const pptxgen = require('pptxgenjs');

const pptx = new pptxgen();
pptx.layout = 'LAYOUT_16x9';
pptx.author = 'MD Anaesthesia Case Team';
pptx.company = 'Academic Presentation';
pptx.subject = 'Diabetes Mellitus in Anaesthesia';
pptx.title = 'Diabetes Mellitus: Case Presentation for MD Anaesthesia';
pptx.lang = 'en-US';

const colors = {
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function addHeader(slide, title) {
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  slide.addText(title, { x: 0.4, y: 0.16, w: 9.2, h: 0.35, fontSize: 20, bold: true, color: colors.white, fontFace: 'Calibri' });
}

function addFooter(slide, txt = 'MD Anaesthesia | Diabetes Mellitus Case') {
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// 1 Title
let s = pptx.addSlide();
s.background = { color: colors.navy };
s.addShape(pptx.ShapeType.rect, { x: 0, y: 4.55, w: 10, h: 0.25, fill: { color: colors.gold }, line: { color: colors.gold } });
s.addText('Diabetes Mellitus', { x: 0.7, y: 1.4, w: 8.7, h: 0.8, fontSize: 44, bold: true, color: colors.white, fontFace: 'Calibri' });
s.addText('Case Presentation for MD Anaesthesia', { x: 0.7, y: 2.3, w: 8.7, h: 0.6, fontSize: 26, color: colors.gold, bold: true, fontFace: 'Calibri' });
s.addText('Department of Anaesthesiology', { x: 0.7, y: 3.05, w: 8.7, h: 0.35, fontSize: 16, color: colors.white });
s.addText('Presenter: ____________________    Date: __________', { x: 0.7, y: 3.45, w: 9.0, h: 0.3, fontSize: 14, color: 'DDE6F2' });

// 2 Objectives
s = pptx.addSlide();
addHeader(s, 'Learning Objectives');
addBullets(s, [
  'Review perioperative implications of diabetes mellitus in surgical patients',
  'Perform focused pre-anaesthetic evaluation including end-organ complications',
  'Plan evidence-based intraoperative glucose and insulin management',
  'Recognize and manage DKA and HHS in perioperative and emergency settings',
  'Apply learning through a representative MD anaesthesia case scenario'
], 0.7, 1.0, 8.9, 4.1, 22);
addFooter(s);

// 3 Epidemiology
s = pptx.addSlide();
addHeader(s, 'Introduction and Epidemiology');
s.addShape(pptx.ShapeType.roundRect, { x: 0.7, y: 1.0, w: 8.7, h: 1.0, radius: 0.08, fill: { color: 'FFF8E8' }, line: { color: 'E8D7A8' } });
s.addText('Global burden: >420 million people with diabetes mellitus', { x: 0.95, y: 1.3, w: 8.2, h: 0.35, fontSize: 20, bold: true, color: colors.darkText });
addBullets(s, [
  'Type 1 DM: 5-10% of cases; absolute insulin deficiency',
  'Type 2 DM: majority; insulin resistance with relative deficiency',
  'High perioperative prevalence in major surgical pathways',
  'Stress response to surgery increases counter-regulatory hormones and hyperglycemia'
], 0.7, 2.2, 8.8, 2.6, 18);
addFooter(s, 'Source: Miller\'s Anesthesia, 10e');

// 4 Classification
s = pptx.addSlide();
addHeader(s, 'Classification of Diabetes Mellitus');
s.addTable([
  [{text:'Type'}, {text:'Core Mechanism'}, {text:'Perioperative Relevance'}],
  [{text:'Type 1'}, {text:'Autoimmune β-cell destruction'}, {text:'Needs insulin; high DKA risk if insulin withheld'}],
  [{text:'Type 2'}, {text:'Insulin resistance + relative deficiency'}, {text:'Common in obese adults; HHS risk in stress states'}],
  [{text:'LADA'}, {text:'Late autoimmune onset'}, {text:'May initially mimic type 2 then become insulin-dependent'}],
  [{text:'Gestational'}, {text:'Pregnancy-related glucose intolerance'}, {text:'Obstetric anaesthesia glycemic planning required'}],
  [{text:'Secondary DM'}, {text:'Drugs/pancreatic disease/monogenic'}, {text:'Treat cause + optimize metabolic state'}]
], {
  x: 0.5, y: 1.1, w: 9.0, h: 3.8,
  border: { type: 'solid', color: 'CCD3DD', pt: 1 },
  fill: colors.white,
  color: colors.darkText,
  fontSize: 15,
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  colW: [1.5,3.4,4.1],
  bold: true,
  autoFit: false
});
addFooter(s, 'Source: Miller\'s Anesthesia, 10e');

// 5 Pathophysiology
s = pptx.addSlide();
addHeader(s, 'Pathophysiology Relevant to Anaesthesia');
s.addShape(pptx.ShapeType.chevron, { x: 0.8, y: 1.2, w: 2.6, h: 0.9, fill: { color: 'EAF1FB' }, line: { color: 'AFC3E1' } });
s.addShape(pptx.ShapeType.chevron, { x: 3.2, y: 1.2, w: 2.6, h: 0.9, fill: { color: 'EAF1FB' }, line: { color: 'AFC3E1' } });
s.addShape(pptx.ShapeType.chevron, { x: 5.6, y: 1.2, w: 2.6, h: 0.9, fill: { color: 'EAF1FB' }, line: { color: 'AFC3E1' } });
s.addText('Insulin deficiency / resistance', { x: 0.95, y: 1.52, w: 2.2, h: 0.3, fontSize: 13, bold: true, align: 'center' });
s.addText('Hyperglycemia + lipolysis', { x: 3.35, y: 1.52, w: 2.2, h: 0.3, fontSize: 13, bold: true, align: 'center' });
s.addText('End-organ injury', { x: 5.75, y: 1.52, w: 2.2, h: 0.3, fontSize: 13, bold: true, align: 'center' });
addBullets(s, [
  'Acute effects: osmotic diuresis, dehydration, electrolyte shifts',
  'Immune dysfunction: reduced chemotaxis/phagocytosis and poor wound healing',
  'Microvascular disease: nephropathy, neuropathy, retinopathy',
  'Macrovascular disease: ischemic heart disease, stroke, heart failure',
  'Autonomic neuropathy: postural hypotension, gastroparesis, resting tachycardia'
], 0.7, 2.4, 8.8, 2.7, 17);
addFooter(s);

// 6 Case
s = pptx.addSlide();
addHeader(s, 'Clinical Case Presentation');
s.addShape(pptx.ShapeType.roundRect, { x: 0.6, y: 0.95, w: 8.9, h: 3.9, radius: 0.08, fill: { color: 'F7FAFF' }, line: { color: 'AFC3E1', pt: 1.5 } });
addBullets(s, [
  'Mr. Ramesh Kumar, 58-year-old male, T2DM for 12 years',
  'Medications: Metformin 1 g BD + Glipizide 5 mg BD',
  'BMI 32 kg/m², hypertension, dyslipidemia; sedentary lifestyle',
  'Planned surgery: Elective right hemicolectomy for carcinoma colon',
  'Labs: HbA1c 8.2%, FBS 186 mg/dL, Creatinine 1.4 mg/dL',
  'Cardiac workup: ECG ST-T changes V4-V5; Echo LVEF 55%, mild LVH',
  'Symptoms: occasional postural dizziness and early satiety'
], 0.8, 1.12, 8.5, 3.45, 16);
addFooter(s);

// 7 Pre-anaesthetic evaluation
s = pptx.addSlide();
addHeader(s, 'Pre-anaesthetic Evaluation: Key Checklist');
addBullets(s, [
  'Confirm DM type, duration, control pattern, and recent hypoglycemic episodes',
  'Drug history: oral agents, insulin regimen, last doses, adherence',
  'Screen comorbidities: CAD, CKD, cerebrovascular disease, OSA, obesity',
  'Focused autonomic history: postural symptoms, gastroparesis, bowel dysfunction',
  'Examination: airway mobility, neuropathy signs, pulse quality, skin/foot status',
  'Review prior anaesthesia records for hemodynamic instability or difficult airway'
], 0.7, 1.0, 8.9, 4.1, 18);
addFooter(s);

// 8 systemic complications
s = pptx.addSlide();
addHeader(s, 'Systemic Complications and Anaesthetic Impact');
s.addTable([
  [{text:'System'}, {text:'Complications'}, {text:'Anaesthetic concern'}],
  [{text:'Cardiovascular'}, {text:'CAD, silent ischemia, HF, CAN'}, {text:'Ischemia risk, hypotension, blunted autonomic responses'}],
  [{text:'Renal'}, {text:'Diabetic nephropathy, CKD'}, {text:'Drug clearance, fluid and electrolyte strategy'}],
  [{text:'Neurologic'}, {text:'Peripheral/autonomic neuropathy'}, {text:'Aspiration risk, pressure injury, hemodynamic lability'}],
  [{text:'Gastrointestinal'}, {text:'Gastroparesis'}, {text:'Delayed gastric emptying; aspiration prophylaxis'}],
  [{text:'Musculoskeletal'}, {text:'Limited joint mobility'}, {text:'Potential difficult laryngoscopy/intubation'}]
], { x:0.45, y:1.05, w:9.1, h:3.9, fontSize:14, color:colors.darkText,
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addFooter(s);

// 9 Investigations
s = pptx.addSlide();
addHeader(s, 'Preoperative Investigations');
addBullets(s, [
  'Blood glucose profile: fasting, random, perioperative trend review',
  'HbA1c to estimate control over previous 2-3 months',
  'Renal profile: urea, creatinine, electrolytes, eGFR',
  '12-lead ECG in all middle-aged/long-standing diabetics',
  'Echocardiography/stress imaging if ischemic risk or poor functional capacity',
  'Urine ketones/blood ketones if symptomatic hyperglycemia or emergency surgery',
  'Baseline CBC and infection screen as clinically indicated'
], 0.7, 1.0, 8.9, 4.1, 18);
addFooter(s, 'HbA1c is more informative than single random clinic glucose');

// 10 Anaesthetic significance
s = pptx.addSlide();
addHeader(s, 'Anaesthetic Significance of Diabetic Complications');
addBullets(s, [
  'CAN: resting tachycardia, orthostatic hypotension, silent ischemia, sudden BP swings',
  'Autonomic dysfunction reduces physiologic reserve during induction and blood loss',
  'Gastroparesis increases aspiration risk: consider rapid sequence approach when indicated',
  'Limited joint mobility (prayer sign) and reduced cervical extension may predict difficult airway',
  'Peripheral neuropathy: cautious positioning, pressure-point protection, postoperative neurologic assessment'
], 0.7, 1.0, 8.9, 4.1, 17);
addFooter(s);

// 11 Glycemic targets
s = pptx.addSlide();
addHeader(s, 'Perioperative Glucose Management Targets');
s.addShape(pptx.ShapeType.roundRect, { x: 1.1, y: 1.1, w: 7.8, h: 1.15, radius: 0.08, fill: { color: 'EAF8EE' }, line: { color: 'B6E1C0', pt: 1.5 } });
s.addText('Recommended perioperative target glucose: 140-180 mg/dL', { x: 1.35, y: 1.45, w: 7.3, h: 0.45, fontSize: 24, bold: true, color: colors.green, align: 'center' });
addBullets(s, [
  'Avoid both hyperglycemia and hypoglycemia; glycemic variability also predicts poor outcomes',
  'Frequent checks and dynamic insulin titration are superior to static sliding-scale-only plans',
  'Intraoperative monitoring every 1-2 hours for major procedures or insulin infusions',
  'Confirm aberrant point-of-care values with laboratory/blood-gas methods when needed'
], 0.7, 2.5, 8.8, 2.4, 16);
addFooter(s, 'Source: Barash Clinical Anesthesia, 9e');

// 12 Drug management
s = pptx.addSlide();
addHeader(s, 'Perioperative Drug Management');
s.addTable([
  [{text:'Drug class'}, {text:'Pre-op plan'}, {text:'Rationale'}],
  [{text:'Metformin'}, {text:'Hold day of surgery (consider 24-48 h if renal risk/contrast)'}, {text:'Reduce risk of lactic acidosis in stress/renal dysfunction'}],
  [{text:'Sulfonylureas'}, {text:'Omit morning dose'}, {text:'Reduce fasting hypoglycemia risk'}],
  [{text:'SGLT2 inhibitors'}, {text:'Stop 3-4 days pre-op'}, {text:'Prevent euglycemic ketoacidosis'}],
  [{text:'Basal insulin'}, {text:'Continue reduced dose (about 50-80% depending protocol)'}, {text:'Prevents ketosis and severe hyperglycemia'}],
  [{text:'Prandial insulin'}, {text:'Hold while fasting; correction doses as needed'}, {text:'Avoid hypoglycemia'}]
], { x:0.45, y:1.05, w:9.1, h:3.9, fontSize:14, color:colors.darkText,
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addFooter(s);

// 13 Choice anaesthesia
s = pptx.addSlide();
addHeader(s, 'Choice of Anaesthesia: GA vs Regional');
s.addShape(pptx.ShapeType.rect, { x:0.6, y:1.1, w:4.3, h:3.8, fill:{color:'F8FBFF'}, line:{color:'BFCFE3', pt:1} });
s.addShape(pptx.ShapeType.rect, { x:5.1, y:1.1, w:4.3, h:3.8, fill:{color:'FFF9ED'}, line:{color:'E4D1A2', pt:1} });
s.addText('General Anaesthesia', { x:0.8, y:1.25, w:3.9, h:0.3, fontSize:18, bold:true, color:colors.navy, align:'center' });
s.addText('Regional Anaesthesia', { x:5.3, y:1.25, w:3.9, h:0.3, fontSize:18, bold:true, color:'8A5A00', align:'center' });
addBullets(s, [
  'Airway control; suitable for long/major surgeries',
  'Allows tight ventilation and hemodynamic control',
  'Need vigilance for aspiration and stress hyperglycemia'
], 0.85, 1.7, 3.9, 2.8, 14);
addBullets(s, [
  'Blunts stress response and opioid requirement',
  'May improve glycemic stability and recovery profile',
  'Caution with neuropathy, anticoagulation, and positioning'
], 5.35, 1.7, 3.9, 2.8, 14);
addFooter(s);

// 14 Intraop
s = pptx.addSlide();
addHeader(s, 'Intraoperative Management');
addBullets(s, [
  'Glucose monitoring every 1-2 h (hourly if unstable or on insulin infusion)',
  'IV insulin infusion preferred for major surgery/critically ill due to reliable titration',
  'Avoid hypothermia, hypovolemia, and prolonged fasting',
  'Use balanced crystalloids and individualized dextrose supplementation',
  'Strict asepsis and antibiotic timing due to elevated infection risk',
  'Protect pressure points and monitor for neuropathy-related positioning injury'
], 0.7, 1.0, 8.9, 4.1, 17);
addFooter(s);

// 15 GIK
s = pptx.addSlide();
addHeader(s, 'Glucose-Insulin-Potassium (GIK) Infusion Concept');
s.addShape(pptx.ShapeType.roundRect, { x:0.7, y:1.0, w:8.8, h:0.8, radius:0.07, fill:{color:'FFF8E8'}, line:{color:'E7D8A7'} });
s.addText('Goal: prevent catabolism, ketosis, and wide glucose excursions during fasting and surgical stress', { x:0.95, y:1.25, w:8.3, h:0.35, fontSize:16, bold:true, color:colors.darkText, align:'center' });
addBullets(s, [
  'Typical approach: dextrose-containing fluid + IV regular insulin infusion ± potassium supplementation',
  'Example starting strategy: insulin 0.5-2 units/h with dextrose infusion, then titrate to target',
  'Monitor glucose, potassium, and acid-base status at regular intervals',
  'Transition to basal-bolus regimen once oral intake resumes and clinical status stabilizes'
], 0.7, 2.0, 8.8, 2.9, 16);
addFooter(s, 'Institution-specific protocols should be followed');

// 16 Postop
s = pptx.addSlide();
addHeader(s, 'Postoperative Management');
addBullets(s, [
  'Continue frequent glucose monitoring in PACU/ICU based on risk and surgery magnitude',
  'Resume basal insulin early; restart oral agents once hemodynamically stable and eating',
  'Watch for infection, AKI, myocardial ischemia, and delayed wound healing',
  'Provide multimodal analgesia to attenuate stress hyperglycemia',
  'Early mobilization and nutrition with endocrine/medicine co-management when needed',
  'ICU consideration: unstable hemodynamics, severe metabolic derangement, major comorbidity burden'
], 0.7, 1.0, 8.9, 4.1, 17);
addFooter(s);

// 17 DKA
s = pptx.addSlide();
addHeader(s, 'Diabetic Ketoacidosis (DKA): Perioperative Relevance');
s.addShape(pptx.ShapeType.roundRect, { x: 0.8, y: 0.95, w: 8.4, h: 0.7, radius: 0.06, fill:{color:'FDEDEC'}, line:{color:'E6B0AA'} });
s.addText('⚠ DKA is a medical emergency. Elective surgery should be deferred until corrected.', { x:1.0, y:1.15, w:8.0, h:0.3, fontSize:14, bold:true, color:colors.red, align:'center' });
addBullets(s, [
  'Typical profile: hyperglycemia, ketonemia/ketonuria, high anion gap metabolic acidosis',
  'Clinical clues: dehydration, Kussmaul breathing, abdominal symptoms, altered sensorium',
  'Management pillars: isotonic fluids, IV insulin infusion, potassium-guided replacement',
  'Avoid rapid osmolar correction; bicarbonate only in selected severe instability',
  'Search and treat trigger: infection, MI, trauma, insulin omission'
], 0.7, 1.9, 8.8, 3.0, 16);
addFooter(s, 'Source: Miller\'s Anesthesia, 10e');

// 18 HHS
s = pptx.addSlide();
addHeader(s, 'Hyperosmolar Hyperglycaemic State (HHS)');
s.addTable([
  [{text:'Feature'}, {text:'DKA'}, {text:'HHS'}],
  [{text:'Typical patient'}, {text:'Type 1 DM'}, {text:'Type 2 DM, elderly'}],
  [{text:'Glucose'}, {text:'250-400 mg/dL (often)'}, {text:'Usually very high (>600 mg/dL)'}],
  [{text:'Ketosis/acidosis'}, {text:'Prominent'}, {text:'Minimal or absent'}],
  [{text:'Osmolality/dehydration'}, {text:'Moderate'}, {text:'Marked hyperosmolality, severe dehydration'}],
  [{text:'Primary treatment'}, {text:'Fluids + insulin + electrolytes'}, {text:'Aggressive fluids then insulin + trigger control'}]
], { x:0.75, y:1.1, w:8.5, h:3.8, fontSize:15, color:colors.darkText,
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addFooter(s);

// 19 Stiff joint
s = pptx.addSlide();
addHeader(s, 'Stiff Joint Syndrome and Difficult Airway');
addBullets(s, [
  'Long-standing diabetes can cause glycosylation of connective tissue and limited joint mobility',
  '“Prayer sign” (inability to approximate palmar surfaces fully) may suggest difficult laryngoscopy',
  'Assess neck extension, atlanto-occipital mobility, and mouth opening in PAC',
  'Prepare difficult airway plan: video laryngoscope, bougie, backup supraglottic airway, awake strategy if needed',
  'Document airway findings clearly for future anaesthetic encounters'
], 0.7, 1.0, 8.9, 4.1, 17);
addFooter(s);

// 20 Key points
s = pptx.addSlide();
addHeader(s, 'Take-Home Messages');
addBullets(s, [
  'Diabetes is a multisystem disease with major perioperative impact beyond glucose values alone',
  'Preoperative risk assessment must actively screen for cardiac, renal, neurologic, and autonomic complications',
  'Perioperative glucose target around 140-180 mg/dL with frequent monitoring and dynamic insulin titration',
  'Avoid medication errors: continue basal insulin, hold selected oral agents appropriately',
  'Early recognition and protocol-based treatment of DKA/HHS can be life-saving',
  'Team-based care (anaesthesia-surgery-endocrine-critical care) improves outcomes'
], 0.7, 1.0, 8.9, 4.1, 17);
addFooter(s);

// 21 references
s = pptx.addSlide();
addHeader(s, 'References');
addBullets(s, [
  'Miller\'s Anesthesia, 10th Edition. Sections: Diabetes Mellitus, Preoperative assessment, DKA/HHS.',
  'Barash, Cullen, and Stoelting\'s Clinical Anesthesia, 9th Edition. Perioperative Hyperglycemia and Outcomes.',
  'Morgan and Mikhail\'s Clinical Anesthesiology, 7th Edition. Diabetic neuropathy and systemic implications.',
  'American Diabetes Association Standards of Care (latest updates for perioperative glycemic targets).'
], 0.7, 1.0, 8.9, 4.1, 16);
addFooter(s, 'Prepared for postgraduate academic discussion');

pptx.writeFile({ fileName: '/home/daytona/workspace/dm-anaesthesia/DM_Anaesthesia_Case_Presentation.pptx' });