Standard Operating Procedure: Massive Transfusion Protocol (MTP)

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  Header, Footer, AlignmentType, HeadingLevel, BorderStyle, WidthType,
  ShadingType, VerticalAlign, PageNumber, UnderlineType,
  TableOfContents, LevelFormat, convertInchesToTwip, PageBreak
} = require('docx');
const fs = require('fs');

// ─── COLOUR PALETTE ───────────────────────────────────────────────
const NAVY   = "1F3864";  // deep navy for headings
const TEAL   = "1F6B75";  // section heading accent
const LTBLUE = "D6E4F0";  // table header bg
const WHITE  = "FFFFFF";
const RED    = "C0392B";
const ORANGE = "E67E22";
const GREEN  = "1E8449";
const GREY   = "F2F3F4";  // alternating table row

// ─── HELPERS ──────────────────────────────────────────────────────
function bold(text, size = 22, color = "000000") {
  return new TextRun({ text, bold: true, size, color, font: "Calibri" });
}
function normal(text, size = 20, color = "000000") {
  return new TextRun({ text, size, color, font: "Calibri" });
}
function italic(text, size = 20, color = "555555") {
  return new TextRun({ text, italics: true, size, color, font: "Calibri" });
}
function colored(text, color, size = 20, isBold = false) {
  return new TextRun({ text, color, size, bold: isBold, font: "Calibri" });
}

function h1(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 32, color: NAVY, font: "Calibri" })],
    spacing: { before: 300, after: 120 },
    border: { bottom: { style: BorderStyle.THICK, size: 6, color: NAVY } }
  });
}
function h2(text) {
  return new Paragraph({
    children: [new TextRun({ text: `  ${text}`, bold: true, size: 26, color: WHITE, font: "Calibri" })],
    spacing: { before: 240, after: 80 },
    shading: { type: ShadingType.CLEAR, fill: TEAL }
  });
}
function h3(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 22, color: NAVY, font: "Calibri" })],
    spacing: { before: 180, after: 60 },
    border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: LTBLUE } }
  });
}
function para(runs, indent = 0) {
  return new Paragraph({
    children: Array.isArray(runs) ? runs : [runs],
    spacing: { after: 80 },
    indent: indent ? { left: indent } : undefined
  });
}
function bullet(text, level = 0) {
  return new Paragraph({
    children: [normal(text)],
    bullet: { level },
    spacing: { after: 60 }
  });
}
function checkItem(text) {
  return new Paragraph({
    children: [normal("☐  " + text)],
    spacing: { after: 60 },
    indent: { left: 360 }
  });
}
function spacer(n = 1) {
  return Array.from({ length: n }, () => new Paragraph({ children: [normal("")], spacing: { after: 40 } }));
}
function pageBreak() {
  return new Paragraph({ children: [new TextRun({ break: 1 })] });
}

// ─── TABLE BUILDERS ───────────────────────────────────────────────
function makeCell(text, opts = {}) {
  const { bg = WHITE, isHeader = false, colspan = 1, align = AlignmentType.LEFT, color = "000000", bold: isBold = false } = opts;
  return new TableCell({
    children: [new Paragraph({
      alignment: align,
      children: [new TextRun({ text, bold: isBold || isHeader, size: isHeader ? 20 : 18, color: isHeader ? WHITE : color, font: "Calibri" })]
    })],
    shading: { type: ShadingType.CLEAR, fill: bg },
    verticalAlign: VerticalAlign.CENTER,
    columnSpan: colspan,
    margins: { top: 60, bottom: 60, left: 100, right: 100 }
  });
}

function makeRow(cells, isHeader = false) {
  return new TableRow({
    children: cells,
    tableHeader: isHeader
  });
}

function simpleTable(headers, rows, headerBg = TEAL) {
  const hCells = headers.map(h => makeCell(h, { bg: headerBg, isHeader: true, align: AlignmentType.CENTER }));
  const bodyRows = rows.map((row, ri) => {
    const bg = ri % 2 === 0 ? WHITE : GREY;
    return makeRow(row.map(cell => {
      if (typeof cell === 'object' && cell.text !== undefined) {
        return makeCell(cell.text, { bg, color: cell.color || "000000", bold: cell.bold || false });
      }
      return makeCell(cell, { bg });
    }));
  });
  return new Table({
    rows: [makeRow(hCells, true), ...bodyRows],
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top:    { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      bottom: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      left:   { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      right:  { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      insideH:{ style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" },
      insideV:{ style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" }
    }
  });
}

// ─── DOCUMENT HEADER BOX ──────────────────────────────────────────
function headerBox() {
  return new Table({
    rows: [
      new TableRow({ children: [
        new TableCell({
          children: [
            new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "HOSPITAL NAME / LOGO", bold: true, size: 28, color: NAVY, font: "Calibri" })] }),
            new Paragraph({ alignment: AlignmentType.CENTER, children: [normal("(Insert Hospital Name, Address, NABH Registration No.)", 18, "555555")] })
          ],
          shading: { type: ShadingType.CLEAR, fill: "EBF5FB" },
          columnSpan: 3,
          margins: { top: 100, bottom: 100, left: 200, right: 200 }
        })
      ]}),
      new TableRow({ children: [
        new TableCell({
          children: [
            new Paragraph({ children: [bold("DOCUMENT TITLE:", 20, NAVY)] }),
            new Paragraph({ children: [bold("STANDARD OPERATING PROCEDURE", 22, TEAL)] }),
            new Paragraph({ children: [bold("MASSIVE TRANSFUSION PROTOCOL (MTP)", 22, RED)] })
          ],
          columnSpan: 2,
          margins: { top: 80, bottom: 80, left: 160, right: 160 }
        }),
        new TableCell({
          children: [
            para([bold("SOP No.:", 18, NAVY), normal("  MTP-TRF-001", 18)]),
            para([bold("Version:", 18, NAVY), normal("  1.0", 18)]),
            para([bold("Dept:", 18, NAVY), normal("  Blood Bank / Emergency / Surgery", 18)]),
            para([bold("Effective Date:", 18, NAVY), normal("  ________________", 18)]),
            para([bold("Review Date:", 18, NAVY), normal("  ________________", 18)]),
            para([bold("Pages:", 18, NAVY), normal("  See footer", 18)])
          ],
          shading: { type: ShadingType.CLEAR, fill: GREY },
          margins: { top: 80, bottom: 80, left: 160, right: 160 }
        })
      ]}),
      new TableRow({ children: [
        new TableCell({
          children: [
            para([bold("Prepared by:", 18, NAVY), normal("  ________________________________", 18)]),
            para([italic("Designation & Signature"), normal("  Date: ____________", 18)])
          ],
          margins: { top: 60, bottom: 60, left: 160, right: 160 }
        }),
        new TableCell({
          children: [
            para([bold("Reviewed by:", 18, NAVY), normal("  ________________________________", 18)]),
            para([italic("Designation & Signature"), normal("  Date: ____________", 18)])
          ],
          margins: { top: 60, bottom: 60, left: 160, right: 160 }
        }),
        new TableCell({
          children: [
            para([bold("Approved by:", 18, NAVY), normal("  ________________________________", 18)]),
            para([italic("Medical Director / CMO"), normal("  Date: ____________", 18)])
          ],
          shading: { type: ShadingType.CLEAR, fill: GREY },
          margins: { top: 60, bottom: 60, left: 160, right: 160 }
        })
      ]})
    ],
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top:    { style: BorderStyle.THICK, size: 6, color: NAVY },
      bottom: { style: BorderStyle.THICK, size: 6, color: NAVY },
      left:   { style: BorderStyle.THICK, size: 6, color: NAVY },
      right:  { style: BorderStyle.THICK, size: 6, color: NAVY },
      insideH:{ style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" },
      insideV:{ style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" }
    }
  });
}

// ─── AMENDMENT TABLE ─────────────────────────────────────────────
function amendmentTable() {
  return simpleTable(
    ["Version", "Date", "Description of Change", "Changed By", "Approved By"],
    [
      ["1.0", "________", "Initial Release", "________", "________"],
      ["", "", "", "", ""],
      ["", "", "", "", ""]
    ]
  );
}

// ─── DISTRIBUTION TABLE ───────────────────────────────────────────
function distributionTable() {
  return simpleTable(
    ["Department / Role", "Copy No.", "Received By", "Date"],
    [
      ["Emergency Department", "01", "________", "________"],
      ["Blood Bank", "02", "________", "________"],
      ["Operation Theatre", "03", "________", "________"],
      ["ICU / HDU", "04", "________", "________"],
      ["Labour & Delivery Ward", "05", "________", "________"],
      ["Quality / NABH Coordinator", "06 (Master)", "________", "________"]
    ]
  );
}

// ─── ACTIVATION TRIGGER TABLE ─────────────────────────────────────
function triggerTable() {
  return simpleTable(
    ["Criteria Type", "Parameter", "Trigger Value"],
    [
      ["Vital Signs", "Systolic Blood Pressure", "< 70 mmHg (any cause)"],
      ["Vital Signs", "SBP + Heart Rate", "SBP 71-90 mmHg AND HR > 108 bpm"],
      ["Injury Pattern", "Penetrating torso injury", "Present with haemodynamic instability"],
      ["Injury Pattern", "Major pelvic fracture", "Present with haemodynamic instability"],
      ["Imaging", "FAST positive", "> 1 body region"],
      ["Laboratory", "Base Deficit", "> -6 mEq/L (72% probability of transfusion)"],
      ["Clinical", "Estimated blood loss", "> 15% of total blood volume with ongoing bleeding"],
      ["Operational", "Anticipated large surgical blood loss", "Surgeon/anaesthetist judgement"]
    ]
  );
}

// ─── PHASE 1 EMPIRIC TRANSFUSION TABLE ───────────────────────────
function phase1Table() {
  return simpleTable(
    ["Blood Pack", "PRBCs", "FFP", "Platelets (Apheresis)", "Cryoprecipitate"],
    [
      [{ text: "Pack 1", bold: true }, "4 units", "2 units", "-", "-"],
      [{ text: "Pack 2", bold: true }, "4 units", "2 units", "1 unit", "10 units pooled"]
    ]
  );
}

// ─── TEG TABLE ────────────────────────────────────────────────────
function tegTable() {
  return simpleTable(
    ["TEG Parameter", "Threshold", "Action"],
    [
      ["rapidTEG-ACT", "> 128 seconds", "Give 2 units FFP (thawed plasma)"],
      ["Angle (Alpha)", "< 65-66 degrees", "Give 10 units pooled cryoprecipitate"],
      ["MA (Maximum Amplitude)", "< 55 mm", "Give 1 unit apheresis platelets"],
      ["LY30 / EPL", ">= 10% / > 9%", "Give Tranexamic Acid 1 g IV"]
    ]
  );
}

// ─── CONVENTIONAL LAB TABLE ──────────────────────────────────────
function labTriggerTable() {
  return simpleTable(
    ["Lab Parameter", "Threshold", "Action"],
    [
      ["PT / APTT", "> 1.5x control", "Give 2 units FFP"],
      ["Platelet Count", "< 50,000 / uL", "Give 1 unit apheresis platelets"],
      ["Fibrinogen", "< 100 mg/dL", "Give 10 units pooled cryoprecipitate"]
    ]
  );
}

// ─── MONITORING TARGETS TABLE ────────────────────────────────────
function monitoringTable() {
  return simpleTable(
    ["Parameter", "Target", "Frequency"],
    [
      ["Haemoglobin", "> 7-8 g/dL", "Every 30-60 min"],
      ["Platelet Count", "> 50,000/uL (> 100,000 if TBI)", "Every 30-60 min"],
      ["INR / PT", "< 1.5x control", "Every 30-60 min"],
      ["APTT", "< 1.5x control", "Every 30-60 min"],
      ["Fibrinogen", "> 100-200 mg/dL", "Every 30-60 min"],
      ["Ionised Calcium", "> 0.9 mmol/L", "Every 30-60 min"],
      ["Core Temperature", "> 35 degrees C", "Continuous"],
      ["pH / Base Excess", "> 7.2 / > -6 mEq/L", "Every 30-60 min"],
      ["Serum Potassium", "3.5-5.5 mEq/L", "Every 30-60 min"],
      ["Urine Output", "> 0.5 mL/kg/hr", "Hourly"]
    ]
  );
}

// ─── LETHAL TRIAD TABLE ──────────────────────────────────────────
function lethalTriadTable() {
  return simpleTable(
    ["Factor", "Target", "Management Steps"],
    [
      [{ text: "HYPOTHERMIA", color: RED, bold: true }, "Core temp > 35 degrees C",
       "Warm IV fluids; blood warmers; Bair Hugger (forced air); warm blankets; heated ventilation circuit; AV rewarming if temp < 30 degrees C"],
      [{ text: "ACIDOSIS", color: ORANGE, bold: true }, "pH > 7.2 / BE > -6",
       "Restore perfusion (haemorrhage control); balanced blood products; avoid large crystalloid volumes; monitor lactate"],
      [{ text: "COAGULOPATHY", color: TEAL, bold: true }, "INR < 1.5 / Fibrinogen > 200 mg/dL",
       "1:1:1 blood product ratio; TXA; cryoprecipitate / fibrinogen concentrate; avoid dilutional coagulopathy"]
    ]
  );
}

// ─── COMPLICATIONS TABLE ─────────────────────────────────────────
function complicationsTable() {
  return simpleTable(
    ["Complication", "Cause", "Prevention / Management"],
    [
      ["Dilutional Coagulopathy", "Crystalloid / PRBC dilution of clotting factors", "Balanced 1:1:1 ratio; FFP; cryoprecipitate"],
      ["Dilutional Thrombocytopenia", "No viable platelets in stored blood", "Platelet transfusion; check count after > 5 units"],
      ["Hypothermia", "Cold products + vasoconstriction", "Blood warmer; warming devices"],
      ["Hypocalcaemia", "Citrate chelation from stored blood", "CaCl2 1 g IV; monitor ionised calcium"],
      ["Hyperkalaemia", "Stored blood K+ leakage", "Monitor electrolytes; ECG surveillance"],
      ["Metabolic Alkalosis", "Citrate -> bicarbonate (hepatic)", "Monitor; usually self-limiting"],
      ["TRALI", "Donor antibodies activating neutrophils", "Supportive; use male-donor or HLA-screened FFP"],
      ["Acute Haemolytic Reaction", "ABO incompatibility", "Stop transfusion immediately; supportive care; notify blood bank"],
      ["DIC", "Consumptive coagulopathy (trauma, sepsis)", "FFP; cryoprecipitate; treat underlying cause"],
      ["Citrate Toxicity", "Rapid infusion / liver failure", "CaCl2 IV; slow infusion rate; monitor in liver disease"]
    ]
  );
}

// ─── SPECIAL POPULATIONS TABLE ───────────────────────────────────
function specialPopTable() {
  return simpleTable(
    ["Population", "Key Modification(s)"],
    [
      ["Traumatic Brain Injury (TBI)", "NO permissive hypotension; target MAP > 80 mmHg; platelets > 100,000/uL; INR < 1.2; target PaCO2 35-40 mmHg"],
      ["Paediatric", "Weight-based product volumes; no validated MTP scoring - use clinical judgement; damage control resuscitation principles apply"],
      ["Obstetric (PPH)", "Early FFP; early fibrinogen/cryoprecipitate; involve obstetric and haematology team; consider cell salvage if available"],
      ["Geriatric (> 65 years)", "Higher mortality; lower physiological reserve; lower transfusion thresholds; early ICU involvement"],
      ["Warfarin anticoagulation", "4-factor PCC 25-50 units/kg + Vitamin K 10 mg IV slow infusion"],
      ["DOAC (Xa inhibitor)", "Andexanet alfa (if available) or activated PCC; avoid FFP alone"],
      ["DOAC (Dabigatran)", "Idarucizumab 5 g IV; dialysis if renal failure"]
    ]
  );
}

// ─── ROLES TABLE ─────────────────────────────────────────────────
function rolesTable() {
  return simpleTable(
    ["Role", "Responsibilities during MTP"],
    [
      ["Trauma Team Leader / Treating Physician", "Activates MTP; coordinates overall management; decides on surgical intervention; terminates MTP"],
      ["Emergency Nurse (Primary)", "IV access; blood sampling; administers products; documents vitals"],
      ["Emergency Nurse (Secondary)", "Blood runner - collects products from blood bank; warms fluids"],
      ["Anaesthesiologist", "Airway management; haemodynamic monitoring; intraoperative product management"],
      ["Surgeon", "Haemorrhage control; operative / interventional decisions"],
      ["Blood Bank Technician / Pathologist", "Expedites crossmatch; releases products in packs; activates emergency blood supply"],
      ["ICU Physician / Intensivist", "Post-resuscitation care; ongoing monitoring; coagulopathy management"],
      ["Documentation Officer / Recorder", "Records all products, times, vitals, and interventions throughout MTP"]
    ]
  );
}

// ─── DOCUMENT FOOTER ──────────────────────────────────────────────
function makeHeader() {
  return new Header({
    children: [new Paragraph({
      alignment: AlignmentType.RIGHT,
      children: [
        bold("SOP: MASSIVE TRANSFUSION PROTOCOL  |  SOP No. MTP-TRF-001  |  Ver 1.0", 16, NAVY)
      ],
      border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: TEAL } }
    })]
  });
}
function makeFooter() {
  return new Footer({
    children: [new Paragraph({
      alignment: AlignmentType.CENTER,
      children: [
        italic("CONFIDENTIAL - FOR INTERNAL USE ONLY  |  Page ", 16),
        new TextRun({ children: [PageNumber.CURRENT], size: 16, font: "Calibri" }),
        italic(" of ", 16),
        new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 16, font: "Calibri" }),
        italic("  |  Review before use - do not use after review date", 16)
      ],
      border: { top: { style: BorderStyle.SINGLE, size: 4, color: TEAL } }
    })]
  });
}

// ═══════════════════════════════════════════════════════════════════
//  MAIN DOCUMENT ASSEMBLY
// ═══════════════════════════════════════════════════════════════════
const doc = new Document({
  creator: "Hospital Quality Department",
  title: "SOP - Massive Transfusion Protocol (MTP)",
  description: "NABH-formatted SOP for Massive Transfusion Protocol",
  styles: {
    default: {
      document: { run: { font: "Calibri", size: 20 } }
    }
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 720, bottom: 720, left: 900, right: 720 }
      }
    },
    headers: { default: makeHeader() },
    footers: { default: makeFooter() },
    children: [

      // ══ COVER / HEADER BOX ══
      headerBox(),
      ...spacer(1),

      // ══ NABH COMPLIANCE NOTE ══
      new Paragraph({
        alignment: AlignmentType.CENTER,
        children: [new TextRun({
          text: "This document complies with NABH Standards: TRM 1, TRM 3, MOM 4, QPS 1, QPS 6",
          bold: true, size: 18, color: TEAL, font: "Calibri"
        })],
        shading: { type: ShadingType.CLEAR, fill: "EBF5FB" },
        border: {
          top: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          bottom: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          left: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          right: { style: BorderStyle.SINGLE, size: 4, color: TEAL }
        },
        spacing: { before: 120, after: 120 }
      }),
      ...spacer(1),

      // ══ AMENDMENT RECORD ══
      h1("AMENDMENT RECORD"),
      amendmentTable(),
      ...spacer(1),

      // ══ DISTRIBUTION LIST ══
      h1("DISTRIBUTION LIST"),
      distributionTable(),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 1 ══
      h1("1. PURPOSE"),
      para([normal(
        "This Standard Operating Procedure (SOP) establishes a systematic, evidence-based framework for the "
        + "recognition, activation, management, and termination of a Massive Transfusion Protocol (MTP) in patients "
        + "with life-threatening haemorrhage. It ensures the timely and appropriate administration of blood and "
        + "blood components in optimised ratios to prevent the lethal triad of hypothermia, acidosis, and coagulopathy."
      )]),
      ...spacer(1),

      // ══ SECTION 2 ══
      h1("2. SCOPE"),
      para([normal("This SOP applies to all clinical areas of the hospital where massive haemorrhage may occur, including:")]),
      bullet("Emergency Department (ED)"),
      bullet("Operating Theatre (OT) and Post-Anaesthesia Care Unit (PACU)"),
      bullet("Intensive Care Unit (ICU) and High-Dependency Unit (HDU)"),
      bullet("Labour and Delivery Ward / Obstetric Unit"),
      bullet("Interventional Radiology"),
      bullet("Any in-patient ward or pre-hospital advanced team"),
      ...spacer(1),

      // ══ SECTION 3 ══
      h1("3. DEFINITIONS"),
      simpleTable(
        ["Term", "Definition"],
        [
          ["Massive Transfusion (MT)", "Transfusion of > 10 units PRBCs in 24 hours; OR replacement of 1 blood volume in 24 hours; OR blood loss > 150 mL/min; OR 50% total blood volume loss in 3 hours"],
          ["MTP", "Massive Transfusion Protocol - structured institutional protocol for coordinated delivery of blood products in life-threatening haemorrhage"],
          ["PRBCs", "Packed Red Blood Cells"],
          ["FFP", "Fresh Frozen Plasma"],
          ["Cryoprecipitate", "Concentrated source of fibrinogen, Factor VIII, vWF, Factor XIII"],
          ["TXA", "Tranexamic Acid - antifibrinolytic agent"],
          ["TEG / ROTEM", "Thromboelastography / Rotational Thromboelastometry - viscoelastic whole-blood coagulation assays"],
          ["DCR", "Damage Control Resuscitation"],
          ["Lethal Triad", "Hypothermia + Acidosis + Coagulopathy - mutually reinforcing causes of death in massive haemorrhage"],
          ["PCC", "Prothrombin Complex Concentrate"],
          ["FAST", "Focused Assessment with Sonography in Trauma"],
          ["SBP / MAP", "Systolic Blood Pressure / Mean Arterial Pressure"]
        ]
      ),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 4 ══
      h1("4. RESPONSIBILITY"),
      rolesTable(),
      ...spacer(1),

      // ══ SECTION 5 ══
      h1("5. INDICATIONS AND ACTIVATION TRIGGERS"),
      h3("5.1  Clinical Triggers for MTP Activation"),
      para([normal("Activate MTP when ")], 0),
      para([bold("ANY ONE", 20, RED), normal(" of the following criteria is present:")]),
      triggerTable(),
      ...spacer(1),
      h3("5.2  How to Activate"),
      bullet("Call the designated MTP activation number: ________________"),
      bullet("State: Patient name / ID, location, clinical status"),
      bullet("Blood bank releases MTP packs immediately upon activation"),
      bullet("Assign team roles and designate a blood product runner"),
      ...spacer(1),

      // ══ SECTION 6 ══
      h1("6. PROCEDURE"),
      h2("STEP 1 - IMMEDIATE ACTIONS (0-5 MINUTES)"),
      ...spacer(1),
      checkItem("Activate MTP - notify blood bank, anaesthesia, surgeon, ICU"),
      checkItem("Establish 2x large-bore IV access (14-16G) or IO / central line"),
      checkItem("Draw STAT bloods: FBC, PT/APTT/INR/fibrinogen, TEG/ROTEM, ABG, BMP, ionised calcium, type & crossmatch"),
      checkItem("Administer Calcium Chloride (CaCl2) 1 g IV immediately"),
      checkItem("Apply external haemorrhage control: direct pressure / tourniquet / pelvic binder"),
      checkItem("Start O-negative PRBCs if type/crossmatch not yet available"),
      checkItem("Warm all IV fluids and blood products - use blood warmer device"),
      checkItem("Minimise crystalloid - only small volumes to maintain BP while blood products prepared"),
      checkItem("Place urinary catheter for hourly urine output monitoring"),
      checkItem("Maintain warm environment: warm blankets, Bair Hugger, elevated room temp"),
      ...spacer(1),

      h2("STEP 2 - EMPIRIC BLOOD PRODUCT TRANSFUSION (Phase 1)"),
      ...spacer(1),
      para([bold("Target ratio: 1 RBC : 1 FFP : 1 Platelet  (balanced component resuscitation)", 20, TEAL)]),
      ...spacer(1),
      phase1Table(),
      ...spacer(1),
      para([normal("Notes:")]),
      bullet("Do NOT use large-volume crystalloid for resuscitation in massive haemorrhage"),
      bullet("Type O, Rh-negative PRBCs for females of childbearing potential (type unknown)"),
      bullet("Type AB FFP is universal plasma"),
      bullet("Whole blood (O low-titre) may be used per institutional protocol"),
      bullet("Liquid plasma (stored 2-6 degrees C, available without thawing) preferred when available"),
      ...spacer(1),

      h2("STEP 3 - GOAL-DIRECTED TRANSFUSION (Phase 2 - TEG/ROTEM Guided)"),
      ...spacer(1),
      h3("3A. If TEG / ROTEM Available (Preferred)"),
      tegTable(),
      ...spacer(1),
      h3("3B. If TEG / ROTEM NOT Available (Conventional Lab Guided)"),
      labTriggerTable(),
      ...spacer(1),
      para([italic("Note: Most institutions use a blend - start with empiric protocol, then tailor based on TEG/ROTEM or lab results as they become available.")]),
      ...spacer(1),

      h2("STEP 4 - ADJUNCT MEDICATIONS"),
      ...spacer(1),
      simpleTable(
        ["Agent", "Dose", "Route", "Timing", "Indication"],
        [
          ["Tranexamic Acid (TXA)", "1 g over 10 min, then 1 g over 8 hours", "IV", "As early as possible; MUST be given within 3 hours of injury", "All trauma with suspected significant haemorrhage (SBP < 110 mmHg OR HR > 110 bpm)"],
          ["Calcium Chloride", "1 g IV (repeat as needed to maintain ionised Ca > 0.9 mmol/L)", "IV slow", "Immediately upon MTP activation and with each blood pack", "Citrate chelation prevention; hypocalcaemia correction"],
          ["Vitamin K", "10 mg IV over 15-30 min (slow)", "IV slow", "With PCC for warfarin reversal", "Warfarin-associated life-threatening haemorrhage"],
          ["4-Factor PCC", "25-50 units/kg IV", "IV", "Warfarin or Factor Xa inhibitor reversal", "Anticoagulant reversal"],
          ["Idarucizumab", "5 g IV (2x 2.5 g)", "IV bolus", "Immediately for dabigatran reversal", "Dabigatran reversal only"],
          ["Vasopressin (Arginine)", "Low dose per local protocol", "IV infusion", "Adjunct in haemorrhagic shock", "May reduce blood product requirements (AVERT-shock 2019)"]
        ]
      ),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 7 - LETHAL TRIAD ══
      h1("7. PREVENTION AND MANAGEMENT OF THE LETHAL TRIAD"),
      para([normal("The three factors below create a self-amplifying cycle that is the leading cause of death in massive haemorrhage. All three must be actively corrected simultaneously:")]),
      ...spacer(1),
      lethalTriadTable(),
      ...spacer(1),

      // ══ SECTION 8 - DCR ══
      h1("8. DAMAGE CONTROL RESUSCITATION (DCR) PRINCIPLES"),
      simpleTable(
        ["Principle", "Detail"],
        [
          [{ text: "Permissive Hypotension", bold: true }, "Target SBP 80-90 mmHg (MAP ~60 mmHg) until definitive haemorrhage control. Avoids dislodging the clot. NOT applicable in concurrent TBI."],
          [{ text: "Minimise Crystalloid", bold: true }, "Large-volume NS or Hartmann's causes dilutional coagulopathy, hypothermia, and tissue oedema. Only small volumes to buy time."],
          [{ text: "Early Blood Products", bold: true }, "PRBCs, FFP, and platelets are the resuscitation fluid. Whole blood if available."],
          [{ text: "Early Haemorrhage Control", bold: true }, "Surgical / IR / endovascular intervention (REBOA if indicated) must proceed with minimum delay."],
          [{ text: "Correct Coagulopathy", bold: true }, "TXA early; viscoelastic or lab-guided correction with FFP, cryoprecipitate, PCC."],
          [{ text: "Avoid Hypothermia", bold: true }, "Active warming from first contact. Hypothermia reduces clotting factor activity by up to 50%."]
        ]
      ),
      ...spacer(1),

      // ══ SECTION 9 - MONITORING ══
      h1("9. MONITORING DURING MTP"),
      monitoringTable(),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 10 - TERMINATION ══
      h1("10. MTP TERMINATION CRITERIA"),
      para([normal("Terminate MTP when ALL of the following criteria are met:")]),
      ...spacer(1),
      checkItem("Surgical or procedural haemorrhage control achieved"),
      checkItem("Haemodynamic stability - SBP > 90 mmHg without vasopressors"),
      checkItem("Coagulation normalising - INR < 1.5, fibrinogen > 200 mg/dL"),
      checkItem("Temperature > 35 degrees C"),
      checkItem("No clinical or laboratory evidence of ongoing active bleeding"),
      checkItem("Urine output > 0.5 mL/kg/hr"),
      checkItem("Notify blood bank to discontinue MTP pack releases"),
      ...spacer(1),

      // ══ SECTION 11 - SPECIAL POPULATIONS ══
      h1("11. SPECIAL POPULATIONS"),
      specialPopTable(),
      ...spacer(1),

      // ══ SECTION 12 - COMPLICATIONS ══
      h1("12. COMPLICATIONS OF MASSIVE TRANSFUSION"),
      complicationsTable(),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 13 - DOCUMENTATION ══
      h1("13. DOCUMENTATION REQUIREMENTS"),
      para([normal("The following MUST be documented in the patient record throughout MTP:")]),
      bullet("Date and time of MTP activation, and name of activating clinician"),
      bullet("Vital signs (BP, HR, SpO2, temperature) at 15-minute intervals"),
      bullet("All blood products transfused: type, volume, unit number, time of administration"),
      bullet("All adjunct medications administered (TXA, CaCl2, PCC, Vitamin K, vasopressin) with doses and times"),
      bullet("All laboratory and TEG/ROTEM results with timestamps"),
      bullet("Procedures performed (intubation, surgical/IR intervention, REBOA, etc.) with times"),
      bullet("Adverse transfusion reactions (nature, time of onset, action taken)"),
      bullet("Time of MTP termination and criteria met"),
      bullet("Attending physician / team leader name and signature"),
      ...spacer(1),
      para([bold("Blood Bank Record:", 20, NAVY)]),
      bullet("MTP activation log (patient details, activating clinician, time)"),
      bullet("Products released per pack with unit IDs and release times"),
      bullet("Any unused returned products with documentation"),
      ...spacer(1),

      // ══ SECTION 14 - TRAINING ══
      h1("14. TRAINING AND COMPETENCY"),
      simpleTable(
        ["Personnel", "Training Required", "Frequency"],
        [
          ["Emergency Physicians", "MTP protocol, TEG/ROTEM interpretation, damage control resuscitation", "Annual + at induction"],
          ["Emergency Nurses", "MTP activation, blood product administration, monitoring", "Annual + at induction"],
          ["Anaesthesiologists", "MTP, haemostatic resuscitation, viscoelastic testing", "Annual"],
          ["Surgeons", "Damage control surgery, haemorrhage control, MTP integration", "Annual"],
          ["Blood Bank Staff", "MTP pack preparation, emergency release protocol, traceability", "Annual"],
          ["ICU Staff", "Post-MTP management, coagulopathy correction", "Annual"],
          ["Obstetric Team", "Obstetric MTP / PPH protocol", "Annual"]
        ]
      ),
      ...spacer(1),
      para([bold("MTP Simulation Drill: ", 20, TEAL), normal("To be conducted minimum once per year. Findings to be documented and fed into quality improvement cycle.")]),
      ...spacer(1),

      // ══ SECTION 15 - AUDIT ══
      h1("15. AUDIT AND QUALITY INDICATORS"),
      simpleTable(
        ["Indicator", "Target", "Responsible", "Frequency"],
        [
          ["MTP activation-to-first-blood time", "< 15 minutes", "Blood Bank / ED In-charge", "Per event"],
          ["Correct blood product ratio (1:1:1)", "> 90% compliance", "Quality Team", "Quarterly"],
          ["TXA administered within 3 hours of injury", "> 95% compliance", "Trauma Lead", "Quarterly"],
          ["Documentation completeness", "100%", "Nursing In-charge", "Per event"],
          ["MTP Termination criteria documented", "100%", "Treating Clinician", "Per event"],
          ["Adverse transfusion reaction reporting", "100% of events reported", "Blood Bank / Quality", "Per event"],
          ["Post-MTP mortality review", "All MTP cases reviewed", "Medical Audit Committee", "Monthly"],
          ["MTP drill conducted", "Minimum 1 per year", "Quality / Training", "Annual"]
        ]
      ),
      ...spacer(1),
      pageBreak(),

      // ══ SECTION 16 - REFERENCES ══
      h1("16. REFERENCES AND EVIDENCE BASE"),
      h3("Textbook Sources"),
      bullet("Schwartz's Principles of Surgery, 11th Edition - MTP for Trauma, p.235"),
      bullet("Tintinalli's Emergency Medicine: A Comprehensive Study - Massive Transfusion Protocols"),
      bullet("Rosen's Emergency Medicine: Concepts and Clinical Practice - Massive Transfusion Protocols"),
      bullet("Bailey & Love's Short Practice of Surgery, 28th Edition - Permissive Hypotension, MTP and TXA"),
      bullet("Henry's Clinical Diagnosis and Management by Laboratory Methods - Massive Transfusion, p.881"),
      bullet("Mulholland & Greenfield's Surgery, 7th Edition - Damage Control Resuscitation"),
      bullet("Current Surgical Therapy, 14th Edition - Principles of Damage Control / MTP"),
      bullet("Roberts & Hedges' Clinical Procedures in Emergency Medicine - Massive Transfusion"),
      bullet("Goldman-Cecil Medicine - Massive Transfusion"),
      bullet("Miller's Anesthesia, 10th Edition - MTP Table 62.2"),
      ...spacer(1),
      h3("Clinical Trial and Guideline References"),
      bullet("PROPPR Trial - 1:1:1 vs 2:1:1 blood product ratios in trauma (Holcomb JB et al., JAMA 2015)"),
      bullet("CRASH-2 Trial - Tranexamic acid in traumatic haemorrhage (Lancet 2010)"),
      bullet("AVERT-Shock Trial - Low-dose vasopressin in haemorrhagic shock (2019)"),
      bullet("EAST Practice Management Guideline - Whole blood resuscitation (PMID: 38531812, J Trauma Acute Care Surg, 2024)"),
      bullet("Cochrane Review - Blood transfusion in postpartum haemorrhage (PMID: 39911088, 2025)"),
      bullet("Systematic Review - MTP in geriatric trauma (PMID: 38821531, Am Surg, 2025)"),
      ...spacer(1),

      // ══ SECTION 17 - RELATED DOCUMENTS ══
      h1("17. RELATED DOCUMENTS"),
      simpleTable(
        ["Document Title", "Document No.", "Location"],
        [
          ["SOP - Blood Transfusion Administration", "BT-TRF-001", "Blood Bank / Nursing Manual"],
          ["SOP - Management of Transfusion Reactions", "BT-TRF-002", "Blood Bank / Nursing Manual"],
          ["SOP - Emergency Release of Blood Products", "BT-TRF-003", "Blood Bank"],
          ["SOP - Trauma Management and ATLS Protocol", "TRM-001", "Emergency / Trauma"],
          ["SOP - Damage Control Surgery", "SRG-DCR-001", "Surgery Manual"],
          ["SOP - Management of Postpartum Haemorrhage", "OBS-PPH-001", "Obstetrics Manual"],
          ["Consent Policy for Blood Transfusion", "POL-BT-001", "Hospital Policy Manual"],
          ["Haemovigilance Reporting Protocol", "QPS-HV-001", "Quality Department"]
        ]
      ),
      ...spacer(2),

      // ══ ACKNOWLEDGEMENT ══
      h1("18. ACKNOWLEDGEMENT OF REVIEW"),
      new Table({
        rows: [
          new TableRow({ children: [
            new TableCell({
              children: [
                new Paragraph({ children: [bold("I acknowledge that I have read and understood this SOP:", 20, NAVY)] }),
                ...spacer(1),
                para([bold("Name: ", 18), normal("________________________________")]),
                para([bold("Designation: ", 18), normal("________________________________")]),
                para([bold("Department: ", 18), normal("________________________________")]),
                para([bold("Date: ", 18), normal("________________")]),
                para([bold("Signature: ", 18), normal("________________")]),
              ],
              margins: { top: 120, bottom: 120, left: 200, right: 200 }
            }),
            new TableCell({
              children: [
                para([bold("Name: ", 18), normal("________________________________")]),
                para([bold("Designation: ", 18), normal("________________________________")]),
                para([bold("Department: ", 18), normal("________________________________")]),
                para([bold("Date: ", 18), normal("________________")]),
                para([bold("Signature: ", 18), normal("________________")]),
              ],
              margins: { top: 120, bottom: 120, left: 200, right: 200 }
            })
          ]})
        ],
        width: { size: 100, type: WidthType.PERCENTAGE },
        borders: {
          top: { style: BorderStyle.SINGLE, size: 4, color: NAVY },
          bottom: { style: BorderStyle.SINGLE, size: 4, color: NAVY },
          left: { style: BorderStyle.SINGLE, size: 4, color: NAVY },
          right: { style: BorderStyle.SINGLE, size: 4, color: NAVY },
          insideH: { style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" },
          insideV: { style: BorderStyle.SINGLE, size: 2, color: "AAAAAA" }
        }
      }),
      ...spacer(2),

      // ══ DISCLAIMER ══
      new Paragraph({
        alignment: AlignmentType.CENTER,
        children: [new TextRun({
          text: "This SOP is a living document. Clinical decisions must be made by qualified healthcare professionals using current evidence and local resources. "
              + "Validity is confirmed only when this document bears an authorised signature and is within its review date.",
          italics: true, size: 16, color: "777777", font: "Calibri"
        })],
        shading: { type: ShadingType.CLEAR, fill: GREY },
        border: {
          top: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          bottom: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          left: { style: BorderStyle.SINGLE, size: 4, color: TEAL },
          right: { style: BorderStyle.SINGLE, size: 4, color: TEAL }
        },
        spacing: { before: 120, after: 120 }
      })

    ] // end children
  }] // end sections
});

Packer.toBuffer(doc).then(buf => {
  fs.writeFileSync("/home/daytona/workspace/mtp-sop/SOP_Massive_Transfusion_Protocol_NABH.docx", buf);
  console.log("SUCCESS: SOP written.");
}).catch(err => {
  console.error("ERROR:", err);
  process.exit(1);
});