4a6fa5'), spaceAfter=14, alignment=TA_CENTER, fontName='Helvetica-Oblique') h1_style = ParagraphStyle('H1', parent=styles['Heading1'], fontSize=14, textColor=colors.white, spaceAfter=6, spaceBefore=14, fontName='Helvetica-Bold', backColor=colors.HexColor('#1a3a5c'), leftIndent=-0.5*cm, rightIndent=-0.5*cm, leading=20, borderPadding=(6,8,6,8)) h2_style = ParagraphStyle('H2', parent=styles['Heading2'], fontSize=12, textColor=colors.HexColor('#1a3a5c'), spaceAfter=4, spaceBefore=10, fontName='Helvetica-Bold', borderPadding=(2,0,2,0)) body_style = ParagraphStyle('Body', parent=styles['Normal'], fontSize=10, leading=14, spaceAfter=6, alignment=TA_JUSTIFY, fontName='Helvetica') bullet_style = ParagraphStyle('Bullet', parent=styles['Normal'], fontSize=10, leading=14, spaceAfter=3, leftIndent=16, bulletIndent=6, fontName='Helvetica') note_style = ParagraphStyle('Note', parent=styles['Normal'], fontSize=9, leading=12, spaceAfter=4, fontName='Helvetica-Oblique', textColor=colors.HexColor('#555555')) ref_style = ParagraphStyle('Ref', parent=styles['Normal'], fontSize=8, leading=11, spaceAfter=2, fontName='Helvetica', textColor=colors.HexColor('#444444')) story = [] # ── TITLE ────────────────────────────────────────────────────────────────── story.append(Spacer(1, 0.3*cm)) story.append(Paragraph("HYDROCORTISONE", title_style)) story.append(Paragraph("A Clinical Reference for Anaesthesia Practice", subtitle_style)) story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#4a6fa5'))) story.append(Spacer(1, 0.4*cm)) # ── 1. OVERVIEW ───────────────────────────────────────────────────────────── story.append(Paragraph("1. Overview", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "Hydrocortisone (cortisol) is the principal endogenous glucocorticoid secreted by the zona fasciculata " "of the adrenal cortex. It has both glucocorticoid (anti-inflammatory, metabolic) and significant " "mineralocorticoid (sodium-retaining) activity. In anaesthetic practice it is used for perioperative " "steroid cover, adrenal crisis management, post-etomidate adrenal suppression, and as an adjunct " "in anaphylaxis/allergic reactions.", body_style)) # Basic pharmacology table pharm_data = [ ['Parameter', 'Value'], ['Drug class', 'Short-acting glucocorticoid (natural)'], ['Anti-inflammatory potency', '1.0 (reference standard)'], ['Mineralocorticoid potency', '1.0 (reference standard)'], ['Equivalent dose', '20 mg (oral/IV)'], ['Half-life', '~90 minutes (plasma); 8–12 h (biological)'], ['Route of administration', 'IV, IM, oral, topical, rectal'], ['Protein binding', '~90% (cortisol-binding globulin + albumin)'], ['Metabolism', 'Hepatic (CYP3A4); renal excretion of metabolites'], ] pharm_table = Table(pharm_data, colWidths=[6.5*cm, 11*cm]) pharm_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('BACKGROUND', (0,1), (-1,-1), colors.HexColor('#f0f4fa')), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f0f4fa'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'), ('VALIGN', (0,0), (-1,-1), 'MIDDLE'), ('PADDING', (0,0), (-1,-1), 5), ])) story.append(pharm_table) story.append(Spacer(1, 0.3*cm)) # ── 2. MECHANISM OF ACTION ────────────────────────────────────────────────── story.append(Paragraph("2. Mechanism of Action", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "Hydrocortisone binds to intracellular glucocorticoid receptors (GR-alpha). The drug-receptor complex " "translocates to the nucleus and modulates transcription of target genes:", body_style)) for pt in [ "<b>Anti-inflammatory:</b> Inhibits phospholipase A2 (via lipocortin-1/annexin-1), reducing synthesis of prostaglandins, leukotrienes, and thromboxanes. Suppresses NF-kB, reducing cytokine production (IL-1, IL-6, TNF-alpha).", "<b>Immunosuppression:</b> Reduces T-lymphocyte proliferation, decreases capillary permeability, inhibits mast cell degranulation.", "<b>Metabolic:</b> Gluconeogenesis promotion, peripheral insulin resistance, lipolysis, protein catabolism.", "<b>Mineralocorticoid:</b> Activates renal mineralocorticoid receptors -> sodium and water retention, potassium excretion.", "<b>HPA axis suppression:</b> Negative feedback on hypothalamus (CRH) and anterior pituitary (ACTH) with chronic use.", ]: story.append(Paragraph(f"• {pt}", bullet_style)) story.append(Spacer(1, 0.2*cm)) # ── 3. INDICATIONS IN ANAESTHESIA ────────────────────────────────────────── story.append(Paragraph("3. Indications in Anaesthesia", h1_style)) story.append(Spacer(1, 0.2*cm)) indic_data = [ ['Indication', 'Rationale'], ['Perioperative steroid cover\n(adrenal suppression)', 'Patients on chronic steroids have HPA suppression\nand cannot mount a cortisol stress response'], ['Acute adrenal insufficiency /\nAddisonian crisis', 'Life-threatening emergency requiring immediate\nhigh-dose replacement'], ['Post-etomidate adrenal suppression', 'Etomidate inhibits 11-beta hydroxylase; single\ndose can suppress cortisol for 4–8 hours'], ['Anaphylaxis (adjunct)', 'Adjunct to epinephrine; attenuates late-phase\nreaction (acts over hours, not minutes)'], ['Critical illness-related corticosteroid\ninsufficiency (CIRCI)', 'Relative adrenal insufficiency in septic shock\nunresponsive to vasopressors'], ['Postoperative nausea and vomiting\n(PONV) prophylaxis', 'Dexamethasone preferred but hydrocortisone used\nwhen mineralocorticoid effect is desired'], ['Airway oedema (post-extubation\nstridor)', 'Reduces mucosal oedema; given before extubation\nin prolonged intubation cases'], ] indic_table = Table(indic_data, colWidths=[8*cm, 9.5*cm]) indic_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f0f4fa'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), ])) story.append(indic_table) story.append(Spacer(1, 0.3*cm)) # ── 4. PERIOPERATIVE STEROID COVER ────────────────────────────────────────── story.append(Paragraph("4. Perioperative Steroid Cover", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Who needs cover?</b> Patients with known adrenal insufficiency OR those with HPA suppression " "from chronic corticosteroid use. HPA suppression should be suspected if:", body_style)) for pt in [ "Prednisone ≥ 20 mg/day for ≥ 5 days (or equivalent)", "Any dose of steroids for ≥ 3 weeks", "Clinically Cushingoid appearance regardless of dose", "Recovery of HPA function can take up to 9–12 months after cessation", ]: story.append(Paragraph(f"• {pt}", bullet_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph("<b>Perioperative Hydrocortisone Dosing by Surgical Stress Level</b>", h2_style)) cover_data = [ ['Surgical Stress', 'Examples', 'Regimen'], ['Minor\n(low stress)', 'Superficial procedures,\nendoscopy, dental', 'Take usual morning steroid dose.\nNo supplementation needed.'], ['Moderate\n(medium stress)', 'Abdominal surgery,\njoint replacement, TURP', 'Take usual morning dose.\nHydrocortisone 50 mg IV at induction,\nthen 25 mg IV q8h for 24–36 h.\nResume usual dose on POD 2.'], ['Major\n(high stress)', 'CABG, major vascular,\nlarge abdominal resection', 'Take usual morning dose.\nHydrocortisone 100 mg IV at induction,\nthen 50 mg IV q8h for 24–36 h.\nTaper over POD 2–3, resume usual dose.'], ] cover_table = Table(cover_data, colWidths=[3.5*cm, 5.5*cm, 8.5*cm]) cover_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f0f4fa'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), ('BACKGROUND', (0,1), (0,1), colors.HexColor('#d4e6f1')), ('BACKGROUND', (0,2), (0,2), colors.HexColor('#aed6f1')), ('BACKGROUND', (0,3), (0,3), colors.HexColor('#5dade2')), ('TEXTCOLOR', (0,3), (0,3), colors.white), ('FONTNAME', (0,3), (0,3), 'Helvetica-Bold'), ])) story.append(cover_table) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<i>Alternative low-dose regimen: Hydrocortisone 25 mg IV after induction, followed by continuous IV " "infusion of 100 mg over 24 h (Symreng et al., Br J Anaesth 1981). Maintains plasma cortisol similar " "to surgical controls without excess. (Barash Clinical Anesthesia 9e, Table 47-7)</i>", note_style)) story.append(Spacer(1, 0.2*cm)) # ── 5. ACUTE ADRENAL CRISIS ───────────────────────────────────────────────── story.append(Paragraph("5. Acute Adrenal Insufficiency / Addisonian Crisis", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph("<b>Clinical features:</b>", h2_style)) for pt in [ "Severe hypotension, haemodynamic shock unresponsive to fluids and vasopressors", "Nausea, vomiting, abdominal pain", "Hyponatraemia, hyperkalaemia (primary AI), hypoglycaemia", "Fever, confusion, decreased consciousness", "Hyperpigmentation (primary AI only - due to elevated ACTH/beta-lipotropin)", ]: story.append(Paragraph(f"• {pt}", bullet_style)) story.append(Paragraph("<b>Emergency Management:</b>", h2_style)) crisis_data = [ ['Step', 'Action'], ['1', 'Hydrocortisone 100 mg IV bolus IMMEDIATELY'], ['2', 'Hydrocortisone 100 mg IV q6h for the first 24 hours'], ['3', 'Aggressive IV fluid resuscitation (0.9% NaCl + dextrose)'], ['4', 'Correct electrolyte abnormalities (Na+, K+, glucose)'], ['5', 'Monitor vital signs, urine output, serum electrolytes closely'], ['6', 'Once stable: taper hydrocortisone, transition to oral, add fludrocortisone'], ] crisis_table = Table(crisis_data, colWidths=[1.5*cm, 16*cm]) crisis_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#c0392b')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#fdf2f2'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#e8c0c0')), ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'), ('VALIGN', (0,0), (-1,-1), 'MIDDLE'), ('PADDING', (0,0), (-1,-1), 5), ('BACKGROUND', (0,1), (1,1), colors.HexColor('#f5b7b1')), ('FONTNAME', (1,1), (1,1), 'Helvetica-Bold'), ])) story.append(crisis_table) story.append(Spacer(1, 0.2*cm)) # ── 6. ETOMIDATE & ADRENAL SUPPRESSION ───────────────────────────────────── story.append(Paragraph("6. Etomidate and Adrenal Suppression", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "Etomidate is a commonly used IV induction agent (especially in haemodynamically compromised patients) " "but it inhibits adrenal mitochondrial 11-beta hydroxylase - the enzyme responsible for cortisol " "synthesis. Even a single induction dose suppresses cortisol production for 4-8 hours, with effects " "potentially lasting up to 24 hours.", body_style)) story.append(Paragraph("<b>Clinical implications:</b>", h2_style)) for pt in [ "Consider stress-dose hydrocortisone after etomidate induction in critically ill or septic patients", "Hydrocortisone 100 mg IV covers the adrenal suppression period", "Evidence: CORTICUS and related trials showed benefit of hydrocortisone in vasopressor-dependent septic shock post-etomidate", "Routine use in all etomidate cases is not universally endorsed - reserve for high-risk patients (sepsis, known adrenal insufficiency)", ]: story.append(Paragraph(f"• {pt}", bullet_style)) story.append(Spacer(1, 0.2*cm)) # ── 7. SEPSIS / CRITICAL ILLNESS ──────────────────────────────────────────── story.append(Paragraph("7. Sepsis and Critical Illness (CIRCI)", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "Critical illness-related corticosteroid insufficiency (CIRCI) describes relative or absolute adrenal " "insufficiency in the critically ill. The clinical picture may mimic sepsis without a source. " "Suspect in any patient with unexplained cardiovascular instability.", body_style)) story.append(Paragraph("<b>Surviving Sepsis Campaign / Current Guidance:</b>", h2_style)) for pt in [ "Hydrocortisone 200 mg/day IV (continuous infusion preferred; or 50 mg q6h bolus) is recommended ONLY if haemodynamic goals are not achievable with adequate fluids and vasopressors", "Do NOT use hydrocortisone as a diagnostic test (ACTH stimulation response does not predict who will respond)", "Taper hydrocortisone when vasopressors are no longer required", "Addition of fludrocortisone 50 mcg orally daily (optional, based on APROCCHSS trial evidence)", ]: story.append(Paragraph(f"• {pt}", bullet_style)) story.append(Spacer(1, 0.2*cm)) # ── 8. ANAPHYLAXIS (ADJUNCT) ──────────────────────────────────────────────── story.append(Paragraph("8. Anaphylaxis - Role as Adjunct", h1_style)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Key principle:</b> Hydrocortisone is NOT a first-line drug in anaphylaxis. " "Epinephrine (adrenaline) is the ONLY first-line treatment. Hydrocortisone is an adjunct " "given AFTER epinephrine to attenuate the late-phase (biphasic) allergic response.", body_style)) anaphl_data = [ ['Drug', 'Role', 'Dose (Adult)', 'Timing'], ['Epinephrine', 'FIRST-LINE - vasopressor,\nbronchodilator', '0.5 mg IM (1:1000)\nor IV infusion', 'IMMEDIATE'], ['Hydrocortisone', 'Adjunct - reduces late-phase\nreaction, prevents relapse', '200 mg IV bolus\n(100–200 mg)', 'After epinephrine,\nwithin minutes'], ['Chlorphenamine\n(antihistamine)', 'Adjunct - reduces urticaria,\nitching', '10 mg IV slow', 'After epinephrine'], ] anaphl_table = Table(anaphl_data, colWidths=[4*cm, 5.5*cm, 4.5*cm, 3.5*cm]) anaphl_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f0f4fa'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), ('BACKGROUND', (0,1), (-1,1), colors.HexColor('#f5b7b1')), ('FONTNAME', (0,1), (-1,1), 'Helvetica-Bold'), ])) story.append(anaphl_table) story.append(Paragraph( "<i>Note: Hydrocortisone takes 4-6 hours to exert its anti-inflammatory effect. " "It does NOT reverse acute bronchospasm or anaphylactic shock acutely.</i>", note_style)) story.append(Spacer(1, 0.2*cm)) # ── 9. GLUCOCORTICOID COMPARISON TABLE ────────────────────────────────────── story.append(Paragraph("9. Glucocorticoid Comparison Table", h1_style)) story.append(Spacer(1, 0.2*cm)) gc_data = [ ['Drug', 'Anti-\ninflammatory', 'Mineralocorticoid', 'Equiv. Dose\n(mg)', 'Duration'], ['Hydrocortisone\n(short-acting)', '1.0', '1.0', '20', '8–12 h'], ['Cortisone\n(short-acting)', '0.8', '0.8', '25', '8–12 h'], ['Prednisone\n(intermediate)', '4.0', '0.25', '5', '12–36 h'], ['Prednisolone\n(intermediate)', '4.0', '0.25', '5', '12–36 h'], ['Methylprednisolone\n(intermediate)', '5.0', 'Minimal', '4', '12–36 h'], ['Dexamethasone\n(long-acting)', '25–30', 'None', '0.75', '36–72 h'], ['Fludrocortisone', '10', '125–150', '~2', '18–36 h'], ] gc_table = Table(gc_data, colWidths=[4.5*cm, 2.5*cm, 3*cm, 2.5*cm, 3*cm]) gc_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#eaf4fb'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'), ('BACKGROUND', (0,1), (-1,1), colors.HexColor('#d6eaf8')), # highlight hydrocortisone ('FONTNAME', (0,1), (-1,1), 'Helvetica-Bold'), ('VALIGN', (0,0), (-1,-1), 'MIDDLE'), ('PADDING', (0,0), (-1,-1), 5), ('ALIGN', (1,0), (-1,-1), 'CENTER'), ])) story.append(gc_table) story.append(Paragraph( "<i>Source: Barash Clinical Anesthesia 9e, Table 47-8; Goodman & Gilman's Pharmacological Basis of Therapeutics</i>", note_style)) story.append(Spacer(1, 0.2*cm)) # ── 10. CONTRAINDICATIONS & SIDE EFFECTS ──────────────────────────────────── story.append(Paragraph("10. Side Effects and Considerations in Anaesthesia", h1_style)) story.append(Spacer(1, 0.2*cm)) se_data = [ ['Side Effect / Consideration', 'Relevance to Anaesthesia'], ['Hyperglycaemia', 'Monitor blood glucose intra/postoperatively; may require insulin'], ['Sodium and water retention', 'Relevant in cardiac/renal patients; monitor fluid balance'], ['Hypokalaemia', 'Risk of cardiac arrhythmias; check K+ preoperatively'], ['Hypertension', 'May worsen perioperative BP; monitor closely'], ['Immunosuppression', 'Increased infection risk; aseptic technique essential'], ['Wound healing impairment', 'Inform surgeon; consider in postoperative assessment'], ['Psychiatric effects', 'Acute mania/psychosis possible at high doses; monitor postoperatively'], ['Osteoporosis (chronic use)', 'Consider bone protection for long-term users'], ['Masking of infection', 'Fever may be blunted; maintain high clinical suspicion'], ['Adrenal suppression', 'Do NOT abruptly stop in patients on chronic therapy'], ] se_table = Table(se_data, colWidths=[6.5*cm, 11*cm]) se_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#7d3c98')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f9f0ff'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#d2b4de')), ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), ])) story.append(se_table) story.append(Spacer(1, 0.3*cm)) # ── 11. DRUG INTERACTIONS ──────────────────────────────────────────────────── story.append(Paragraph("11. Relevant Drug Interactions", h1_style)) story.append(Spacer(1, 0.2*cm)) di_data = [ ['Interacting Drug/Class', 'Mechanism', 'Clinical Effect'], ['NSAIDs', 'Additive GI irritation', 'Increased risk of GI bleed/ulceration'], ['Antidiabetics / Insulin', 'Hydrocortisone raises glucose', 'Reduced hypoglycaemic effect; increase insulin dose'], ['Anticoagulants (warfarin)', 'Altered clotting factor synthesis', 'Variable; monitor INR closely'], ['Diuretics (thiazide/loop)', 'Additive potassium loss', 'Severe hypokalaemia; monitor K+'], ['CYP3A4 inducers\n(rifampicin, phenytoin)', 'Increased hydrocortisone metabolism', 'Reduced efficacy; increase dose'], ['CYP3A4 inhibitors\n(azole antifungals)', 'Reduced hydrocortisone metabolism', 'Enhanced effect; toxicity risk'], ['Neuromuscular blockers', 'Hypokalaemia potentiates block', 'Prolonged neuromuscular blockade'], ['Etomidate', 'Blocks cortisol synthesis', 'Worsens adrenal suppression'], ['Live vaccines', 'Immunosuppression', 'Risk of disseminated infection; avoid'], ] di_table = Table(di_data, colWidths=[5*cm, 5*cm, 7.5*cm]) di_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a3a5c')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f0f4fa'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#c0c8d8')), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), ])) story.append(di_table) story.append(Spacer(1, 0.3*cm)) # ── 12. QUICK REFERENCE DOSING CARD ───────────────────────────────────────── story.append(Paragraph("12. Quick Reference - Dosing Summary", h1_style)) story.append(Spacer(1, 0.2*cm)) qr_data = [ ['Clinical Scenario', 'Dose', 'Route', 'Notes'], ['Adrenal crisis\n(emergency)', '100 mg bolus, then\n100 mg q6h x 24h', 'IV', 'With fluids & electrolytes'], ['Major surgery cover', '100 mg at induction,\n50 mg q8h x 24–36h', 'IV', 'Taper to home dose POD 2–3'], ['Moderate surgery cover', '50 mg at induction,\n25 mg q8h x 24h', 'IV', 'Usual home dose morning of sx'], ['Minor surgery cover', 'None (extra dose)', 'Oral/IV', 'Take usual morning dose only'], ['Septic shock (CIRCI)', '200 mg/day', 'IV infusion\nor 50 mg q6h', 'Only if vasopressor-refractory'], ['Post-etomidate cover\n(critical illness)', '100 mg', 'IV', 'Single dose; reassess daily'], ['Anaphylaxis (adjunct)', '100–200 mg', 'IV', 'After epinephrine; not first-line'], ['Maintenance replacement\n(AI, unstressed)', '20 mg AM + 10 mg PM', 'Oral', 'With fludrocortisone 0.05–0.1 mg'], ['Physiologic infusion\n(low-dose protocol)', '25 mg induction +\n100 mg over 24h infusion', 'IV', 'Symreng et al. protocol'], ] qr_table = Table(qr_data, colWidths=[4.5*cm, 4.5*cm, 2.5*cm, 6*cm]) qr_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#27ae60')), ('TEXTCOLOR', (0,0), (-1,0), colors.white), ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 9), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#eafaf1'), colors.white]), ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#a9dfbf')), ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('PADDING', (0,0), (-1,-1), 5), # Highlight adrenal crisis row ('BACKGROUND', (0,1), (-1,1), colors.HexColor('#fadbd8')), ('FONTNAME', (0,1), (-1,1), 'Helvetica-Bold'), ])) story.append(qr_table) story.append(Spacer(1, 0.3*cm)) # ── REFERENCES ─────────────────────────────────────────────────────────────── story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#aaaaaa'))) story.append(Spacer(1, 0.15*cm)) story.append(Paragraph("References", h2_style)) refs = [ "Barash PG, et al. Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed. Wolters Kluwer, 2022. (Tables 47-6, 47-7, 47-8; Fig. 47-4)", "Brunton LL, et al. Goodman & Gilman's The Pharmacological Basis of Therapeutics, 13th ed. McGraw-Hill, 2018.", "Goldman L, et al. Goldman-Cecil Medicine, 26th ed. Elsevier, 2020.", "Symreng T, et al. Physiological cortisol substitution of long-term steroid-treated patients undergoing major surgery. Br J Anaesth. 1981;53:949.", "Evans CH, Rosenbaum G. Management of adrenal insufficiency. Mulholland & Greenfield's Surgery, 7th ed.", "Tintinalli JE, et al. Tintinalli's Emergency Medicine, 9th ed. McGraw-Hill, 2020.", "Annane D, et al. Corticosteroids for treating sepsis in children and adults. Cochrane Database Syst Rev. 2025 Jun 5. PMID: 40470636", "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.", ] for i, ref in enumerate(refs, 1): story.append(Paragraph(f"{i}. {ref}", ref_style)) story.append(Spacer(1, 0.3*cm)) story.append(Paragraph( "<i>This document is for educational purposes. Always follow current local/national clinical guidelines " "and institutional protocols. Clinical judgement should guide individual patient management.</i>", note_style)) doc.build(story) print("PDF created successfully!") EOF