mkdir -p /home/daytona/workspace/ijv-note && ls /home/daytona/workspace/ijv-note…

~/ijv-note/generate_ijv_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
import os

OUTPUT = "/home/daytona/workspace/ijv-note/IJV_Cannulation_MD_Anaesthesia.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.8*cm, leftMargin=1.8*cm,
    topMargin=1.8*cm, bottomMargin=1.8*cm
)

W, H = A4
styles = getSampleStyleSheet()

# ── Custom styles ────────────────────────────────────────────────
title_style = ParagraphStyle(
    "TitleCustom",
    parent=styles["Title"],
    fontSize=16,
    leading=20,
    textColor=colors.HexColor("#1a3a5c"),
    spaceAfter=4,
    alignment=TA_CENTER,
)
subtitle_style = ParagraphStyle(
    "SubTitle",
    parent=styles["Normal"],
    fontSize=9,
    textColor=colors.HexColor("#555555"),
    alignment=TA_CENTER,
    spaceAfter=2,
)
h1_style = ParagraphStyle(
    "H1",
    parent=styles["Heading1"],
    fontSize=12,
    leading=15,
    textColor=colors.white,
    backColor=colors.HexColor("#1a3a5c"),
    spaceBefore=10,
    spaceAfter=4,
    leftIndent=-4,
    rightIndent=-4,
    borderPad=4,
)
h2_style = ParagraphStyle(
    "H2",
    parent=styles["Heading2"],
    fontSize=10.5,
    leading=13,
    textColor=colors.HexColor("#1a3a5c"),
    spaceBefore=7,
    spaceAfter=3,
    borderPad=2,
)
h3_style = ParagraphStyle(
    "H3",
    parent=styles["Heading3"],
    fontSize=9.5,
    leading=12,
    textColor=colors.HexColor("#c0392b"),
    spaceBefore=5,
    spaceAfter=2,
)
body_style = ParagraphStyle(
    "Body",
    parent=styles["Normal"],
    fontSize=9,
    leading=13,
    alignment=TA_JUSTIFY,
    spaceAfter=3,
)
bullet_style = ParagraphStyle(
    "Bullet",
    parent=styles["Normal"],
    fontSize=9,
    leading=12,
    leftIndent=14,
    bulletIndent=4,
    spaceAfter=1,
)
sub_bullet_style = ParagraphStyle(
    "SubBullet",
    parent=styles["Normal"],
    fontSize=8.5,
    leading=11.5,
    leftIndent=26,
    bulletIndent=14,
    spaceAfter=1,
)
key_style = ParagraphStyle(
    "Key",
    parent=styles["Normal"],
    fontSize=8.5,
    leading=11,
    textColor=colors.HexColor("#7d1111"),
    backColor=colors.HexColor("#fff3f3"),
    leftIndent=6,
    rightIndent=6,
    borderPad=3,
    spaceAfter=2,
)
footer_style = ParagraphStyle(
    "Footer",
    parent=styles["Normal"],
    fontSize=7.5,
    textColor=colors.HexColor("#888888"),
    alignment=TA_CENTER,
)

def section(title):
    return [
        Spacer(1, 4),
        Paragraph(f"  {title}", h1_style),
    ]

def h2(text):
    return Paragraph(text, h2_style)

def h3(text):
    return Paragraph(text, h3_style)

def p(text):
    return Paragraph(text, body_style)

def b(text):
    return Paragraph(f"• {text}", bullet_style)

def sb(text):
    return Paragraph(f"◦ {text}", sub_bullet_style)

def sp(n=4):
    return Spacer(1, n)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc"), spaceAfter=3)

def key_point(text):
    return Paragraph(f"<b>KEY:</b> {text}", key_style)

# ════════════════════════════════════════════════════════════════
story = []

# ── TITLE BLOCK ─────────────────────────────────────────────────
story.append(Spacer(1, 6))
story.append(Paragraph("INTERNAL JUGULAR VEIN (IJV)", title_style))
story.append(Paragraph("Anatomy | Methods of Cannulation | Complications", subtitle_style))
story.append(Paragraph("Short Note — MD Anaesthesia Examination (20 Marks)", subtitle_style))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor("#1a3a5c"), spaceAfter=6))
story.append(sp(2))

# ═══════════════════════════════════════════════════════════════
# SECTION 1: ANATOMY
# ═══════════════════════════════════════════════════════════════
story += section("1. ANATOMY OF THE INTERNAL JUGULAR VEIN")
story.append(sp(2))

story.append(h2("1.1  Origin and Course"))
story += [
    p("The IJV is the largest vein draining the head and neck. It is a continuation of the "
      "<b>sigmoid sinus</b> and begins at the <b>jugular foramen</b> at the base of the skull. "
      "It descends within the <b>carotid sheath</b> alongside the common carotid artery (medially) "
      "and the vagus nerve (posteriorly), terminating by joining the <b>subclavian vein</b> behind "
      "the sternoclavicular joint to form the <b>brachiocephalic (innominate) vein</b>."),
    sp(2),
    p("The right IJV has a <b>shorter, straighter course</b> to the superior vena cava (SVC) and "
      "right atrium, making it the preferred cannulation site. The left IJV joins the left subclavian "
      "vein, increasing the risk of thoracic duct injury and pleural effusion."),
]

story.append(h2("1.2  Surface Anatomy & Relations"))
anatomy_data = [
    ["Relation", "Structure"],
    ["Anterior/Medial", "Common carotid artery (CCA)"],
    ["Posterior", "Vagus nerve; anterior scalene muscle; dome of pleura (left > right)"],
    ["Lateral", "Sternocleidomastoid (SCM) muscle"],
    ["Medial (lower)", "Thyroid gland; trachea; oesophagus"],
    ["Posterior (root of neck)", "Phrenic nerve on anterior scalene; subclavian artery"],
    ["Left side only", "Thoracic duct (enters junction of L IJV and L subclavian vein)"],
]
t_anatomy = Table(anatomy_data, colWidths=[5.5*cm, 10.5*cm])
t_anatomy.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,-1), 8.5),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#f0f4f8"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(t_anatomy)
story.append(sp(4))

story.append(h2("1.3  The SCM Triangle (Key Landmark)"))
story += [
    p("The <b>two heads of the SCM muscle</b> (sternal and clavicular) and the <b>clavicle</b> "
      "form a triangle. The apex of this triangle is the primary landmark for IJV cannulation. "
      "The IJV lies just <b>deep to the apex</b>, lateral to the carotid pulse, and medial to "
      "the lateral (clavicular) head of SCM."),
    b("<b>Size:</b> diameter approximately 1.5–2.5 cm in an adult; distends in Trendelenburg position"),
    b("The vein is <b>compressible</b> on ultrasound — key to distinguishing it from the carotid artery"),
    b("Normally lies <b>antero-lateral</b> to the carotid artery in the lower neck"),
]
story.append(key_point("Right IJV preferred: Right IJV + right innominate vein + SVC = nearly straight line to right atrium. Avoids thoracic duct. Lower complication rate."))
story.append(sp(3))

# ═══════════════════════════════════════════════════════════════
# SECTION 2: INDICATIONS & CONTRAINDICATIONS
# ═══════════════════════════════════════════════════════════════
story += section("2. INDICATIONS & CONTRAINDICATIONS")
story.append(sp(2))

ind_contra = [
    ["INDICATIONS", "CONTRAINDICATIONS / PRECAUTIONS"],
    [
        "CVP monitoring\nInfusion of vasoactive / caustic drugs\nTotal parenteral nutrition (TPN)\nPoor peripheral venous access\nRapid fluid resuscitation (large-bore)\nTranscutaneous pacing / PA catheter insertion\nAspiration of venous air embolism\nScvO2 monitoring (sepsis bundles)\nECMO cannulation (R IJV - double lumen)",
        "Local infection / cellulitis at site\nIpsilateral carotid endarterectomy\nCoagulopathy (relative — use R IJV, compressible)\nRecent neck surgery / irradiation\nContralateral pneumothorax (use same side)\nCervical spine immobilisation\nKnown SVC thrombosis\nTumour / AV fistula in neck\nSevere thrombocytopaenia (relative)"
    ],
]
t_ic = Table(ind_contra, colWidths=[8*cm, 8*cm])
t_ic.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,-1), 8.5),
    ("FONTNAME", (0,1), (-1,-1), "Helvetica"),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#f0f4f8"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t_ic)
story.append(sp(4))

# ═══════════════════════════════════════════════════════════════
# SECTION 3: METHODS OF CANNULATION
# ═══════════════════════════════════════════════════════════════
story += section("3. METHODS OF CANNULATION")
story.append(sp(2))

story.append(h2("3.1  Pre-Procedure Preparation"))
story += [
    b("Informed consent; time-out protocol (right patient, right side)"),
    b("Position: <b>Trendelenburg 15°</b> — distends IJV, reduces air embolism risk"),
    b("Head turned <b>30° to the contralateral side</b> (over-rotation collapses IJV)"),
    b("Full aseptic technique: sterile gloves, gown, mask, cap; chlorhexidine-alcohol skin prep; large sterile drape"),
    b("Equipment: central line kit (18G introducer needle, J-wire, dilator, triple/quadruple lumen catheter), 10 mL syringe, 1% lidocaine, USG machine"),
    b("<b>Ultrasound guidance is standard of care</b> — mandated by most institutions for IJV cannulation"),
]
story.append(sp(3))

story.append(h2("3.2  Three Landmark Approaches"))
story.append(p("All three approaches target the IJV as it lies beneath the SCM triangle. "
               "The <b>central (median) approach</b> is most widely used in anaesthesia."))
story.append(sp(3))

# Approaches table
approaches = [
    ["Approach", "Needle Entry Point", "Direction", "Advantages / Notes"],
    [
        "Central\n(Median)\n★ MOST USED",
        "Apex of SCM triangle\n(junction of sternal &\nclavicular heads)",
        "30-45° to skin;\naim toward ipsilateral\nnipple; lateral to\ncarotid pulse",
        "Highest success rate\nLow pneumothorax risk\nCarotid haematoma\neasily compressible\nBest for beginners"
    ],
    [
        "Anterior",
        "Medial border of SCM,\nat the level of thyroid\ncartilage",
        "30-45° to skin;\naim toward ipsilateral\nnipple; lateral to\ncarotid artery",
        "Good visualisation of\ncarotid\nHigher accidental\ncarotid puncture risk"
    ],
    [
        "Posterior",
        "Posterior border of SCM,\n5 cm above clavicle\n(junction of external\njugular & SCM)",
        "Needle passes beneath\nSCM; directed toward\nsternal notch",
        "Avoids carotid artery\nMore difficult to perform\nHigher pneumothorax\nrisk; for experienced\noperators"
    ],
]
t_app = Table(approaches, colWidths=[3.2*cm, 4.3*cm, 4.3*cm, 4.2*cm])
t_app.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,-1), 8),
    ("FONTNAME", (0,1), (-1,-1), "Helvetica"),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#eaf0fb"), colors.HexColor("#f9f9f9")]),
    ("BACKGROUND", (0,1), (0,1), colors.HexColor("#d4edda")),  # highlight central approach
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t_app)
story.append(sp(4))

story.append(h2("3.3  Seldinger Technique (Step-by-Step)"))
story.append(p("The <b>Seldinger (catheter over guidewire) technique</b> is used for the "
               "overwhelming majority of central lines. Steps:"))
story.append(sp(2))
steps = [
    ("1", "Infiltrate skin/subcutaneous tissue with 1–2% lidocaine at insertion site."),
    ("2", "Locate IJV with <b>USG (short-axis/in-plane view)</b> or anatomical landmarks."),
    ("3", "Insert 22G finder needle at 30–45° toward ipsilateral nipple; aspirate gently — "
          "dark (venous) blood confirms entry. <i>(Optional step — skip with USG)</i>"),
    ("4", "Insert 18G introducer needle along same path. Confirm free venous blood aspiration "
          "in 10 mL syringe. USG confirms needle tip in IJV (not carotid)."),
    ("5", "Stabilise needle. Disconnect syringe; occlude hub with thumb to prevent air entry."),
    ("6", "Advance <b>J-tipped guidewire</b> through needle — should pass with ZERO resistance. "
          "ECG monitoring: PVCs indicate wire in RV — withdraw slightly."),
    ("7", "<b>Never let go of the guidewire.</b> Confirm wire position with USG or fluoroscopy."),
    ("8", "Withdraw needle over wire. Nick skin with No. 11 blade alongside wire."),
    ("9", "Advance dilator over wire with a gentle twisting motion. Remove dilator."),
    ("10", "Thread central venous catheter (CVC) over wire. Target depth: R IJV 12–14 cm "
           "(tip at SVC-RA junction)."),
    ("11", "Remove wire. Aspirate and flush all ports. Confirm blood return."),
    ("12", "Secure catheter with suture. Apply sterile occlusive dressing."),
    ("13", "<b>Confirm position with chest X-ray</b> (tip at carina level) and <b>rule out "
           "pneumothorax</b>."),
]
sdata = [["Step", "Action"]] + [[s, Paragraph(d, body_style)] for s, d in steps]
t_steps = Table(sdata, colWidths=[1.2*cm, 14.8*cm])
t_steps.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#2c6e8a")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (0,-1), 8.5),
    ("ALIGN", (0,0), (0,-1), "CENTER"),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#eef6fa"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t_steps)
story.append(sp(4))

story.append(h2("3.4  Ultrasound Guidance"))
story += [
    p("<b>USG is now the standard of care</b> for IJV cannulation "
      "(Barash Clinical Anaesthesia, 9e; Morgan & Mikhail, 7e). "
      "Real-time USG reduces failed attempts, arterial puncture, haematoma, and time to cannulation."),
    sp(2),
]
usg_data = [
    ["Technique", "Description"],
    ["Short-axis\n(out-of-plane)", "Transverse view: IJV appears as compressible circle, "
     "CCA as pulsatile non-compressible circle. Needle visualised as hyperechoic dot. "
     "Risk: needle may be anterior to transducer (anterior wall puncture without posterior wall seen)."],
    ["Long-axis\n(in-plane)", "Needle visualised along its entire length. "
     "Allows confirmation of wire placement in real time. Technically more demanding but reduces complications."],
    ["Dynamic vs static", "Dynamic (real-time) guidance preferred over static (pre-cannulation marking) — "
     "significantly reduces failure and complications."],
]
t_usg = Table(usg_data, colWidths=[3*cm, 13*cm])
t_usg.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#2c6e8a")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,-1), 8.5),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#eef6fa"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t_usg)
story.append(sp(4))

# ═══════════════════════════════════════════════════════════════
# SECTION 4: COMPLICATIONS
# ═══════════════════════════════════════════════════════════════
story += section("4. COMPLICATIONS")
story.append(sp(2))

story.append(h2("4.1  Classification of Complications"))
story.append(p("Complications are classified by <b>timing</b> (immediate / early / late) "
               "and <b>mechanism</b> (mechanical / thromboembolic / infectious)."))
story.append(sp(3))

comp_data = [
    ["Category", "Complication", "Notes / Incidence"],
    # MECHANICAL - IMMEDIATE
    ["MECHANICAL\n(Immediate)", "Arterial puncture\n(Carotid artery)", 
     "Most common serious complication. Incidence ~3–5% (landmark), <1% (USG).\nManagement: Remove needle; apply firm direct pressure for 5–10 min.\nIf unrecognised arterial dilation/catheter placed: do NOT remove — seek vascular surgical help. Risk: haematoma, airway compression, stroke, death."],
    ["", "Pneumothorax", 
     "Incidence: ~0.5% (IJV) vs 1.5–3% (subclavian). Lower with USG.\nPresents: decreased breath sounds, hypoxia, CXR confirms.\nTreatment: needle decompression / chest drain if significant."],
    ["", "Air embolism", 
     "Prevented by Trendelenburg position & occluding needle hub.\nTreatment: Durant's manoeuvre (L lateral decubitus + Trendelenburg), 100% O2, aspirate via CVC."],
    ["", "Arrhythmias", 
     "Guidewire or catheter tip in RV/RA. Prevented by not inserting wire >20 cm.\nSelf-limiting once wire repositioned."],
    ["", "Haematoma / haemothorax", 
     "More common with coagulopathy. IJV preferred over subclavian in coagulopathic patients (direct compression possible)."],
    # MECHANICAL - EARLY
    ["MECHANICAL\n(Early)", "Malposition of catheter tip",
     "Tip in R atrium (arrhythmias, tamponade), SVC (poor CVP reading), IJV ascending (rare).\nConfirm tip position by CXR — tip should lie at the carina level (SVC-RA junction)."],
    ["", "Cardiac tamponade",
     "Due to cardiac perforation by guidewire or stiff catheter tip. Life-threatening — pericardiocentesis required."],
    ["", "Nerve injury",
     "Brachial plexus, phrenic nerve, vagus, recurrent laryngeal nerve, stellate ganglion (Horner syndrome), accessory nerve. More common with posterior approach."],
    ["", "Thoracic duct injury (L side)",
     "Chylothorax. Occurs with left IJV cannulation. Avoided by preferring right side."],
    ["", "Guidewire / catheter embolism",
     "Never let go of the wire. If lost: immediate CXR; interventional radiology retrieval."],
    # THROMBOEMBOLIC
    ["THROMBOEMBOLIC\n(Late)", "Venous thrombosis",
     "CVC-related DVT. IJV < subclavian < femoral. Long-term catheters increase risk.\nClinical: arm oedema, SVC syndrome.\nManagement: anticoagulation, line removal."],
    ["", "Pulmonary embolism",
     "Can arise from catheter tip thrombus. Potentially fatal."],
    # INFECTIOUS
    ["INFECTIOUS\n(Late)", "CLABSI (Central Line-\nAssociated Bloodstream\nInfection)",
     "Rate: ~1–2 per 1000 catheter-days (IJV > subclavian for infection risk).\nPrevention: maximal sterile barrier, chlorhexidine prep, early removal when no longer needed, daily review.\nTreatment: remove line, blood cultures, antibiotics."],
    ["", "Exit site / tunnel infection",
     "Erythema, pus at insertion site. Change line if persistent."],
    # MISCELLANEOUS
    ["MISCELLANEOUS", "Hydrothorax",
     "Inadvertent IV fluid infusion into pleural space from malpositioned catheter.\nDiagnosis: pleural fluid glucose = serum glucose."],
    ["", "Chylothorax (L side)",
     "Thoracic duct injury. Milky pleural fluid; high triglycerides."],
    ["", "AV fistula (rare)",
     "Carotid artery-IJV fistula — rare complication of cannulation."],
]

# Build complication table rows with merged cells
comp_style_data = [
    ["Category", "Complication", "Notes / Incidence"],
]
for row in comp_data[1:]:
    comp_style_data.append([
        Paragraph(f"<b>{row[0]}</b>", ParagraphStyle("tc", fontSize=8, leading=10)),
        Paragraph(f"<b>{row[1]}</b>", ParagraphStyle("tc2", fontSize=8, leading=10)),
        Paragraph(row[2], ParagraphStyle("tc3", fontSize=7.8, leading=10.5))
    ])

t_comp = Table(comp_style_data, colWidths=[3.2*cm, 3.8*cm, 9*cm])
t_comp.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,0), 8.5),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#fef9f0"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    # Colour category rows
    ("BACKGROUND", (0,1), (0,5), colors.HexColor("#fde8e8")),
    ("BACKGROUND", (0,6), (0,10), colors.HexColor("#fff3cd")),
    ("BACKGROUND", (0,11), (0,12), colors.HexColor("#d4edda")),
    ("BACKGROUND", (0,13), (0,14), colors.HexColor("#d1ecf1")),
    ("BACKGROUND", (0,15), (0,17), colors.HexColor("#f3e8ff")),
]))
story.append(t_comp)
story.append(sp(4))

story.append(h2("4.2  Prevention Strategies"))
prev_data = [
    ["Prevention Bundle", "Rationale"],
    ["Ultrasound guidance (real-time)", "Reduces arterial puncture, pneumothorax, failed attempts"],
    ["Trendelenburg positioning", "Distends IJV; reduces air embolism risk"],
    ["Maximal sterile barrier precautions", "Reduces CLABSI (sterile gown, gloves, mask, cap, full drape)"],
    ["Chlorhexidine-alcohol skin antisepsis", "Superior to povidone-iodine for infection prevention"],
    ["Right IJV preference", "Straight path to SVC-RA; avoids thoracic duct"],
    ["Confirm guidewire with USG / fluoroscopy", "Prevents inadvertent arterial dilation"],
    ["Daily catheter necessity review", "Early removal = fewer infections"],
    ["Post-insertion chest X-ray", "Confirms tip position; rules out pneumothorax"],
]
t_prev = Table(prev_data, colWidths=[7*cm, 9*cm])
t_prev.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#2c6e8a")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,-1), 8.5),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#eef6fa"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(t_prev)
story.append(sp(4))

# ═══════════════════════════════════════════════════════════════
# SECTION 5: HIGH-YIELD EXAM POINTS
# ═══════════════════════════════════════════════════════════════
story += section("5. HIGH-YIELD EXAM POINTS (MD ANAESTHESIA)")
story.append(sp(3))

high_yield = [
    ("Why right IJV?", "Straight course: R IJV → R innominate vein → SVC → RA. "
     "Avoids thoracic duct. Lower complication rate. CVC tip at correct position easier to achieve."),
    ("Trendelenburg position", "Distends IJV (increases calibre), reduces risk of air embolism. "
     "15° head-down is optimal. Over-rotation of head (>45°) may collapse the IJV."),
    ("Catheter tip ideal position", "SVC-RA junction — at or just above the level of the carina on CXR. "
     "Too deep → arrhythmias, cardiac perforation; too high → inaccurate CVP."),
    ("Carotid artery puncture", "Most common serious complication. Remove needle, apply pressure. "
     "NEVER dilate if artery inadvertently cannulated without vascular surgical backup."),
    ("Air embolism prevention", "Trendelenburg; occlude needle hub; guidewire inserted during expiration "
     "or positive pressure breath."),
    ("CLABSI prevention", "Maximal sterile barrier + chlorhexidine + daily review for removal = central "
     "line bundle. CLABSI is higher with IJV vs subclavian — femoral is highest risk."),
    ("USG guidance", "Standard of care. Reduces arterial puncture (3–5% → <0.5%), improves first-pass "
     "success. Short-axis most used; long-axis gives better needle visualisation."),
    ("Guidewire rule", "NEVER release the guidewire. PVCs on ECG during wire insertion = wire in RV — withdraw."),
    ("Left IJV risks", "Thoracic duct injury → chylothorax; more tortuous path; higher pleural effusion risk."),
    ("Depth of insertion", "Right IJV: 12–14 cm to SVC-RA junction. Left IJV: ~16 cm."),
]

hy_rows = [["Point", "Answer"]] + [[Paragraph(f"<b>{k}</b>", ParagraphStyle("k", fontSize=8, leading=10)),
                                     Paragraph(v, ParagraphStyle("v", fontSize=8, leading=10.5))]
                                    for k, v in high_yield]
t_hy = Table(hy_rows, colWidths=[4.5*cm, 11.5*cm])
t_hy.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0,0), (-1,0), colors.white),
    ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE", (0,0), (-1,0), 8.5),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.HexColor("#f5f0ff"), colors.white]),
    ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t_hy)
story.append(sp(5))

# ── FOOTER / REFERENCES ─────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#1a3a5c"), spaceAfter=4))
story.append(Paragraph(
    "<b>References:</b> Morgan &amp; Mikhail's Clinical Anaesthesiology 7e (Ch.5) | "
    "Miller's Anaesthesia 10e | Barash Clinical Anaesthesia 9e | "
    "Tintinalli's Emergency Medicine | Roberts &amp; Hedges' Clinical Procedures | "
    "Pfenninger &amp; Fowler's Procedures for Primary Care",
    footer_style
))
story.append(Paragraph(
    "Prepared for MD Anaesthesia Examination | Orris Medical AI | July 2026",
    footer_style
))

# ── BUILD PDF ───────────────────────────────────────────────────
doc.build(story)
print(f"PDF generated: {OUTPUT}")

cd /home/daytona/workspace/ijv-note && python generate_ijv_pdf.py 2>&1

ls -lh /home/daytona/workspace/ijv-note/IJV_Cannulation_MD_Anaesthesia.pdf

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/…