The Role of Anaesthesia in the Intensive Care Unit (ICU)

"""
Build a completed PADIS Visual Abstract PDF combining:
- The 2025 focused update's 5 new recommendations (from the existing visual abstract)
- The 2018 PADIS guidelines' recommendations for Pain (no updates made in 2025)
- 2018 background recommendations for Agitation/Sedation, Delirium, Immobility, Sleep
  that were not updated in 2025 (they remain current)
"""

from reportlab.lib.pagesizes import A3
from reportlab.lib import colors
from reportlab.lib.units import mm, inch
from reportlab.pdfgen import canvas
from reportlab.platypus import Paragraph, Frame, KeepInFrame
from reportlab.lib.styles import ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import textwrap

# ─── Color Palette (matching SCCM PADIS branding) ───────────────────────────
SCCM_NAVY      = colors.HexColor("#1B3A6B")   # Deep navy header
SCCM_TEAL      = colors.HexColor("#007C91")   # Teal section bars
SCCM_ORANGE    = colors.HexColor("#E87722")   # Orange highlights
SCCM_GREEN     = colors.HexColor("#3D9E4B")   # Green (strong for)
SCCM_YELLOW    = colors.HexColor("#F5A623")   # Yellow (conditional)
SCCM_RED       = colors.HexColor("#C0392B")   # Red (against)
SCCM_GRAY      = colors.HexColor("#F2F2F2")   # Light background
SCCM_MED_GRAY  = colors.HexColor("#CCCCCC")   # Medium gray
SCCM_DARK_GRAY = colors.HexColor("#555555")   # Dark text
SCCM_PAIN      = colors.HexColor("#8B1A4A")   # Pain section (burgundy/purple)
SCCM_ANXIETY   = colors.HexColor("#007C91")   # Anxiety (teal)
SCCM_SEDATION  = colors.HexColor("#005A87")   # Sedation (dark blue)
SCCM_DELIRIUM  = colors.HexColor("#4A235A")   # Delirium (purple)
SCCM_IMMOB     = colors.HexColor("#1B5E20")   # Immobility (dark green)
SCCM_SLEEP     = colors.HexColor("#004D8C")   # Sleep (midnight blue)
SCCM_LIGHT_BG  = colors.HexColor("#FAFAFA")

W, H = A3  # 297 x 420 mm landscape → use portrait
# Use landscape A3 for wider layout
W, H = 420*mm, 297*mm  # A3 landscape

c = canvas.Canvas("/home/daytona/workspace/padis-visual-abstract/PADIS_Complete_Visual_Abstract.pdf",
                  pagesize=(W, H))

def set_font(cv, name="Helvetica", size=10):
    cv.setFont(name, size)

def draw_rounded_rect(cv, x, y, w, h, r=4, fill_color=None, stroke_color=None, stroke_width=0.5):
    if fill_color:
        cv.setFillColor(fill_color)
    if stroke_color:
        cv.setStrokeColor(stroke_color)
        cv.setLineWidth(stroke_width)
    else:
        cv.setStrokeColor(colors.transparent)
    cv.roundRect(x, y, w, h, r, stroke=1 if stroke_color else 0, fill=1 if fill_color else 0)

def draw_text_wrapped(cv, text, x, y, max_width, font="Helvetica", size=7.5,
                       color=SCCM_DARK_GRAY, line_height=None, align="left"):
    if line_height is None:
        line_height = size * 1.35
    cv.setFillColor(color)
    cv.setFont(font, size)
    # Simple word wrap
    words = text.split()
    lines = []
    current_line = ""
    for word in words:
        test = (current_line + " " + word).strip()
        if cv.stringWidth(test, font, size) <= max_width:
            current_line = test
        else:
            if current_line:
                lines.append(current_line)
            current_line = word
    if current_line:
        lines.append(current_line)
    
    cur_y = y
    for line in lines:
        if align == "center":
            text_w = cv.stringWidth(line, font, size)
            cv.drawString(x + (max_width - text_w) / 2, cur_y, line)
        else:
            cv.drawString(x, cur_y, line)
        cur_y -= line_height
    return cur_y  # return final y position

def section_header(cv, x, y, w, h, title, bg_color, text_color=colors.white, font_size=9.5):
    draw_rounded_rect(cv, x, y, w, h, r=3, fill_color=bg_color)
    cv.setFillColor(text_color)
    cv.setFont("Helvetica-Bold", font_size)
    text_w = cv.stringWidth(title, "Helvetica-Bold", font_size)
    cv.drawString(x + (w - text_w) / 2, y + h/2 - font_size/2.5, title)

def rec_box(cv, x, y, w, text, strength_label, strength_color, evidence_label,
            evidence_color=None, font_size=7.2, padding=4):
    """Draw a single recommendation box."""
    if evidence_color is None:
        evidence_color = SCCM_DARK_GRAY
    
    # Estimate height
    approx_lines = max(2, len(text) // 38 + 1)
    h = approx_lines * (font_size * 1.4) + 28
    
    # Main box
    draw_rounded_rect(cv, x, y - h, w, h, r=4,
                       fill_color=SCCM_LIGHT_BG, stroke_color=SCCM_MED_GRAY, stroke_width=0.7)
    
    # Strength stripe on left
    cv.setFillColor(strength_color)
    cv.roundRect(x, y - h, 5, h, 2, stroke=0, fill=1)
    
    # Recommendation text
    final_y = draw_text_wrapped(cv, text, x + 9, y - 7, w - 14,
                                  font="Helvetica", size=font_size,
                                  color=SCCM_DARK_GRAY, line_height=font_size * 1.35)
    
    # Bottom badges
    badge_y = y - h + 4
    # Strength badge
    strength_w = cv.stringWidth(strength_label, "Helvetica-Bold", 6) + 6
    draw_rounded_rect(cv, x + 8, badge_y, strength_w, 10, r=2, fill_color=strength_color)
    cv.setFillColor(colors.white)
    cv.setFont("Helvetica-Bold", 6)
    cv.drawString(x + 11, badge_y + 2.5, strength_label)
    
    # Evidence badge
    ev_w = cv.stringWidth(evidence_label, "Helvetica", 6) + 6
    draw_rounded_rect(cv, x + 10 + strength_w, badge_y, ev_w, 10, r=2, fill_color=evidence_color)
    cv.setFillColor(colors.white)
    cv.setFont("Helvetica", 6)
    cv.drawString(x + 13 + strength_w, badge_y + 2.5, evidence_label)
    
    return h

def insuff_box(cv, x, y, w, text, font_size=7.2):
    """Draw an 'insufficient evidence' box."""
    approx_lines = max(2, len(text) // 38 + 1)
    h = approx_lines * (font_size * 1.4) + 22
    
    draw_rounded_rect(cv, x, y - h, w, h, r=4,
                       fill_color=colors.HexColor("#FFF8E1"),
                       stroke_color=colors.HexColor("#F5A623"), stroke_width=0.8)
    cv.setFillColor(colors.HexColor("#F5A623"))
    cv.roundRect(x, y - h, 5, h, 2, stroke=0, fill=1)
    
    draw_text_wrapped(cv, text, x + 9, y - 7, w - 14,
                       font="Helvetica-Oblique", size=font_size,
                       color=SCCM_DARK_GRAY, line_height=font_size * 1.35)
    
    badge_y = y - h + 4
    label = "Insufficient Evidence"
    badge_w = cv.stringWidth(label, "Helvetica-Bold", 6) + 6
    draw_rounded_rect(cv, x + 8, badge_y, badge_w, 10, r=2,
                       fill_color=colors.HexColor("#F5A623"))
    cv.setFillColor(colors.white)
    cv.setFont("Helvetica-Bold", 6)
    cv.drawString(x + 11, badge_y + 2.5, label)
    
    return h

# ═══════════════════════════════════════════════════════════════════════════
# PAGE LAYOUT  (A3 landscape: 420mm wide × 297mm tall)
# ═══════════════════════════════════════════════════════════════════════════
margin = 8*mm
col_gap = 4*mm
header_h = 28*mm
key_h = 18*mm
footer_h = 10*mm

usable_w = W - 2*margin
usable_h = H - margin*2 - header_h - key_h - footer_h

# 6 columns: Pain | Anxiety | Agitation/Sedation | Delirium | Immobility | Sleep
n_cols = 6
col_w = (usable_w - (n_cols - 1) * col_gap) / n_cols

col_x = [margin + i * (col_w + col_gap) for i in range(n_cols)]
content_top = H - margin - header_h - key_h  # y where columns start

# ─── HEADER ─────────────────────────────────────────────────────────────────
draw_rounded_rect(c, margin, H - margin - header_h, usable_w, header_h, r=5,
                   fill_color=SCCM_NAVY)

c.setFillColor(colors.white)
c.setFont("Helvetica-Bold", 13)
title1 = "Clinical Practice Guidelines for the Prevention and Management of"
title2 = "Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU"
c.drawCentredString(W/2, H - margin - 10*mm, title1)
c.setFont("Helvetica-Bold", 11)
c.drawCentredString(W/2, H - margin - 17*mm, title2)

c.setFont("Helvetica", 8)
subtitle = "2018 PADIS Guidelines | 2025 Focused Update  ·  Society of Critical Care Medicine (SCCM)"
c.drawCentredString(W/2, H - margin - 23.5*mm, subtitle)

# 2025 FOCUSED UPDATE badge
badge_x = W - margin - 42*mm
badge_y = H - margin - header_h + 6*mm
draw_rounded_rect(c, badge_x, badge_y, 38*mm, 14*mm, r=4,
                   fill_color=SCCM_ORANGE)
c.setFillColor(colors.white)
c.setFont("Helvetica-Bold", 8.5)
c.drawCentredString(badge_x + 19*mm, badge_y + 5*mm, "2025 FOCUSED UPDATE")

# ─── SYMBOL / LEGEND KEY ────────────────────────────────────────────────────
key_y = H - margin - header_h - key_h
draw_rounded_rect(c, margin, key_y, usable_w, key_h - 2*mm, r=3,
                   fill_color=colors.HexColor("#EEF2F7"),
                   stroke_color=SCCM_MED_GRAY, stroke_width=0.4)

c.setFont("Helvetica-Bold", 7.5)
c.setFillColor(SCCM_NAVY)
c.drawString(margin + 3*mm, key_y + 10*mm, "SYMBOL KEY:")

legends = [
    ("■", SCCM_GREEN,  "Strong Recommendation FOR"),
    ("■", SCCM_YELLOW, "Conditional Recommendation FOR"),
    ("■", SCCM_RED,    "Strong Recommendation AGAINST"),
    ("■", colors.HexColor("#E67E22"), "Conditional Recommendation AGAINST"),
    ("■", colors.HexColor("#F5A623"), "Insufficient Evidence"),
]
ev_legends = [
    ("◆", SCCM_NAVY, "High Certainty"),
    ("◆", SCCM_TEAL, "Moderate Certainty"),
    ("◆", colors.HexColor("#80B0C8"), "Low Certainty"),
    ("◆", SCCM_MED_GRAY, "Very Low Certainty"),
]

lx = margin + 30*mm
for sym, col, lbl in legends:
    c.setFillColor(col)
    c.setFont("Helvetica-Bold", 9)
    c.drawString(lx, key_y + 10*mm, sym)
    c.setFillColor(SCCM_DARK_GRAY)
    c.setFont("Helvetica", 7)
    c.drawString(lx + 5*mm, key_y + 10*mm, lbl)
    lx += c.stringWidth(lbl, "Helvetica", 7) + 12*mm

lx += 4*mm
c.setFont("Helvetica-Bold", 7.5)
c.setFillColor(SCCM_NAVY)
c.drawString(lx, key_y + 10*mm, "CERTAINTY:")
lx += 20*mm
for sym, col, lbl in ev_legends:
    c.setFillColor(col)
    c.setFont("Helvetica-Bold", 9)
    c.drawString(lx, key_y + 10*mm, sym)
    c.setFillColor(SCCM_DARK_GRAY)
    c.setFont("Helvetica", 7)
    c.drawString(lx + 5*mm, key_y + 10*mm, lbl)
    lx += c.stringWidth(lbl, "Helvetica", 7) + 12*mm

# Population note
c.setFont("Helvetica-Oblique", 7)
c.setFillColor(SCCM_DARK_GRAY)
c.drawString(margin + 3*mm, key_y + 4*mm,
             "POPULATION: Adult Critically Ill Patients  |  Specific recommendations for pediatric patients are not made.")

# ─── COLUMN SECTION HEADERS ─────────────────────────────────────────────────
section_colors = [SCCM_PAIN, SCCM_ANXIETY, SCCM_SEDATION, SCCM_DELIRIUM, SCCM_IMMOB, SCCM_SLEEP]
section_titles = ["Prevention &\nManagement of PAIN",
                  "ANXIETY",
                  "AGITATION /\nSEDATION",
                  "DELIRIUM",
                  "IMMOBILITY",
                  "SLEEP\nDISRUPTION"]

for i, (title, col_color) in enumerate(zip(section_titles, section_colors)):
    sx = col_x[i]
    sy = content_top - 1*mm
    draw_rounded_rect(c, sx, sy - 13*mm, col_w, 13*mm, r=3, fill_color=col_color)
    c.setFillColor(colors.white)
    lines = title.split("\n")
    if len(lines) == 2:
        c.setFont("Helvetica-Bold", 7.5)
        c.drawCentredString(sx + col_w/2, sy - 6*mm, lines[0])
        c.drawCentredString(sx + col_w/2, sy - 10.5*mm, lines[1])
    else:
        c.setFont("Helvetica-Bold", 8)
        c.drawCentredString(sx + col_w/2, sy - 8*mm, title)

# ─── HELPER: draw box with auto height tracking ─────────────────────────────
def draw_rec(cv, col_i, cur_y, text, strength_label, strength_color,
             evidence_label, evidence_color=SCCM_DARK_GRAY, font_size=7.0):
    x = col_x[col_i]
    w = col_w
    h = rec_box(cv, x, cur_y, w, text, strength_label, strength_color,
                 evidence_label, evidence_color, font_size=font_size)
    return cur_y - h - 2.5*mm

def draw_ins(cv, col_i, cur_y, text, font_size=7.0):
    x = col_x[col_i]
    w = col_w
    h = insuff_box(cv, x, cur_y, w, text, font_size=font_size)
    return cur_y - h - 2.5*mm

def sub_header(cv, col_i, cur_y, text, col_color):
    """Small sub-section label within a column."""
    x = col_x[col_i]
    w = col_w
    h = 8*mm
    cv.setFillColor(col_color)
    cv.setFillAlpha(0.15)
    cv.rect(x, cur_y - h, w, h, stroke=0, fill=1)
    cv.setFillAlpha(1.0)
    cv.setFillColor(col_color)
    cv.setFont("Helvetica-Bold", 7)
    cv.drawString(x + 2*mm, cur_y - 5.5*mm, text)
    return cur_y - h - 1*mm

# ─── NOTE BADGE (2025 NEW) ────────────────────────────────────────────────────
def new_2025_badge(cv, col_i, cur_y):
    x = col_x[col_i]
    w = col_w
    cv.setFillColor(SCCM_ORANGE)
    bw = 26*mm
    bh = 6*mm
    cv.roundRect(x + w - bw - 1*mm, cur_y - bh, bw, bh, 2, stroke=0, fill=1)
    cv.setFillColor(colors.white)
    cv.setFont("Helvetica-Bold", 6.5)
    cv.drawCentredString(x + w - bw/2 - 1*mm, cur_y - 4.5*mm, "★ 2025 FOCUSED UPDATE")
    return cur_y - bh - 1*mm

# ─── START COLUMN CONTENT ────────────────────────────────────────────────────
TOP = content_top - 14.5*mm   # below section header bars

# ════════════════════════ COL 0: PAIN ═══════════════════════════════════════
# 2025 update: "No updates made to previous guidelines recommendations for pain."
# → All from 2018 PADIS

y0 = TOP
c.setFillColor(SCCM_PAIN)
c.setFillAlpha(0.12)
c.rect(col_x[0], H - margin - header_h - key_h - (content_top - TOP + 14.5*mm) - 200*mm,
       col_w, 200*mm, stroke=0, fill=1)
c.setFillAlpha(1.0)

# Note: no 2025 updates
c.setFillColor(SCCM_PAIN)
c.setFont("Helvetica-Oblique", 6.8)
c.drawString(col_x[0] + 1*mm, y0 + 1*mm,
             "No updates in 2025; recommendations from 2018 PADIS guidelines")

y0 -= 3*mm

y0 = sub_header(c, 0, y0, "ASSESSMENT", SCCM_PAIN)

y0 = draw_rec(c, 0, y0,
    "Use NRS (0-10) for pain intensity in adult ICU patients able to self-report.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y0 = draw_rec(c, 0, y0,
    "Use the CPOT or BPS to assess pain in adult ICU patients unable to self-report.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y0 = draw_ins(c, 0, y0,
    "Vital signs alone should NOT be used as a primary indicator of pain in ICU patients.")

y0 = sub_header(c, 0, y0, "MANAGEMENT — PHARMACOLOGIC", SCCM_PAIN)

y0 = draw_rec(c, 0, y0,
    "Use IV opioids as the first-line drug class to treat non-neuropathic pain in critically ill adults. (Use lowest effective dose.)",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y0 = draw_rec(c, 0, y0,
    "Consider IV acetaminophen as an adjunct or alternative to IV opioids to decrease opioid dose and opioid-related side effects.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y0 = draw_rec(c, 0, y0,
    "Consider IV ketamine (low dose, sub-anesthetic) as an adjunct to opioids to reduce opioid consumption in post-surgical ICU adults.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y0 = draw_rec(c, 0, y0,
    "Consider neuropathic pain medications (gabapentin, carbamazepine, pregabalin) as adjuncts for neuropathic pain management.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y0 = draw_rec(c, 0, y0,
    "Use thoracic epidural analgesia for post-operative abdominal aortic surgery patients.",
    "Strong FOR", SCCM_GREEN, "Moderate", colors.HexColor("#007C91"))

y0 = sub_header(c, 0, y0, "ANALGOSEDATION / PROCEDURE PAIN", SCCM_PAIN)

y0 = draw_rec(c, 0, y0,
    "Use an assessment-driven, protocol-based (analgesia-first/analgosedation) stepwise approach for pain and sedation management.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y0 = draw_rec(c, 0, y0,
    "Pre-medicate with analgesia and/or non-pharmacologic interventions for procedural pain (e.g. chest tube removal, line insertion).",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

# ════════════════════════ COL 1: ANXIETY ════════════════════════════════════
# NEW topic in 2025 update

y1 = TOP
new_2025_badge(c, 1, y1 + 7*mm)
y1 -= 2*mm

c.setFillColor(SCCM_ANXIETY)
c.setFont("Helvetica-Oblique", 6.8)
c.drawString(col_x[1] + 1*mm, y1 + 1*mm,
             "NEW topic added in 2025 focused update")
y1 -= 4*mm

y1 = sub_header(c, 1, y1, "ASSESSMENT", SCCM_ANXIETY)

y1 = draw_rec(c, 1, y1,
    "Use a validated tool to assess anxiety in adult ICU patients. (No single tool strongly recommended yet.)",
    "Conditional FOR", SCCM_YELLOW, "Very Low", SCCM_MED_GRAY)

y1 = sub_header(c, 1, y1, "MANAGEMENT — PHARMACOLOGIC", SCCM_ANXIETY)

y1 = draw_ins(c, 1, y1,
    "Rec. 1: There is insufficient evidence to make a recommendation for or against the use of benzodiazepines to treat anxiety in adult ICU patients.")

y1 = sub_header(c, 1, y1, "MANAGEMENT — NON-PHARMACOLOGIC", SCCM_ANXIETY)

y1 = draw_rec(c, 1, y1,
    "Consider non-pharmacologic interventions (e.g. music therapy, virtual reality, relaxation techniques, family presence) as first-line approaches for anxiety.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y1 = sub_header(c, 1, y1, "KEY MESSAGES", SCCM_ANXIETY)

c.setFont("Helvetica", 7)
c.setFillColor(SCCM_DARK_GRAY)
key_msgs = [
    "• Anxiety is among the most distressing ICU symptoms reported by survivors.",
    "• Effects often persist after hospital discharge (post-ICU syndrome).",
    "• Benzodiazepines reduce anxiety but increase delirium risk — balance carefully.",
    "• Virtual reality and music therapy show early promising evidence.",
]
ky = y1
for msg in key_msgs:
    final_y = draw_text_wrapped(c, msg, col_x[1] + 2*mm, ky, col_w - 3*mm,
                                 font="Helvetica", size=7, color=SCCM_DARK_GRAY,
                                 line_height=9.5)
    ky = final_y - 1*mm

# ════════════════════════ COL 2: AGITATION / SEDATION ═══════════════════════
y2 = TOP
new_2025_badge(c, 2, y2 + 7*mm)
y2 -= 2*mm

y2 = sub_header(c, 2, y2, "ASSESSMENT & TARGET", SCCM_SEDATION)

y2 = draw_rec(c, 2, y2,
    "Routinely assess sedation depth with RASS or SAS. Target light sedation (RASS -1 to 0; SAS 3-4) unless specific clinical indications for deeper sedation exist.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y2 = sub_header(c, 2, y2, "DRUG CHOICE (2025 UPDATE)", SCCM_SEDATION)

y2 = draw_rec(c, 2, y2,
    "Rec. 2: Suggest dexmedetomidine over propofol for sedation in mechanically ventilated adult ICU patients where light sedation and/or reduction in delirium are of highest priorities.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y2 = sub_header(c, 2, y2, "DRUG CHOICE (2018 PADIS)", SCCM_SEDATION)

y2 = draw_rec(c, 2, y2,
    "Suggest propofol or dexmedetomidine over benzodiazepines for sedation in mechanically ventilated adult ICU patients.",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y2 = draw_rec(c, 2, y2,
    "Suggest propofol over a benzodiazepine for sedation in mechanically ventilated post-cardiac surgery adults.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y2 = sub_header(c, 2, y2, "SEDATION STRATEGIES (2018)", SCCM_SEDATION)

y2 = draw_rec(c, 2, y2,
    "Use daily interruption of sedatives (spontaneous awakening trial, SAT) in mechanically ventilated adults — 'sedation holiday'. Pair SAT with spontaneous breathing trial (SBT): 'Wake-Up and Breathe' bundle.",
    "Strong FOR", SCCM_GREEN, "High", SCCM_NAVY)

y2 = draw_rec(c, 2, y2,
    "Use targeted light sedation rather than deep sedation to reduce ventilator days, ICU LOS, and post-ICU cognitive impairment.",
    "Strong FOR", SCCM_GREEN, "High", SCCM_NAVY)

# ════════════════════════ COL 3: DELIRIUM ═══════════════════════════════════
y3 = TOP
new_2025_badge(c, 3, y3 + 7*mm)
y3 -= 2*mm

y3 = sub_header(c, 3, y3, "ASSESSMENT", SCCM_DELIRIUM)

y3 = draw_rec(c, 3, y3,
    "Routinely monitor for delirium in adult ICU patients. Use CAM-ICU or ICDSC as validated assessment tools.",
    "Strong FOR", SCCM_GREEN, "Moderate", colors.HexColor("#007C91"))

y3 = sub_header(c, 3, y3, "PREVENTION — NON-PHARMACOLOGIC (2018)", SCCM_DELIRIUM)

y3 = draw_rec(c, 3, y3,
    "Use a multicomponent, non-pharmacologic intervention focused on (but not limited to) reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y3 = sub_header(c, 3, y3, "PREVENTION — PHARMACOLOGIC (2018)", SCCM_DELIRIUM)

y3 = draw_rec(c, 3, y3,
    "Do NOT use haloperidol, atypical antipsychotics, dexmedetomidine, statins, or ketamine to prevent delirium in adult ICU patients.",
    "Conditional AGAINST", colors.HexColor("#E67E22"), "Very Low", SCCM_MED_GRAY)

y3 = sub_header(c, 3, y3, "TREATMENT (2025 UPDATE)", SCCM_DELIRIUM)

y3 = draw_ins(c, 3, y3,
    "Rec. 3: Unable to issue a recommendation for or against the use of antipsychotics over usual care for the TREATMENT of delirium in adult ICU patients. Current evidence shows minimal or no effect on ICU/hospital LOS.")

y3 = sub_header(c, 3, y3, "TREATMENT — SPECIAL CASES (2018)", SCCM_DELIRIUM)

y3 = draw_rec(c, 3, y3,
    "Suggest using dexmedetomidine for delirium in adult ICU patients where agitation is precluding weaning/extubation.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

# ════════════════════════ COL 4: IMMOBILITY ═════════════════════════════════
y4 = TOP
new_2025_badge(c, 4, y4 + 7*mm)
y4 -= 2*mm

y4 = sub_header(c, 4, y4, "REHABILITATION / MOBILIZATION (2018)", SCCM_IMMOB)

y4 = draw_rec(c, 4, y4,
    "Suggest performing rehabilitation or mobilization in critically ill adults. (Conditional, Low certainty)",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y4 = draw_rec(c, 4, y4,
    "Serious safety events or harms do NOT occur commonly during physical rehabilitation or mobilization in the ICU.",
    "Ungraded", SCCM_MED_GRAY, "Ungraded", SCCM_MED_GRAY)

y4 = sub_header(c, 4, y4, "ENHANCED MOBILIZATION (2025 UPDATE)", SCCM_IMMOB)

y4 = draw_rec(c, 4, y4,
    "Rec. 4: Suggest providing ENHANCED mobilization/rehabilitation over usual care mobilization/rehabilitation to adult ICU patients. (Includes: progressive exercise, ambulation, early PT/OT starting within 24-48h.)",
    "Conditional FOR", SCCM_YELLOW, "Moderate", colors.HexColor("#007C91"))

y4 = sub_header(c, 4, y4, "ABCDEF BUNDLE CONTEXT", SCCM_IMMOB)

c.setFont("Helvetica", 7)
c.setFillColor(SCCM_DARK_GRAY)
bundle_items = [
    ("A", "Assess, prevent, & manage Pain"),
    ("B", "Both SAT and SBT"),
    ("C", "Choice of analgesia & sedation"),
    ("D", "Delirium: assess, prevent, manage"),
    ("E", "Early mobility & Exercise"),
    ("F", "Family engagement & empowerment"),
]
by = y4 - 2*mm
for letter, desc in bundle_items:
    draw_rounded_rect(c, col_x[4] + 1*mm, by - 8*mm, 8*mm, 8*mm, r=2,
                       fill_color=SCCM_IMMOB)
    c.setFillColor(colors.white)
    c.setFont("Helvetica-Bold", 8)
    c.drawCentredString(col_x[4] + 5*mm, by - 5.5*mm, letter)
    c.setFillColor(SCCM_DARK_GRAY)
    c.setFont("Helvetica", 6.8)
    c.drawString(col_x[4] + 11*mm, by - 5.5*mm, desc)
    by -= 10*mm

y4 = by - 2*mm

y4 = sub_header(c, 4, y4, "INDICATORS FOR INITIATION (2018)", SCCM_IMMOB)

y4 = draw_rec(c, 4, y4,
    "Start mobilization when: patient is responsive to verbal stimulation, HR 40-130, MAP ≥55 mmHg, SpO2 ≥88%, FiO2 ≤0.6, PEEP ≤10, RR ≤40.",
    "Ungraded", SCCM_MED_GRAY, "Clinical Guidance", SCCM_MED_GRAY)

# ════════════════════════ COL 5: SLEEP DISRUPTION ═══════════════════════════
y5 = TOP
new_2025_badge(c, 5, y5 + 7*mm)
y5 -= 2*mm

y5 = sub_header(c, 5, y5, "ASSESSMENT (2018)", SCCM_SLEEP)

y5 = draw_rec(c, 5, y5,
    "Use validated subjective sleep assessment tools (Richards-Campbell Sleep Questionnaire — RCSQ) in adult ICU patients able to self-report.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y5 = sub_header(c, 5, y5, "NON-PHARMACOLOGIC (2018)", SCCM_SLEEP)

y5 = draw_rec(c, 5, y5,
    "Use non-pharmacologic sleep promotion interventions: earplugs, eye masks, noise reduction, light modulation, and care clustering to reduce sleep fragmentation.",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y5 = draw_rec(c, 5, y5,
    "Use music to reduce anxiety and improve sleep in adult ICU patients.",
    "Conditional FOR", SCCM_YELLOW, "Very Low", SCCM_MED_GRAY)

y5 = sub_header(c, 5, y5, "PHARMACOLOGIC (2025 UPDATE)", SCCM_SLEEP)

y5 = draw_rec(c, 5, y5,
    "Rec. 5: Suggest administering melatonin over no melatonin in adult ICU patients to improve sleep quality. (Exogenous melatonin; timing aligned with circadian rhythm.)",
    "Conditional FOR", SCCM_YELLOW, "Low", colors.HexColor("#80B0C8"))

y5 = sub_header(c, 5, y5, "PHARMACOLOGIC (2018)", SCCM_SLEEP)

y5 = draw_ins(c, 5, y5,
    "No recommendation for or against use of propofol to promote sleep (insufficient evidence). No recommendation on dexmedetomidine specifically for sleep promotion.")

y5 = draw_rec(c, 5, y5,
    "Do NOT use benzodiazepines as primary sleep-promoting agent in ICU (increased delirium risk outweighs sleep benefit).",
    "Conditional AGAINST", colors.HexColor("#E67E22"), "Low", colors.HexColor("#80B0C8"))

y5 = sub_header(c, 5, y5, "CIRCADIAN RHYTHM (2018)", SCCM_SLEEP)

y5 = draw_rec(c, 5, y5,
    "Promote sleep-wake cycling: expose patients to natural light during day, minimize light and noise at night. Reorient patients to time of day.",
    "Conditional FOR", SCCM_YELLOW, "Very Low", SCCM_MED_GRAY)

# ─── KEY MESSAGES BOX (bottom spanning all columns) ─────────────────────────
km_top = min(y0, y1, y2, y3, y4, y5) - 3*mm
if km_top > margin + footer_h + 8*mm:
    draw_rounded_rect(c, margin, margin + footer_h, usable_w, km_top - margin - footer_h,
                       r=3, fill_color=colors.HexColor("#EEF4FB"),
                       stroke_color=SCCM_TEAL, stroke_width=0.7)
    c.setFillColor(SCCM_NAVY)
    c.setFont("Helvetica-Bold", 8)
    c.drawString(margin + 3*mm, km_top - 5*mm, "KEY MESSAGES")
    msgs = [
        "• Survivors of critical illness often experience profound physical, mental, and cognitive impairments (post-ICU syndrome) that may persist for years after discharge.",
        "• These impairments may be avoided/minimized by applying the ABCDEF bundle: analgesia-first, daily SAT+SBT, non-benzodiazepine sedation, delirium monitoring, early mobility, family engagement.",
        "• 2025 update: Dexmedetomidine now preferred over propofol for light sedation. Antipsychotics are NOT recommended for delirium treatment. Anxiety added as a new PADIS domain. Melatonin suggested for sleep.",
        "• Citation: Lewis K, Balas MC, Stollings JL, et al. Crit Care Med. 2025 Mar;53(3):e711-e727. | Devlin JW, et al. Crit Care Med. 2018 Sep;46(9):e825-e873.",
    ]
    mky = km_top - 12*mm
    for msg in msgs:
        final_y = draw_text_wrapped(c, msg, margin + 3*mm, mky, usable_w - 6*mm,
                                     font="Helvetica", size=7, color=SCCM_DARK_GRAY)
        mky = final_y - 1.5*mm

# ─── FOOTER ─────────────────────────────────────────────────────────────────
c.setFillColor(SCCM_NAVY)
c.rect(margin, margin/2, usable_w, 7*mm, stroke=0, fill=1)
c.setFillColor(colors.white)
c.setFont("Helvetica", 6)
footer_text = ("Disclaimer: This infographic is not a validated clinical decision aid. "
               "For full disclaimer, see sccm.org/termsandconditions. "
               "SCCM PADIS 2025 Focused Update + 2018 Guidelines. Compiled July 2026.")
c.drawCentredString(W/2, margin/2 + 2.5*mm, footer_text)

# ─── SAVE ────────────────────────────────────────────────────────────────────
c.save()
print("PDF saved successfully.")

"""
PADIS Complete Visual Abstract – high-resolution PNG (300 DPI, A3 landscape)
Combines 2025 SCCM focused update + all retained 2018 PADIS recommendations.
"""

from PIL import Image, ImageDraw, ImageFont
import os, textwrap

# ── Canvas setup ────────────────────────────────────────────────────────────
DPI    = 300
MM     = DPI / 25.4          # pixels per mm
W      = int(420 * MM)       # A3 landscape width  ~4961 px
H      = int(297 * MM)       # A3 landscape height ~3508 px

img  = Image.new("RGB", (W, H), "#FFFFFF")
draw = ImageDraw.Draw(img)

# ── Font loader ──────────────────────────────────────────────────────────────
FONT_PATHS = {
    "regular":      "/usr/share/fonts/truetype/dejavu/DejaVuSans.ttf",
    "bold":         "/usr/share/fonts/truetype/dejavu/DejaVuSans-Bold.ttf",
    "italic":       "/usr/share/fonts/truetype/dejavu/DejaVuSans-Oblique.ttf",
    "bold_italic":  "/usr/share/fonts/truetype/dejavu/DejaVuSans-BoldOblique.ttf",
}

_font_cache = {}
def F(style="regular", size=28):
    key = (style, size)
    if key not in _font_cache:
        _font_cache[key] = ImageFont.truetype(FONT_PATHS[style], size)
    return _font_cache[key]

# ── Colour palette ───────────────────────────────────────────────────────────
NAVY      = "#1B3A6B"
TEAL      = "#007C91"
ORANGE    = "#E87722"
GREEN     = "#2E7D32"
COND_FOR  = "#F5A623"   # amber – conditional for
COND_AG   = "#E67E22"   # burnt orange – conditional against
RED_STR   = "#C0392B"   # strong against
GRAY_BG   = "#F4F6FA"
GRAY_MED  = "#CCCCCC"
GRAY_DARK = "#444444"
WHITE     = "#FFFFFF"
INSUFF    = "#FFF8E1"
INSUFF_BD = "#F5A623"

COL_PAIN   = "#7B1A4B"
COL_ANX    = "#007C91"
COL_SED    = "#1A4F7A"
COL_DEL    = "#4A235A"
COL_IMM    = "#1B5E20"
COL_SLP    = "#003D6B"

# ── Helpers ──────────────────────────────────────────────────────────────────
def px(mm_val): return int(mm_val * MM)
def rect(xy, fill=None, outline=None, lw=2, radius=0):
    x0,y0,x1,y1 = xy
    if radius:
        draw.rounded_rectangle(xy, radius=radius, fill=fill, outline=outline, width=lw)
    else:
        draw.rectangle(xy, fill=fill, outline=outline, width=lw)

def text_box(txt, x, y, max_w, font, fill=GRAY_DARK, line_gap=6, align="left"):
    """Word-wrap txt into max_w pixels. Returns final y."""
    words = txt.split()
    lines, cur = [], ""
    for w in words:
        test = (cur + " " + w).strip()
        bbox = draw.textbbox((0,0), test, font=font)
        if bbox[2] <= max_w:
            cur = test
        else:
            if cur: lines.append(cur)
            cur = w
    if cur: lines.append(cur)
    cy = y
    for ln in lines:
        if align == "center":
            bx = draw.textbbox((0,0), ln, font=font)
            draw.text((x + (max_w - bx[2])//2, cy), ln, font=font, fill=fill)
        else:
            draw.text((x, cy), ln, font=font, fill=fill)
        cy += font.size + line_gap
    return cy

def section_bar(x, y, w, h, color, title_lines, fs=32):
    rect([x, y, x+w, y+h], fill=color, radius=8)
    total_th = sum(F("bold", fs).size + 4 for _ in title_lines)
    ty = y + (h - total_th)//2
    for line in title_lines:
        bx = draw.textbbox((0,0), line, font=F("bold", fs))
        tx = x + (w - bx[2])//2
        draw.text((tx, ty), line, font=F("bold", fs), fill=WHITE)
        ty += F("bold", fs).size + 4

def badge(x, y, label, bg, fs=22):
    font = F("bold", fs)
    bx = draw.textbbox((0,0), label, font=font)
    bw, bh = bx[2] + px(2.5), bx[3] + px(1.5)
    rect([x, y, x+bw, y+bh], fill=bg, radius=5)
    draw.text((x + px(1.2), y + px(0.7)), label, font=font, fill=WHITE)
    return bw, bh

def estimate_box_h(text, max_w, fs=26, padding_top=px(3), padding_bot=px(5), badge_h=px(8)):
    font = F("regular", fs)
    words = text.split()
    lines, cur = [], ""
    for w in words:
        test = (cur + " " + w).strip()
        bx = draw.textbbox((0,0), test, font=font)
        if bx[2] <= max_w - px(7):
            cur = test
        else:
            if cur: lines.append(cur)
            cur = w
    if cur: lines.append(cur)
    n = max(len(lines), 1)
    return padding_top + n*(font.size + 5) + badge_h + padding_bot + px(2)

def rec_box(x, y, w, text, strength_label, stripe_color, ev_label, fs=26, insuff=False):
    h = estimate_box_h(text, w, fs)
    bg = INSUFF if insuff else GRAY_BG
    bd = INSUFF_BD if insuff else GRAY_MED
    rect([x, y, x+w, y+h], fill=bg, outline=bd, lw=2, radius=8)
    # left stripe
    rect([x, y, x+px(3), y+h], fill=stripe_color, radius=5)
    # text
    inner_x = x + px(4.5)
    inner_w  = w - px(6)
    font = F("italic" if insuff else "regular", fs)
    fy = text_box(text, inner_x, y + px(3), inner_w, font=font,
                   fill=GRAY_DARK, line_gap=5)
    # badges
    bx_pos = x + px(4)
    by_pos = y + h - px(7)
    bw1, bh1 = badge(bx_pos, by_pos, strength_label, stripe_color, fs=20)
    bx_pos2 = bx_pos + bw1 + px(2)
    ev_col = {"High": NAVY, "Moderate": TEAL, "Low": "#6BAED6",
              "Very Low": GRAY_MED, "Ungraded": GRAY_MED,
              "Insufficient Evidence": INSUFF_BD,
              "Clinical Guidance": GRAY_MED}.get(ev_label, GRAY_MED)
    badge(bx_pos2, by_pos, ev_label, ev_col, fs=20)
    return y + h + px(2)

def sub_hdr(x, y, w, label, col):
    h = px(6.5)
    # transparent tinted bar
    overlay = Image.new("RGBA", (w, h), col + "28")
    img.paste(Image.new("RGB", (w, h), col + "28"), (x, y))
    # left accent
    rect([x, y, x+px(2), y+h], fill=col)
    font = F("bold", 24)
    draw.text((x + px(3), y + (h - font.size)//2), label, font=font, fill=col)
    return y + h + px(1.5)

def new_badge(x, y):
    bw, bh = badge(x, y, "★ 2025 NEW / UPDATED", ORANGE, fs=21)
    return y + bh + px(1)

# ════════════════════════════════════════════════════════════════════════════
#  LAYOUT CONSTANTS
# ════════════════════════════════════════════════════════════════════════════
MAR       = px(6)
HDR_H     = px(26)
KEY_H     = px(14)
GAP       = px(3)

N_COLS    = 6
usable_w  = W - 2*MAR
col_w     = (usable_w - (N_COLS-1)*GAP) // N_COLS
col_xs    = [MAR + i*(col_w + GAP) for i in range(N_COLS)]

CONTENT_TOP = MAR + HDR_H + KEY_H + px(2)

SEC_H  = px(12)   # section header bar height
CSTART = CONTENT_TOP + SEC_H + px(1.5)

# ── HEADER ──────────────────────────────────────────────────────────────────
rect([MAR, MAR, W-MAR, MAR+HDR_H], fill=NAVY, radius=12)

t1 = "Clinical Practice Guidelines for the Prevention and Management of"
t2 = "Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult ICU Patients"
t3 = "2018 PADIS Guidelines  |  2025 Focused Update  ·  Society of Critical Care Medicine (SCCM)"

for txt, fs, dy in [(t1,46,px(5)), (t2,42,px(13)), (t3,30,px(20.5))]:
    bx = draw.textbbox((0,0), txt, font=F("bold" if dy<px(20) else "regular", fs))
    draw.text(((W - bx[2])//2, MAR+dy), txt,
              font=F("bold" if dy<px(20) else "regular", fs), fill=WHITE)

# 2025 badge top-right
bw2,bh2 = badge(W - MAR - px(52), MAR + px(6), "  2025 FOCUSED UPDATE  ", ORANGE, fs=28)

# ── LEGEND KEY ───────────────────────────────────────────────────────────────
ky = MAR + HDR_H + px(1)
rect([MAR, ky, W-MAR, ky+KEY_H], fill="#EEF2F7", outline=GRAY_MED, lw=1, radius=6)

kx = MAR + px(4)
draw.text((kx, ky+px(1.5)), "STRENGTH:", font=F("bold",26), fill=NAVY)
kx += draw.textbbox((0,0),"STRENGTH:",font=F("bold",26))[2] + px(4)

strengths = [("■ Strong FOR", GREEN), ("■ Conditional FOR", COND_FOR),
             ("■ Conditional AGAINST", COND_AG), ("■ Insufficient Evidence", INSUFF_BD)]
for lbl, col in strengths:
    draw.text((kx, ky+px(1.5)), lbl, font=F("regular",24), fill=col)
    kx += draw.textbbox((0,0),lbl,font=F("regular",24))[2] + px(5)

kx += px(4)
draw.text((kx, ky+px(1.5)), "CERTAINTY:", font=F("bold",26), fill=NAVY)
kx += draw.textbbox((0,0),"CERTAINTY:",font=F("bold",26))[2] + px(3)
certs = [("◆ High",NAVY),("◆ Moderate",TEAL),("◆ Low","#6BAED6"),("◆ Very Low",GRAY_MED)]
for lbl, col in certs:
    draw.text((kx, ky+px(1.5)), lbl, font=F("regular",24), fill=col)
    kx += draw.textbbox((0,0),lbl,font=F("regular",24))[2] + px(4)

pop = "POPULATION: Adult Critically Ill Patients  (Recommendations for pediatric patients are not made)"
draw.text((MAR+px(4), ky+px(7)), pop, font=F("italic",22), fill=GRAY_DARK)

# ── SECTION HEADER BARS ──────────────────────────────────────────────────────
sec_data = [
    (COL_PAIN,  ["PREVENTION &", "MANAGEMENT", "OF PAIN"]),
    (COL_ANX,   ["ANXIETY"]),
    (COL_SED,   ["AGITATION /", "SEDATION"]),
    (COL_DEL,   ["DELIRIUM"]),
    (COL_IMM,   ["IMMOBILITY"]),
    (COL_SLP,   ["SLEEP", "DISRUPTION"]),
]
for i,(col,lines) in enumerate(sec_data):
    section_bar(col_xs[i], CONTENT_TOP, col_w, SEC_H, col, lines, fs=30)

# ═══════════════════════════════════════════════════════════════════════════
#  COLUMN CONTENT
# ═══════════════════════════════════════════════════════════════════════════

# ── COL 0: PAIN (no 2025 updates – all from 2018) ──────────────────────────
y = CSTART
draw.text((col_xs[0]+px(1), y), "No updates in 2025 — all recommendations from 2018 PADIS",
          font=F("italic",21), fill=COL_PAIN)
y += px(6)

y = sub_hdr(col_xs[0], y, col_w, "ASSESSMENT", COL_PAIN)
y = rec_box(col_xs[0], y, col_w,
    "Use NRS (0–10) for pain assessment in adult ICU patients able to self-report.",
    "Conditional FOR", COND_FOR, "Moderate")
y = rec_box(col_xs[0], y, col_w,
    "Use CPOT or BPS to assess pain in adult ICU patients unable to self-report.",
    "Conditional FOR", COND_FOR, "Moderate")
y = rec_box(col_xs[0], y, col_w,
    "Do NOT rely on vital signs alone as primary indicator of pain in ICU patients.",
    "Conditional AGAINST", COND_AG, "Low", insuff=True)

y = sub_hdr(col_xs[0], y, col_w, "PHARMACOLOGIC MANAGEMENT", COL_PAIN)
y = rec_box(col_xs[0], y, col_w,
    "Use IV opioids as first-line drug class for non-neuropathic pain in critically ill adults. Titrate to lowest effective dose.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[0], y, col_w,
    "Consider IV acetaminophen as adjunct/alternative to reduce opioid dose and side effects.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[0], y, col_w,
    "Consider low-dose IV ketamine (sub-anaesthetic) as opioid adjunct in post-surgical ICU adults.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[0], y, col_w,
    "Gabapentinoids (gabapentin, pregabalin) as adjuncts for neuropathic ICU pain.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[0], y, col_w,
    "Use thoracic epidural analgesia in post-operative abdominal aortic surgery patients.",
    "Strong FOR", GREEN, "Moderate")

y = sub_hdr(col_xs[0], y, col_w, "ANALGOSEDATION / PROCEDURAL", COL_PAIN)
y = rec_box(col_xs[0], y, col_w,
    "Use an assessment-driven, protocol-based analgosedation (analgesia-first) stepwise approach for pain and sedation management.",
    "Conditional FOR", COND_FOR, "Moderate")
y = rec_box(col_xs[0], y, col_w,
    "Pre-medicate with analgesia and/or non-pharmacologic interventions before painful ICU procedures (e.g. line insertion, suctioning).",
    "Conditional FOR", COND_FOR, "Low")

# ── COL 1: ANXIETY (NEW 2025) ────────────────────────────────────────────────
y = CSTART
y = new_badge(col_xs[1], y)

y = sub_hdr(col_xs[1], y, col_w, "ASSESSMENT", COL_ANX)
y = rec_box(col_xs[1], y, col_w,
    "Use a validated tool to assess anxiety in adult ICU patients. No single tool is strongly recommended.",
    "Conditional FOR", COND_FOR, "Very Low")

y = sub_hdr(col_xs[1], y, col_w, "PHARMACOLOGIC  [REC. 1 — 2025]", COL_ANX)
y = rec_box(col_xs[1], y, col_w,
    "REC 1: Insufficient evidence to recommend FOR or AGAINST benzodiazepines to treat anxiety in adult ICU patients.",
    "Insufficient Evidence", INSUFF_BD, "Insufficient Evidence", insuff=True)

y = sub_hdr(col_xs[1], y, col_w, "NON-PHARMACOLOGIC", COL_ANX)
y = rec_box(col_xs[1], y, col_w,
    "Consider non-pharmacologic interventions first: music therapy, virtual reality, relaxation techniques, reorientation, and family presence.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[1], y, col_w, "CLINICAL NOTES", COL_ANX)
notes = [
    "• Anxiety is among the most distressing ICU experiences reported by survivors.",
    "• Anxiety persists after discharge as part of post-ICU syndrome (PICS).",
    "• Benzodiazepines reduce anxiety but significantly increase delirium risk.",
    "• Virtual reality and music therapy show promising early evidence.",
    "• Screen for anxiety routinely, especially pre-procedurally.",
]
for n in notes:
    draw.text((col_xs[1]+px(2), y), n, font=F("regular",22), fill=GRAY_DARK)
    y += px(7.5)

# ── COL 2: AGITATION / SEDATION ─────────────────────────────────────────────
y = CSTART
y = new_badge(col_xs[2], y)

y = sub_hdr(col_xs[2], y, col_w, "ASSESSMENT & TARGETING (2018)", COL_SED)
y = rec_box(col_xs[2], y, col_w,
    "Routinely assess sedation depth using RASS or SAS. Target LIGHT sedation (RASS −1 to 0; SAS 3–4) unless specific indication for deep sedation exists.",
    "Conditional FOR", COND_FOR, "Moderate")

y = sub_hdr(col_xs[2], y, col_w, "DRUG CHOICE  [REC. 2 — 2025 UPDATE]", COL_SED)
y = rec_box(col_xs[2], y, col_w,
    "REC 2: Suggest dexmedetomidine OVER propofol for sedation in mechanically ventilated adults in the ICU where LIGHT SEDATION and/or REDUCTION IN DELIRIUM are highest priorities. (Dexmedetomidine may cause bradycardia — consider alternatives if deep sedation or high bradycardia risk.)",
    "Conditional FOR", COND_FOR, "Moderate")

y = sub_hdr(col_xs[2], y, col_w, "DRUG CHOICE (2018 PADIS — RETAINED)", COL_SED)
y = rec_box(col_xs[2], y, col_w,
    "Suggest propofol or dexmedetomidine OVER benzodiazepines for sedation in mechanically ventilated adults.",
    "Conditional FOR", COND_FOR, "Moderate")
y = rec_box(col_xs[2], y, col_w,
    "Suggest propofol over benzodiazepine for sedation in mechanically ventilated post-cardiac surgery adults.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[2], y, col_w, "SEDATION STRATEGIES (2018 — RETAINED)", COL_SED)
y = rec_box(col_xs[2], y, col_w,
    "Perform daily spontaneous awakening trials (SAT) + daily spontaneous breathing trials (SBT) — the 'Wake-Up and Breathe' bundle. Reduces ventilator days, ICU/hospital LOS, and 1-year mortality.",
    "Strong FOR", GREEN, "High")
y = rec_box(col_xs[2], y, col_w,
    "Target LIGHT sedation over deep sedation in all mechanically ventilated ICU adults to reduce ventilator days, delirium, and post-ICU cognitive impairment.",
    "Strong FOR", GREEN, "High")

# RASS table
y = sub_hdr(col_xs[2], y, col_w, "RASS SCALE REFERENCE", COL_SED)
rass = [("+4","Combative"), ("+3","Very Agitated"), ("+2","Agitated"),
        ("+1","Restless"), ("0","Alert & Calm ← TARGET"),
        ("−1","Drowsy ← TARGET"), ("−2","Light Sedation"),
        ("−3","Moderate Sedation"), ("−4","Deep Sedation"), ("−5","Unarousable")]
for score, label in rass:
    col_r = GREEN if "TARGET" in label else (COND_FOR if score in ["+1","−2","−3"] else (RED_STR if score in ["+2","+3","+4"] else (NAVY if score in ["−4","−5"] else GRAY_DARK)))
    row_txt = f"  {score:>3}   {label}"
    fs_r = 21
    bx = draw.textbbox((0,0), row_txt, font=F("bold" if "TARGET" in label else "regular", fs_r))
    draw.text((col_xs[2]+px(2), y), row_txt,
              font=F("bold" if "TARGET" in label else "regular", fs_r), fill=col_r)
    y += px(5.8)

# ── COL 3: DELIRIUM ───────────────────────────────────────────────────────────
y = CSTART
y = new_badge(col_xs[3], y)

y = sub_hdr(col_xs[3], y, col_w, "ASSESSMENT (2018)", COL_DEL)
y = rec_box(col_xs[3], y, col_w,
    "Routinely monitor for delirium in all adult ICU patients. Use CAM-ICU or ICDSC as validated tools.",
    "Strong FOR", GREEN, "Moderate")

y = sub_hdr(col_xs[3], y, col_w, "PREVENTION — NON-PHARMACOLOGIC (2018)", COL_DEL)
y = rec_box(col_xs[3], y, col_w,
    "Use a multicomponent non-pharmacologic intervention: reduce modifiable delirium risk factors, improve cognition, optimize sleep, mobility, hearing, and vision.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[3], y, col_w,
    "Promote early mobilization (ABCDEF bundle — E component) as cornerstone of delirium prevention.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[3], y, col_w, "PREVENTION — PHARMACOLOGIC (2018)", COL_DEL)
y = rec_box(col_xs[3], y, col_w,
    "Do NOT use haloperidol, atypical antipsychotics, dexmedetomidine, statins, or ketamine specifically to PREVENT delirium.",
    "Conditional AGAINST", COND_AG, "Very Low")

y = sub_hdr(col_xs[3], y, col_w, "TREATMENT  [REC. 3 — 2025 UPDATE]", COL_DEL)
y = rec_box(col_xs[3], y, col_w,
    "REC 3: Unable to issue recommendation FOR or AGAINST antipsychotics (haloperidol or atypical agents) over usual care for TREATMENT of delirium. Current evidence shows minimal/no effect on ICU/hospital LOS or mortality.",
    "Insufficient Evidence", INSUFF_BD, "Low", insuff=True)

y = sub_hdr(col_xs[3], y, col_w, "TREATMENT — SELECTED CASES (2018)", COL_DEL)
y = rec_box(col_xs[3], y, col_w,
    "Suggest dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning or extubation.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[3], y, col_w, "RISK FACTORS", COL_DEL)
risks = ["• Deep sedation / benzodiazepine use",
         "• Immobility & sleep deprivation",
         "• Pain (uncontrolled)",
         "• Mechanical ventilation duration",
         "• Age, prior cognitive impairment",
         "• Sepsis, organ failure, hypoxia"]
for r in risks:
    draw.text((col_xs[3]+px(2), y), r, font=F("regular",22), fill=GRAY_DARK)
    y += px(7)

# ── COL 4: IMMOBILITY ─────────────────────────────────────────────────────────
y = CSTART
y = new_badge(col_xs[4], y)

y = sub_hdr(col_xs[4], y, col_w, "MOBILIZATION (2018 — RETAINED)", COL_IMM)
y = rec_box(col_xs[4], y, col_w,
    "Suggest performing rehabilitation/mobilization in critically ill adults. Serious safety events do NOT commonly occur during ICU mobilization.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[4], y, col_w, "ENHANCED MOBILIZATION  [REC. 4 — 2025]", COL_IMM)
y = rec_box(col_xs[4], y, col_w,
    "REC 4: Suggest providing ENHANCED mobilization/rehabilitation over usual-care mobilization to adult ICU patients. Includes: progressive exercise, ambulation, early PT/OT initiation within 24–48 h of ICU admission.",
    "Conditional FOR", COND_FOR, "Moderate")

y = sub_hdr(col_xs[4], y, col_w, "ABCDEF BUNDLE", COL_IMM)
bundle = [("A","Assess, prevent & manage Pain"),
          ("B","Both SAT + SBT daily"),
          ("C","Choice of analgesia/sedation"),
          ("D","Delirium — assess, prevent, manage"),
          ("E","Early mobility & Exercise"),
          ("F","Family engagement & empowerment")]
for letter, desc in bundle:
    bx0, by0 = col_xs[4]+px(1.5), y
    rect([bx0, by0, bx0+px(8), by0+px(8.5)], fill=COL_IMM, radius=5)
    draw.text((bx0+px(1.5), by0+px(1)), letter, font=F("bold",28), fill=WHITE)
    draw.text((bx0+px(10), by0+px(2)), desc, font=F("regular",23), fill=GRAY_DARK)
    y += px(10.5)

y += px(2)
y = sub_hdr(col_xs[4], y, col_w, "INITIATION CRITERIA (CLINICAL GUIDANCE)", COL_IMM)
criteria = ["HR 40–130 bpm", "MAP ≥ 55 mmHg",
            "SpO₂ ≥ 88%", "FiO₂ ≤ 0.6  |  PEEP ≤ 10",
            "RR ≤ 40 /min", "Responsive to verbal stimuli"]
for cr in criteria:
    rect([col_xs[4]+px(1.5), y, col_xs[4]+px(3), y+px(6.5)], fill=COL_IMM)
    draw.text((col_xs[4]+px(4), y+px(0.5)), cr, font=F("regular",23), fill=GRAY_DARK)
    y += px(8)

y = sub_hdr(col_xs[4], y, col_w, "BENEFITS OF EARLY MOBILITY", COL_IMM)
benefits = ["↓ ICU-acquired weakness",
            "↓ Delirium duration & incidence",
            "↓ Ventilator days",
            "↓ ICU and hospital length of stay",
            "↑ Functional independence at discharge",
            "↓ Post-ICU syndrome (PICS)"]
for b in benefits:
    draw.text((col_xs[4]+px(2), y), b, font=F("regular",22), fill=GRAY_DARK)
    y += px(7.2)

# ── COL 5: SLEEP DISRUPTION ──────────────────────────────────────────────────
y = CSTART
y = new_badge(col_xs[5], y)

y = sub_hdr(col_xs[5], y, col_w, "ASSESSMENT (2018)", COL_SLP)
y = rec_box(col_xs[5], y, col_w,
    "Use a validated subjective tool for sleep assessment — Richards-Campbell Sleep Questionnaire (RCSQ) in patients able to self-report.",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[5], y, col_w, "NON-PHARMACOLOGIC (2018 — RETAINED)", COL_SLP)
y = rec_box(col_xs[5], y, col_w,
    "Use non-pharmacologic sleep-promotion interventions: earplugs, eye masks, noise and light reduction at night, and clustering of care activities to allow undisturbed sleep periods.",
    "Conditional FOR", COND_FOR, "Low")
y = rec_box(col_xs[5], y, col_w,
    "Use music therapy during waking hours to reduce anxiety and improve subjective sleep quality.",
    "Conditional FOR", COND_FOR, "Very Low")
y = rec_box(col_xs[5], y, col_w,
    "Promote sleep-wake cycling: expose patients to natural daylight, minimize light and noise at night, reorient to time of day.",
    "Conditional FOR", COND_FOR, "Very Low")

y = sub_hdr(col_xs[5], y, col_w, "PHARMACOLOGIC  [REC. 5 — 2025 UPDATE]", COL_SLP)
y = rec_box(col_xs[5], y, col_w,
    "REC 5: Suggest administering MELATONIN over no melatonin in adult ICU patients to improve sleep quality. Timing should align with circadian rhythm (evening dosing).",
    "Conditional FOR", COND_FOR, "Low")

y = sub_hdr(col_xs[5], y, col_w, "PHARMACOLOGIC (2018 — RETAINED)", COL_SLP)
y = rec_box(col_xs[5], y, col_w,
    "Do NOT use benzodiazepines as primary sleep-promoting agent in the ICU — delirium risk outweighs benefit.",
    "Conditional AGAINST", COND_AG, "Low")
y = rec_box(col_xs[5], y, col_w,
    "No recommendation for or against propofol or dexmedetomidine specifically for sleep promotion (insufficient evidence).",
    "Insufficient Evidence", INSUFF_BD, "Insufficient Evidence", insuff=True)

y = sub_hdr(col_xs[5], y, col_w, "SLEEP DISRUPTION CONSEQUENCES", COL_SLP)
conseq = ["• Increased delirium risk",
          "• Impaired immune function",
          "• Delayed weaning from ventilator",
          "• Prolonged ICU length of stay",
          "• Post-ICU cognitive impairment",
          "• Anxiety and PTSD after discharge"]
for c in conseq:
    draw.text((col_xs[5]+px(2), y), c, font=F("regular",22), fill=GRAY_DARK)
    y += px(7.2)

# ── BOTTOM KEY MESSAGES BAR ──────────────────────────────────────────────────
km_y = H - px(22)
rect([MAR, km_y, W-MAR, H-MAR], fill="#EEF4FB", outline=TEAL, lw=2, radius=8)
draw.text((MAR+px(4), km_y+px(2)), "KEY MESSAGES:", font=F("bold",28), fill=NAVY)
msgs = [
    "1. Survivors of critical illness often experience profound physical, mental & cognitive impairments (PICS) that may persist for years.",
    "2. ABCDEF Bundle implementation significantly reduces delirium, coma-free days, ventilator days, and ICU/hospital LOS.",
    "3. 2025 Updates: Dexmedetomidine preferred over propofol for light sedation | Antipsychotics NOT recommended for delirium treatment | Anxiety is a new PADIS domain | Melatonin suggested for sleep.",
    "4. Citations: Lewis K et al. Crit Care Med 2025;53(3):e711–e727 (2025 Update)  |  Devlin JW et al. Crit Care Med 2018;46(9):e825–e873 (2018 PADIS Guidelines)"
]
mx = MAR + px(4)
my = km_y + px(9)
for msg in msgs:
    my = text_box(msg, mx, my, usable_w - px(8),
                  font=F("regular",23), fill=GRAY_DARK, line_gap=4)
    my += px(2)

# ── FOOTER STRIP ─────────────────────────────────────────────────────────────
rect([MAR, H-MAR-px(6), W-MAR, H-MAR], fill=NAVY, radius=5)
footer = ("Disclaimer: This infographic is not a validated clinical decision aid. "
          "Not a substitute for clinical judgment. SCCM PADIS 2025 + 2018. Compiled July 2026. sccm.org/termsandconditions")
bx = draw.textbbox((0,0), footer, font=F("regular",20))
draw.text(((W - bx[2])//2, H-MAR-px(4.5)), footer, font=F("regular",20), fill=WHITE)

# ── SAVE ─────────────────────────────────────────────────────────────────────
out = "/home/daytona/workspace/PADIS_Complete_Visual_Abstract.png"
img.save(out, "PNG", dpi=(DPI, DPI), optimize=False, compress_level=3)
print(f"Saved: {out}")
sz = os.path.getsize(out)
print(f"File size: {sz/1024/1024:.1f} MB  |  Dimensions: {img.size}")

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