Septic Shock Management

const {
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  AlignmentType, HeadingLevel, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageOrientation, Header, Footer, PageNumber,
  NumberFormat, UnderlineType
} = require('docx');
const fs = require('fs');

// ── Colour palette ──────────────────────────────────────────────────────────
const RED    = "C0392B";
const DKRED  = "922B21";
const BLUE   = "1A5276";
const LBLUE  = "D6EAF8";
const ORANGE = "CA6F1E";
const LORANGE= "FDEBD0";
const GREEN  = "1E8449";
const LGREEN = "D5F5E3";
const PURPLE = "6C3483";
const LPURPLE= "E8DAEF";
const DGREY  = "2C3E50";
const LGREY  = "EBF5FB";
const WHITE  = "FFFFFF";
const YELLOW = "F9E79F";
const LYELLOW= "FFFDE7";

// ── Helper: shaded cell ─────────────────────────────────────────────────────
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function dataRow(label, value, bgHex) {
  return new TableRow({
    children: [
      shadedCell(label, bgHex || LGREY, DGREY, true, 18),
      shadedCell(value, WHITE, "000000", false, 18, 3)
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// ── Section title paragraph ─────────────────────────────────────────────────
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function spacer() {
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// ── TITLE BLOCK ─────────────────────────────────────────────────────────────
function titleBlock() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({
        children: [
          headerCell("🏥  iPD CARDEX", RED, 2),
          headerCell("SEPTIC SHOCK", DKRED, 2)
        ]
      }),
      new TableRow({
        children: [
          shadedCell("Ward / Unit:", LGREY, DGREY, true, 18),
          shadedCell("ICU / HDU", WHITE, "000000", false, 18),
          shadedCell("Date:", LGREY, DGREY, true, 18),
          shadedCell("_____________", WHITE, "000000", false, 18)
        ]
      }),
      new TableRow({
        children: [
          shadedCell("Patient Name:", LGREY, DGREY, true, 18),
          shadedCell("___________________________", WHITE, "000000", false, 18),
          shadedCell("MRN:", LGREY, DGREY, true, 18),
          shadedCell("_______________", WHITE, "000000", false, 18)
        ]
      }),
      new TableRow({
        children: [
          shadedCell("Age / Sex / Weight:", LGREY, DGREY, true, 18),
          shadedCell("_____ yrs  /  M  F  /  _____ kg  (IBW: _____ kg)", WHITE, "000000", false, 18),
          shadedCell("Allergies:", LGREY, DGREY, true, 18),
          shadedCell("NKDA  /  _______________", WHITE, "000000", false, 18)
        ]
      }),
      new TableRow({
        children: [
          shadedCell("Admitting Diagnosis:", LGREY, DGREY, true, 18),
          shadedCell("Septic Shock — Source: ________________________", WHITE, "000000", false, 18),
          shadedCell("Consultant:", LGREY, DGREY, true, 18),
          shadedCell("___________________________", WHITE, "000000", false, 18)
        ]
      })
    ]
  });
}

// ── VITAL SIGNS / MONITORING ─────────────────────────────────────────────────
function monitoringTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("📊  MONITORING & TARGETS", BLUE, 4)] }),
      new TableRow({
        children: [
          headerCell("Parameter", DGREY, 1),
          headerCell("Target", DGREY, 1),
          headerCell("Frequency", DGREY, 1),
          headerCell("Current Value", DGREY, 1)
        ]
      }),
      ...[
        ["HR", "60–100 bpm", "Continuous"],
        ["BP (Arterial / NIBP)", "MAP ≥ 65 mmHg  (60–65 in elderly)", "Continuous (arterial line preferred)"],
        ["SpO₂", "90–96%", "Continuous"],
        ["RR", "12–20 /min", "Continuous / q1h"],
        ["Temperature", "Afebrile / normalise", "q4h"],
        ["Urine Output", "≥ 0.5 mL/kg/h", "Hourly"],
        ["Serum Lactate", "< 2 mmol/L  (clearance ≥10% q2h)", "q2h until normal"],
        ["Capillary Refill Time (CRT)", "≤ 3 seconds", "q2h"],
        ["CVP (if line in situ)", "8–12 mmHg (MV: 12–15)", "q4h"],
        ["ScvO₂", "≥ 70%", "q4–8h"],
        ["GCS / Neuro status", "Document baseline", "q1h"],
        ["Blood Glucose", "140–180 mg/dL", "q1–2h (if on insulin)"],
        ["Fluid Balance (I/O)", "Avoid positive balance post-resus", "Hourly / cumulative"],
        ["Daily Weight", "Trend / fluid overload", "Daily"],
      ].map(([p, t, f]) => new TableRow({
        children: [
          shadedCell(p, LGREY, DGREY, true, 17),
          shadedCell(t, LGREEN, GREEN, true, 17),
          shadedCell(f, WHITE, "000000", false, 17),
          shadedCell("", WHITE, "000000", false, 17)
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      }))
    ]
  });
}

// ── INVESTIGATIONS ──────────────────────────────────────────────────────────
function investigationsTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🔬  INVESTIGATIONS", BLUE, 4)] }),
      new TableRow({
        children: [
          headerCell("Investigation", DGREY, 1),
          headerCell("Frequency", DGREY, 1),
          headerCell("Purpose", DGREY, 1),
          headerCell("Result", DGREY, 1)
        ]
      }),
      ...[
        ["Blood cultures (×2 sets)", "On admission (before ABx)", "Identify organism & sensitivities"],
        ["CBC with differential", "Admission → Daily", "WBC, platelets (DIC screen)"],
        ["CMP / Electrolytes", "Admission → q8–12h", "K⁺, Na⁺, Creatinine, BUN"],
        ["Serum Lactate", "On admission → q2h", "Resuscitation endpoint"],
        ["ABG / VBG", "Admission → q4–8h", "pH, PaO₂, PaCO₂, HCO₃⁻"],
        ["Coagulation (PT, INR, aPTT)", "Admission → Daily", "DIC monitoring"],
        ["Fibrinogen", "Admission → Daily if DIC", "DIC — transfuse if <150 mg/dL"],
        ["D-dimer", "Admission", "DIC screening"],
        ["LFTs + Bilirubin", "Admission → Daily", "Hepatic dysfunction"],
        ["Procalcitonin (PCT)", "Admission → q48–72h", "Guide antibiotic de-escalation"],
        ["CRP", "Admission → Daily", "Inflammatory marker, trend"],
        ["Procalcitonin", "Admission", "Baseline; guide de-escalation"],
        ["Urinalysis + Urine C&S", "Admission", "Source identification"],
        ["Chest X-ray", "Admission → Daily if MV", "ARDS / effusion / infiltrates"],
        ["ECG", "Admission", "Rule out cardiac cause"],
        ["Echo (Bedside/POCUS)", "As needed", "Cardiac function, effusion, volume"],
        ["CT Chest/Abdomen/Pelvis", "If source unknown", "Identify occult source"],
      ].map(([i, f, p]) => new TableRow({
        children: [
          shadedCell(i, LGREY, DGREY, true, 17),
          shadedCell(f, WHITE, "000000", false, 17),
          shadedCell(p, WHITE, "000000", false, 17),
          shadedCell("", WHITE, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── FLUID RESUSCITATION ─────────────────────────────────────────────────────
function fluidTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("💧  FLUID RESUSCITATION", BLUE, 4)] }),
      new TableRow({
        children: [
          headerCell("Phase", DGREY, 1),
          headerCell("Fluid / Volume", DGREY, 1),
          headerCell("Rate / Condition", DGREY, 1),
          headerCell("Notes", DGREY, 1)
        ]
      }),
      ...[
        ["Initial Bolus (0–3h)", "Balanced crystalloid\n(Lactated Ringer's / PlasmaLyte)", "30 mL/kg over 1–3 h", "Avoid normal saline (hyperchloraemic acidosis); avoid HES (↑AKI)"],
        ["Further fluid challenges", "Balanced crystalloid 250–500 mL", "Only if fluid-responsive\n(PLR, PPV, SVV)", "Use dynamic assessments; CVP alone is unreliable"],
        ["Colloid adjunct", "20% Albumin 100 mL", "If large volumes required (>3 L crystalloid)", "Consider in refractory hypotension"],
        ["De-resuscitation phase", "Fluid removal / conservative strategy", "After haemodynamic stabilisation", "2026 SSC: active fluid removal recommended post-resus to prevent overload"],
        ["AVOID", "HES / Gelatin / Dextran", "—", "Associated with AKI and increased mortality"],
      ].map(([ph, fl, r, n]) => new TableRow({
        children: [
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          shadedCell(fl, WHITE, "000000", false, 17),
          shadedCell(r, WHITE, "000000", false, 17),
          shadedCell(n, LYELLOW, ORANGE, false, 17)
        ]
      }))
    ]
  });
}

// ── VASOPRESSORS / INOTROPES ────────────────────────────────────────────────
function vasopressorTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("💉  VASOPRESSORS & INOTROPES", RED, 4)] }),
      new TableRow({
        children: [
          headerCell("Agent", DKRED, 1),
          headerCell("Dose", DKRED, 1),
          headerCell("Line / Route", DKRED, 1),
          headerCell("Notes", DKRED, 1)
        ]
      }),
      ...[
        ["Norepinephrine\n(1st LINE)", "0.01–0.25 µg/kg/min\nStart 0.05 µg/kg/min, titrate", "Central line preferred\n(peripheral short-term if needed)", "Target MAP ≥65 mmHg; preferred over dopamine"],
        ["Vasopressin\n(2nd LINE — ADD ON)", "Fixed 0.03–0.04 units/min", "Central line", "Add when NE ≥0.25–0.5 µg/kg/min; do NOT use alone; steroid-sparing"],
        ["Epinephrine\n(3rd LINE)", "0.01–0.3 µg/kg/min", "Central line", "Add if NE + vasopressin insufficient; also for septic cardiomyopathy"],
        ["Dobutamine\n(for low CO)", "2–20 µg/kg/min", "Central or peripheral", "Add for low cardiac output; use with vasopressor; monitor for tachycardia"],
        ["Dopamine\n(AVOID routinely)", "Not recommended", "—", "Only in highly selected cases (bradycardia + low arrhythmia risk)"],
        ["Terlipressin / Levosimendan", "NOT RECOMMENDED", "—", "SSC 2021/2026: insufficient evidence"],
      ].map(([a, d, r, n]) => new TableRow({
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          shadedCell(n, LYELLOW, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── ANTIBIOTICS ─────────────────────────────────────────────────────────────
function antibioticTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("💊  ANTIMICROBIALS", GREEN, 4)] }),
      new TableRow({
        children: [
          headerCell("Item", "1E8449", 1),
          headerCell("Details", "1E8449", 3)
        ]
      }),
      ...[
        ["Timing", "⚡ Administer within 1 HOUR of recognition — every hour of delay worsens mortality"],
        ["Blood Cultures", "Obtain ≥2 sets (peripheral + central) BEFORE antibiotics — do NOT delay >45 min for cultures"],
        ["Empiric Regimen\n(Community-onset)", "Piperacillin-Tazobactam 4.5 g IV q8h + Vancomycin 25–30 mg/kg loading dose\nOR Meropenem 1 g IV q8h if high ESBL/KPC risk"],
        ["Empiric Regimen\n(Hospital/ICU-onset)", "Meropenem 1–2 g IV q8h + Vancomycin 25–30 mg/kg loading\nConsider antifungal (Micafungin 100 mg IV daily) if high fungal risk"],
        ["Specific Source Adjustment", "Urinary: ceftriaxone ± gentamicin\nPulmonary: add azithromycin/levofloxacin\nIntra-abdominal: pip-tazo or meropenem\nSkin/soft tissue: add clindamycin"],
        ["De-escalation", "Daily review of cultures & sensitivities; narrow spectrum as soon as possible"],
        ["Duration", "7–10 days; shorter if good source control; longer for bacteraemia/endocarditis"],
        ["Procalcitonin-guided stop", "Use PCT trend to guide stopping — avoid using to START antibiotics"],
        ["Antifungals", "Only if HIGH risk (prolonged neutropenia, Candida colonisation, TPN, abdominal source)"],
      ].map(([item, details]) => new TableRow({
        children: [
          shadedCell(item, LGREEN, GREEN, true, 17),
          shadedCell(details, WHITE, "000000", false, 17, 3)
        ]
      }))
    ]
  });
}

// ── CORTICOSTEROIDS ─────────────────────────────────────────────────────────
function steroidTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🧪  CORTICOSTEROIDS", PURPLE, 4)] }),
      new TableRow({
        children: [
          headerCell("Drug", "6C3483", 1),
          headerCell("Dose & Route", "6C3483", 1),
          headerCell("Indication / Condition", "6C3483", 1),
          headerCell("Notes", "6C3483", 1)
        ]
      }),
      ...[
        ["Hydrocortisone", "200 mg/day IV\n(50 mg q6h OR 200 mg infusion over 24h)", "Refractory septic shock: persisting vasopressor requirement despite adequate fluids", "Start when NE dose ≥0.25 µg/kg/min; reduces vasopressor duration; no proven mortality benefit"],
        ["Fludrocortisone\n(optional)", "50 µg PO/NG once daily", "Add-on to hydrocortisone (Annane protocol)", "Mineralocorticoid supplementation; continue for same duration as hydrocortisone"],
        ["Tapering", "Taper once vasopressors weaned", "Do NOT stop abruptly", "Gradual taper over 48–72h post-vasopressor discontinuation"],
      ].map(([d, dose, ind, n]) => new TableRow({
        children: [
          shadedCell(d, LPURPLE, PURPLE, true, 17),
          shadedCell(dose, WHITE, "000000", false, 17),
          shadedCell(ind, WHITE, "000000", false, 17),
          shadedCell(n, LYELLOW, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── RESPIRATORY SUPPORT ─────────────────────────────────────────────────────
function respiratoryTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🫁  RESPIRATORY SUPPORT", BLUE, 4)] }),
      new TableRow({
        children: [
          headerCell("Mode", DGREY, 1),
          headerCell("Setting / Target", DGREY, 1),
          headerCell("Indication", DGREY, 1),
          headerCell("Notes", DGREY, 1)
        ]
      }),
      ...[
        ["Supplemental O₂", "SpO₂ 90–96% (avoid hyperoxia)", "All septic shock patients", "Nasal cannula 2–6 L/min or simple face mask"],
        ["HFNC (High-Flow Nasal Cannula)", "FiO₂ titrated, flow 40–60 L/min", "Mild-moderate hypoxia with adequate neurology", "First-line for non-intubated patients; delay intubation if tolerating"],
        ["Non-invasive ventilation (NIV)", "CPAP / BiPAP", "Cardiogenic pulmonary oedema / selected ARDS", "Avoid if haemodynamically unstable or altered consciousness"],
        ["Invasive MV (Intubation)", "Tidal volume: 6 mL/kg IBW\nPlateau pressure ≤30 cmH₂O\nDrive pressure ≤15 cmH₂O\nPEEP: titrate per ARDSnet table", "ARDS (P/F <300), refractory hypoxia, respiratory failure, airway protection", "Lung-protective ventilation mandatory; avoid volume-limited barotrauma"],
        ["Prone positioning", "≥12 hours/day", "Moderate-severe ARDS (P/F <150)", "NMB recommended to facilitate; coordinate team turns"],
        ["VV-ECMO", "Refer to ECMO centre", "Refractory ARDS (P/F <80 on optimal MV)", "Only if experienced team available; SSC 2021 suggestion"],
      ].map(([m, s, ind, n]) => new TableRow({
        children: [
          shadedCell(m, LBLUE, BLUE, true, 17),
          shadedCell(s, WHITE, "000000", false, 17),
          shadedCell(ind, WHITE, "000000", false, 17),
          shadedCell(n, LYELLOW, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── ORGAN SUPPORT / SUPPORTIVE CARE ─────────────────────────────────────────
function organSupportTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🏥  ORGAN SUPPORT & SUPPORTIVE CARE", DGREY, 4)] }),
      new TableRow({
        children: [
          headerCell("System", DGREY, 1),
          headerCell("Intervention", DGREY, 2),
          headerCell("Target / Notes", DGREY, 1)
        ]
      }),
      ...[
        ["RENAL", "• Avoid nephrotoxins (NSAIDs, contrast, aminoglycosides)\n• Renal Replacement Therapy (CVVH/CVVHDF) if indicated", "Indications: progressive AKI, K⁺ >6, pH <7.1, urea >35, fluid overload\nNa-bicarb if AKI + pH <7.2"],
        ["HAEMATOLOGY\n(Transfusion)", "• RBC transfusion\n• FFP\n• Platelets\n• Cryoprecipitate", "Hb <7 g/dL (or <8 if CAD/acute haem)\nActive bleeding + coagulopathy\nPlt <10,000/µL; or <20,000 + bleeding\nFibrinogen <150 mg/dL + bleeding"],
        ["GLYCAEMIC\nCONTROL", "• Start insulin infusion when BGL ≥180 mg/dL\n• Avoid hypoglycaemia", "Target: 140–180 mg/dL\nCheck BGL q1–2h on insulin"],
        ["NUTRITION", "• Early enteral feeding (within 48h if shock controlled)\n• Parenteral if enteral not tolerated by day 7", "Avoid overfeeding; caloric target: 20–25 kcal/kg/day\nNasogastric tube if not eating"],
        ["STRESS ULCER\nPROPHYLAXIS", "• Pantoprazole 40 mg IV/PO once daily", "High-risk: MV ≥48h, coagulopathy, prior GI bleed\nDiscontinue when enteral feeding established"],
        ["DVT\nPROPHYLAXIS", "• Enoxaparin 40 mg SC daily (if no contraindication)\n• Compression stockings / IPC device", "Hold if Plt <50,000 or active bleeding\nUse mechanical prophylaxis if anticoagulation contraindicated"],
        ["SEDATION /\nANALGESIA", "• Analgesia-first (fentanyl/morphine)\n• Light sedation (RASS 0 to -1)\n• Daily sedation interruption", "SAT + SBT protocol daily\nAvoid heavy sedation; reduces ventilator days"],
        ["BOWEL CARE", "• Stool chart; lactulose if constipated", "Prevent ileus; facilitate early enteral nutrition"],
        ["ORAL CARE", "• Chlorhexidine oral rinse q6–8h if MV", "Prevent VAP"],
        ["ELEVATED HOB", "• Head of bed 30–45°", "Prevents aspiration and VAP"],
        ["GOALS OF CARE", "• Discuss prognosis and goals with patient/family\n• Integrate palliative care principles as appropriate", "ICU admission within 6h of diagnosis\nDocument code status"],
      ].map(([sys, int, t]) => new TableRow({
        children: [
          shadedCell(sys, LGREY, DGREY, true, 17),
          shadedCell(int, WHITE, "000000", false, 17, 2),
          shadedCell(t, LYELLOW, ORANGE, false, 16)
        ]
      }))
    ]
  });
}

// ── SOURCE CONTROL ──────────────────────────────────────────────────────────
function sourceControlTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🎯  SOURCE CONTROL", DKRED, 4)] }),
      new TableRow({
        children: [
          headerCell("Action", DKRED, 1),
          headerCell("Timing", DKRED, 1),
          headerCell("Examples", DKRED, 2)
        ]
      }),
      ...[
        ["Identify source", "Immediate", "Clinical exam + imaging (CT, USS, X-ray) to find abscess, necrosis, obstruction"],
        ["Drain / decompress", "Within 6–12h of identification", "Percutaneous or surgical drainage of abscess; biliary decompression; empyema drainage"],
        ["Debride / resect", "As soon as surgically feasible", "Necrotising fasciitis: emergency OR; infarcted bowel: resection; infected prosthesis"],
        ["Remove IV devices", "Immediately if source suspected", "Remove CVC/peripheral line suspected as source; replace at new site"],
        ["Urology source", "Urgent urology review", "Urinary obstruction → nephrostomy or catheter; pyelonephritis with obstruction"],
        ["Gynaecological source", "Urgent gynaecology review", "Septic abortion, tubo-ovarian abscess, postpartum endometritis"],
      ].map(([a, t, e]) => new TableRow({
        children: [
          shadedCell(a, LORANGE, ORANGE, true, 17),
          shadedCell(t, WHITE, ORANGE, true, 17),
          shadedCell(e, WHITE, "000000", false, 17, 2)
        ]
      }))
    ]
  });
}

// ── ESCALATION / RED FLAGS ───────────────────────────────────────────────────
function escalationTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("🚨  ESCALATION TRIGGERS & RED FLAGS", RED, 4)] }),
      new TableRow({
        children: [
          headerCell("Parameter", DKRED, 1),
          headerCell("Threshold", DKRED, 1),
          headerCell("Action", DKRED, 2)
        ]
      }),
      ...[
        ["MAP", "< 55 mmHg despite vasopressors", "Escalate vasopressor; consider adding hydrocortisone; call senior"],
        ["Lactate", "Rising lactate or not clearing by 10%/2h", "Re-assess fluid status, vasopressors, cardiac output; consider POCUS/Echo"],
        ["Urine Output", "< 0.3 mL/kg/h for >2h", "IV fluid challenge; check foley patency; consider RRT referral"],
        ["SpO₂", "< 88% despite HFNC", "Consider NIV; escalate to intubation"],
        ["GCS", "Falling GCS (drop ≥2 points)", "Airway assessment; CT head; consider intubation"],
        ["HR", "> 150 or < 40 bpm", "12-lead ECG; treat arrhythmia; call cardiologist"],
        ["Temperature", "> 40°C or < 35°C", "Culture again; review antibiotics; cooling/warming measures"],
        ["Glucose", "< 70 mg/dL", "STOP insulin; 50 mL of 50% dextrose IV; recheck in 15 min"],
        ["Vasopressor requirement", "NE > 0.5 µg/kg/min", "Add vasopressin; consider hydrocortisone; senior review"],
        ["New organ dysfunction", "Any new organ involvement", "Review antibiotics; POCUS; source control review; ICU consult"],
      ].map(([p, t, a]) => new TableRow({
        children: [
          shadedCell(p, "FADBD2", DKRED, true, 17),
          shadedCell(t, WHITE, RED, true, 17),
          shadedCell(a, WHITE, "000000", false, 17, 2)
        ]
      }))
    ]
  });
}

// ── NURSING CARE ─────────────────────────────────────────────────────────────
function nursingTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("👩‍⚕️  NURSING CARE PLAN", BLUE, 2)] }),
      new TableRow({
        children: [
          headerCell("Problem / Need", DGREY, 1),
          headerCell("Nursing Interventions", DGREY, 1)
        ]
      }),
      ...[
        ["Haemodynamic instability", "• Continuous ECG, SpO₂, arterial BP monitoring\n• Hourly urine output via IDC\n• Record ALL fluid input and output\n• Report MAP <65 or UO <0.5 mL/kg/h immediately"],
        ["Risk of infection / sepsis progression", "• Strict aseptic technique for all procedures\n• Document IV line insertion date/site; change as per protocol\n• Observe catheter/wound/line sites for signs of infection"],
        ["Impaired tissue perfusion", "• Assess peripheries q2h (CRT, skin colour, temperature)\n• Reposition q2h; pressure area care\n• TED stockings / IPC device"],
        ["Risk of respiratory failure", "• Monitor RR, SpO₂, work of breathing q1h\n• Maintain HOB 30–45°\n• Suction as required; oral chlorhexidine q6h if intubated"],
        ["Altered level of consciousness", "• GCS/AVPU assessment q1h\n• Minimise sedation; agitation-sedation-delirium (CAM-ICU) screening\n• Reorientation; day/night cues; family presence"],
        ["Nutritional deficit", "• Insert NGT if not eating; commence EN per dietitian order\n• Monitor for gastric residuals\n• Blood glucose q1–2h if on insulin"],
        ["Communication / family support", "• Regular updates to family\n• Facilitate goals of care discussion with medical team\n• Chaplaincy/social work referral as needed"],
      ].map(([p, i]) => new TableRow({
        children: [
          shadedCell(p, LGREY, DGREY, true, 17),
          shadedCell(i, WHITE, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── MEDICATION CHART ─────────────────────────────────────────────────────────
function medicationTable() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [headerCell("💊  REGULAR MEDICATIONS (Sample — Adjust per local guidelines)", GREEN, 6)] }),
      new TableRow({
        children: [
          headerCell("Drug", "1E8449", 1),
          headerCell("Dose", "1E8449", 1),
          headerCell("Route", "1E8449", 1),
          headerCell("Frequency", "1E8449", 1),
          headerCell("Indication", "1E8449", 1),
          headerCell("✓ Given", "1E8449", 1)
        ]
      }),
      ...[
        ["Norepinephrine", "Start 0.05 µg/kg/min — titrate to MAP ≥65", "IV infusion (CVC)", "Continuous", "Vasopressor", ""],
        ["Piperacillin-Tazobactam", "4.5 g", "IV (over 30 min)", "q8h × 7 days", "Empiric antibiotic", ""],
        ["Vancomycin", "25–30 mg/kg loading; AUC-guided", "IV (over 90–120 min)", "q8–12h (PK-guided)", "MRSA/Gram+ coverage", ""],
        ["Hydrocortisone", "50 mg", "IV bolus", "q6h (or 200 mg/24h infusion)", "Refractory shock", ""],
        ["Pantoprazole", "40 mg", "IV/PO", "Once daily", "Stress ulcer prophylaxis", ""],
        ["Enoxaparin", "40 mg", "SC", "Once daily", "DVT prophylaxis", ""],
        ["Insulin (actrapid)", "Per sliding scale / infusion", "IV infusion", "Continuous (if BGL ≥180)", "Glycaemic control", ""],
        ["Paracetamol", "1 g (if weight ≥50 kg)", "IV/PO/NG", "q6h (max 4 g/day)", "Antipyretic / analgesia", ""],
        ["Morphine / Fentanyl", "As prescribed", "IV PRN / infusion", "PRN or continuous", "Analgesia-first sedation", ""],
        ["Midazolam / Propofol", "Per sedation protocol", "IV infusion", "Continuous (if MV)", "Sedation (RASS target 0 to -1)", ""],
      ].map(([d, dose, r, f, ind, g]) => new TableRow({
        children: [
          shadedCell(d, LGREEN, GREEN, true, 17),
          shadedCell(dose, WHITE, "000000", false, 17),
          shadedCell(r, WHITE, "000000", false, 17),
          shadedCell(f, WHITE, "000000", false, 17),
          shadedCell(ind, WHITE, "000000", false, 17),
          shadedCell(g, WHITE, "000000", false, 17)
        ]
      }))
    ]
  });
}

// ── FOOTER ────────────────────────────────────────────────────────────────────
function footerPara() {
  return new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { before: 120 },
    children: [
      new TextRun({
        text: "Based on SSC 2026 Guidelines (Crit Care Med 2026;54:725-812) | Harrison's 22e (2025) | Rosen's EM | Goldman-Cecil Medicine  |  For clinical use under supervising clinician — individualise to patient",
        size: 14,
        color: "888888",
        italics: true,
        font: "Calibri"
      })
    ]
  });
}

// ── ASSEMBLE DOCUMENT ────────────────────────────────────────────────────────
const doc = new Document({
  styles: {
    default: {
      document: {
        run: { font: "Calibri", size: 18 }
      }
    }
  },
  sections: [{
    properties: {
      page: {
        size: { orientation: PageOrientation.PORTRAIT },
        margin: { top: 600, bottom: 600, left: 700, right: 700 }
      }
    },
    children: [
      // Main title
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 160 },
        children: [
          new TextRun({ text: "INTENSIVE CARE PATIENT CARDEX", bold: true, size: 36, color: DKRED, font: "Calibri" }),
          new TextRun({ text: "  |  SEPTIC SHOCK", bold: true, size: 36, color: BLUE, font: "Calibri" })
        ]
      }),

      // Patient block
      titleBlock(),
      spacer(),

      // 1. Monitoring
      sectionTitle("1.  MONITORING & TARGETS", BLUE),
      monitoringTable(),
      spacer(),

      // 2. Investigations
      sectionTitle("2.  INVESTIGATIONS", BLUE),
      investigationsTable(),
      spacer(),

      // 3. Fluid resuscitation
      sectionTitle("3.  FLUID RESUSCITATION", BLUE),
      fluidTable(),
      spacer(),

      // 4. Vasopressors
      sectionTitle("4.  VASOPRESSORS & INOTROPES", RED),
      vasopressorTable(),
      spacer(),

      // 5. Antimicrobials
      sectionTitle("5.  ANTIMICROBIALS", GREEN),
      antibioticTable(),
      spacer(),

      // 6. Source control
      sectionTitle("6.  SOURCE CONTROL", DKRED),
      sourceControlTable(),
      spacer(),

      // 7. Corticosteroids
      sectionTitle("7.  CORTICOSTEROIDS", PURPLE),
      steroidTable(),
      spacer(),

      // 8. Respiratory
      sectionTitle("8.  RESPIRATORY SUPPORT", BLUE),
      respiratoryTable(),
      spacer(),

      // 9. Organ support
      sectionTitle("9.  ORGAN SUPPORT & SUPPORTIVE CARE", DGREY),
      organSupportTable(),
      spacer(),

      // 10. Medications
      sectionTitle("10.  MEDICATION CHART (Sample)", GREEN),
      medicationTable(),
      spacer(),

      // 11. Nursing
      sectionTitle("11.  NURSING CARE PLAN", BLUE),
      nursingTable(),
      spacer(),

      // 12. Escalation
      sectionTitle("12.  ESCALATION TRIGGERS & RED FLAGS", RED),
      escalationTable(),
      spacer(),

      footerPara()
    ]
  }]
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync("/home/daytona/workspace/septic-shock-cardex/Septic_Shock_iPD_Cardex.docx", buffer);
  console.log("✅ Created: Septic_Shock_iPD_Cardex.docx");
}).catch(err => {
  console.error("❌ Error:", err);
  process.exit(1);
});