from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR
from pptx.oxml.ns import qn
import copy

# ---------- Palette ----------
NAVY = RGBColor(0x0B, 0x2B, 0x45)
TEAL = RGBColor(0x0E, 0x7C, 0x86)
LIGHT_TEAL = RGBColor(0xE4, 0xF3, 0xF3)
ACCENT = RGBColor(0xE8, 0x7A, 0x1E)
WHITE = RGBColor(0xFF, 0xFF, 0xFF)
DARK = RGBColor(0x2B, 0x2B, 0x2B)
GREY = RGBColor(0x6E, 0x6E, 0x6E)
LIGHT_GREY = RGBColor(0xF2, 0xF2, 0xF2)

prs = Presentation()
prs.slide_width = Inches(13.333)
prs.slide_height = Inches(7.5)
SW, SH = prs.slide_width, prs.slide_height
BLANK = prs.slide_layouts[6]

def add_slide():
    return prs.slides.add_slide(BLANK)

def set_bg(slide, color=WHITE):
    slide.background.fill.solid()
    slide.background.fill.fore_color.rgb = color

def add_rect(slide, x, y, w, h, color, line=False):
    sh = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, x, y, w, h)
    sh.fill.solid()
    sh.fill.fore_color.rgb = color
    if line:
        sh.line.color.rgb = color
        sh.line.width = Pt(0.75)
    else:
        sh.line.fill.background()
    sh.shadow.inherit = False
    return sh

def add_text(slide, x, y, w, h, text, size=18, color=DARK, bold=False, italic=False,
             align=PP_ALIGN.LEFT, font="Calibri", anchor=MSO_ANCHOR.TOP, wrap=True, line_spacing=1.0):
    tb = slide.shapes.add_textbox(x, y, w, h)
    tf = tb.text_frame
    tf.word_wrap = wrap
    tf.vertical_anchor = anchor
    tf.margin_left = 0; tf.margin_right = 0; tf.margin_top = 0; tf.margin_bottom = 0
    lines = text.split("\n")
    for i, line in enumerate(lines):
        p = tf.paragraphs[0] if i == 0 else tf.add_paragraph()
        p.text = line
        p.alignment = align
        p.line_spacing = line_spacing
        r = p.runs[0]
        r.font.size = Pt(size)
        r.font.bold = bold
        r.font.italic = italic
        r.font.color.rgb = color
        r.font.name = font
    return tb

def add_bullets(slide, x, y, w, h, items, size=16, color=DARK, bold_first=False,
                 font="Calibri", space_after=8, level_sizes=None, line_spacing=1.05):
    """items: list of (level, text) or plain strings (level 0)"""
    tb = slide.shapes.add_textbox(x, y, w, h)
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = 0; tf.margin_right = 0; tf.margin_top = 0; tf.margin_bottom = 0
    first = True
    for item in items:
        if isinstance(item, tuple):
            lvl, txt = item
        else:
            lvl, txt = 0, item
        p = tf.paragraphs[0] if first else tf.add_paragraph()
        first = False
        bullet_char = "\u25CF " if lvl == 0 else ("\u2013 " if lvl == 1 else "\u2022 ")
        p.text = bullet_char + txt
        p.level = 0
        p.space_after = Pt(space_after)
        p.line_spacing = line_spacing
        r = p.runs[0]
        sz = size if lvl == 0 else size - 2
        r.font.size = Pt(sz)
        r.font.color.rgb = TEAL if lvl == 0 else color
        r.font.name = font
        r.font.bold = (lvl == 0 and bold_first)
        if lvl > 0:
            # indent
            pPr = p._pPr
            p.text = ""  # reset then rebuild with indent via level attr trick
    # simpler indentation approach: rebuild using paragraph indent levels
    return tb

def header(slide, title, kicker="AMBULATORY ANAESTHESIA", slide_no=None, total=None):
    add_rect(slide, 0, 0, SW, Inches(1.15), NAVY)
    add_rect(slide, 0, Inches(1.15), SW, Pt(3), ACCENT)
    add_text(slide, Inches(0.55), Inches(0.12), Inches(8), Inches(0.3), kicker,
              size=12, color=RGBColor(0x9F,0xC9,0xCF), bold=True, font="Calibri")
    add_text(slide, Inches(0.55), Inches(0.38), Inches(11.5), Inches(0.7), title,
              size=27, color=WHITE, bold=True, font="Calibri")
    if slide_no:
        add_text(slide, SW-Inches(1.0), SH-Inches(0.4), Inches(0.6), Inches(0.3),
                  str(slide_no), size=11, color=GREY, align=PP_ALIGN.RIGHT)

def footer_note(slide, text="Miller's Anesthesia, 10th Edition - Ch. 68 Ambulatory Anesthesia"):
    add_text(slide, Inches(0.55), SH-Inches(0.4), Inches(9), Inches(0.3), text,
              size=10, color=GREY, italic=True)

def bullet_slide(title, items, kicker="AMBULATORY ANAESTHESIA", size=17, slide_no=None,
                  note=None, two_col=False):
    s = add_slide(); set_bg(s)
    header(s, title, kicker, slide_no)
    if two_col:
        half = (len(items)+1)//2
        add_bullets(s, Inches(0.6), Inches(1.55), Inches(5.95), Inches(5.4), items[:half], size=size)
        add_bullets(s, Inches(6.75), Inches(1.55), Inches(5.95), Inches(5.4), items[half:], size=size)
    else:
        add_bullets(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(5.4), items, size=size)
    footer_note(s, note) if note else footer_note(s)
    return s

def section_slide(number, title, subtitle):
    s = add_slide(); set_bg(s, NAVY)
    add_rect(s, 0, Inches(3.3), SW, Inches(0.06), ACCENT)
    add_text(s, Inches(0.9), Inches(2.2), Inches(3), Inches(1), number, size=64,
              color=ACCENT, bold=True)
    add_text(s, Inches(0.95), Inches(3.5), Inches(11), Inches(1), title, size=36,
              color=WHITE, bold=True)
    add_text(s, Inches(0.95), Inches(4.3), Inches(11), Inches(0.8), subtitle, size=17,
              color=RGBColor(0xB9,0xD4,0xD8), italic=True)
    return s

def add_table(slide, x, y, w, h, data, col_widths=None, header_color=TEAL,
              font_size=12, header_font_size=13, header_font_color=WHITE,
              body_color_alt=LIGHT_TEAL):
    rows = len(data); cols = len(data[0])
    gtable = slide.shapes.add_table(rows, cols, x, y, w, h).table
    if col_widths:
        total = sum(col_widths)
        for i, cw in enumerate(col_widths):
            gtable.columns[i].width = Emu(int(w * cw / total))
    for r in range(rows):
        for c in range(cols):
            cell = gtable.cell(r, c)
            cell.text = str(data[r][c])
            cell.margin_left = Pt(6); cell.margin_right = Pt(6)
            cell.margin_top = Pt(3); cell.margin_bottom = Pt(3)
            cell.vertical_anchor = MSO_ANCHOR.MIDDLE
            para = cell.text_frame.paragraphs[0]
            run = para.runs[0] if para.runs else para.add_run()
            if r == 0:
                cell.fill.solid(); cell.fill.fore_color.rgb = header_color
                run.font.bold = True
                run.font.size = Pt(header_font_size)
                run.font.color.rgb = header_font_color
            else:
                cell.fill.solid()
                cell.fill.fore_color.rgb = body_color_alt if r % 2 == 0 else WHITE
                run.font.size = Pt(font_size)
                run.font.color.rgb = DARK
    return gtable

def table_slide(title, data, col_widths=None, kicker="AMBULATORY ANAESTHESIA",
                 slide_no=None, note=None, table_h=5.1, font_size=13, header_font_size=14,
                 caption=None):
    s = add_slide(); set_bg(s)
    header(s, title, kicker, slide_no)
    top = Inches(1.55)
    if caption:
        add_text(s, Inches(0.6), top, Inches(11.9), Inches(0.35), caption, size=13,
                  color=GREY, italic=True)
        top = top + Inches(0.4)
    add_table(s, Inches(0.6), top, Inches(12.1), Inches(table_h), data, col_widths,
              font_size=font_size, header_font_size=header_font_size)
    footer_note(s, note) if note else footer_note(s)
    return s

def add_box(slide, x, y, w, h, text, fill=TEAL, font_color=WHITE, size=13, bold=True,
            shape=MSO_SHAPE.ROUNDED_RECTANGLE, line_color=None):
    sh = slide.shapes.add_shape(shape, x, y, w, h)
    sh.fill.solid(); sh.fill.fore_color.rgb = fill
    if line_color:
        sh.line.color.rgb = line_color; sh.line.width = Pt(1.5)
    else:
        sh.line.fill.background()
    sh.shadow.inherit = False
    tf = sh.text_frame
    tf.word_wrap = True
    tf.margin_left = Pt(4); tf.margin_right = Pt(4); tf.margin_top = Pt(2); tf.margin_bottom = Pt(2)
    tf.vertical_anchor = MSO_ANCHOR.MIDDLE
    p = tf.paragraphs[0]
    p.text = text
    p.alignment = PP_ALIGN.CENTER
    r = p.runs[0]
    r.font.size = Pt(size); r.font.bold = bold; r.font.color.rgb = font_color
    r.font.name = "Calibri"
    return sh

def add_arrow(slide, x1, y1, x2, y2, color=NAVY, width=2.0):
    conn = slide.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, x1, y1, x2, y2)
    conn.line.color.rgb = color
    conn.line.width = Pt(width)
    conn.line.end_arrowhead = True
    ln = conn.line._get_or_add_ln()
    tail = ln.makeelement(qn('a:tailEnd'), {'type': 'triangle', 'w': 'med', 'len': 'med'})
    ln.append(tail)
    return conn

# ================= SLIDE 1: TITLE =================
s = add_slide(); set_bg(s, NAVY)
add_rect(s, 0, Inches(0), Inches(0.35), SH, ACCENT)
add_text(s, Inches(1.0), Inches(2.15), Inches(11), Inches(0.5), "MD SEMINAR", size=20,
          color=RGBColor(0x9F,0xC9,0xCF), bold=True)
add_text(s, Inches(1.0), Inches(2.6), Inches(11.5), Inches(1.6), "Ambulatory Anaesthesia", size=52,
          color=WHITE, bold=True)
add_text(s, Inches(1.0), Inches(3.85), Inches(11), Inches(0.6), "Day-Case / Outpatient Anaesthesia: Principles and Practice", size=22,
          color=RGBColor(0xE8,0x7A,0x1E))
add_rect(s, Inches(1.0), Inches(4.55), Inches(3.2), Pt(3), ACCENT)
add_text(s, Inches(1.0), Inches(4.85), Inches(11), Inches(0.5),
          "Reference: Miller's Anesthesia, 10th Edition - Chapter 68", size=15, color=RGBColor(0xC8,0xD8,0xDC), italic=True)
add_text(s, Inches(1.0), Inches(6.6), Inches(6), Inches(0.4), "Department of Anaesthesiology", size=13, color=RGBColor(0x9F,0xC9,0xCF))

# ================= SLIDE 2: OUTLINE =================
outline = [
 "Introduction, definitions and scope of ambulatory anaesthesia",
 "Benefits and facility models (hospital-integrated, freestanding, office-based)",
 "Patient selection - surgical, medical and social factors",
 "Preoperative assessment, fasting and premedication",
 "Anaesthetic techniques - general, regional, sedation/MAC",
 "Intraoperative monitoring and depth-of-anaesthesia",
 "OT-to-discharge patient flow (flowchart)",
 "Recovery phases and the Modified Aldrete Score",
 "Postoperative pain - multimodal analgesia",
 "PONV/PDNV - risk scoring and prophylaxis",
 "ERAS, office-based and non-OR anaesthesia",
 "Discharge criteria, adverse effects and outcome measures",
 "Key takeaways for practice",
]
bullet_slide("Seminar Outline", outline, size=18, slide_no=2)

# ================= SLIDE 3: INTRODUCTION =================
s = add_slide(); set_bg(s); header(s, "Introduction & Definitions", slide_no=3)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(2.2), [
 "Ambulatory (day-case) surgery: patient is admitted, operated upon, and discharged home on the same calendar day.",
 "Now accounts for the majority of elective surgical procedures performed worldwide.",
 "Driven by minimally invasive surgical techniques, shorter-acting anaesthetic drugs, improved patient selection, and cost-containment pressures.",
], size=17)
add_rect(s, Inches(0.7), Inches(3.9), Inches(11.9), Inches(2.6), LIGHT_TEAL)
add_text(s, Inches(0.95), Inches(4.05), Inches(11.4), Inches(0.4), "Key Points (Miller's, Ch. 68)", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(0.95), Inches(4.45), Inches(11.4), Inches(1.9), [
 "Use of ambulatory surgery continues to increase worldwide.",
 "Few absolute contraindications exist; patients should NOT be excluded on the basis of arbitrary limits such as age, BMI, or ASA physical status alone.",
 "Effective preoperative assessment is essential for safe, high-quality, efficient ambulatory care.",
 "Provider experience and attention to detail are key to rapid recovery with minimal side effects.",
], size=15)
footer_note(s)

# ================= SLIDE 4: BENEFITS =================
benefits = [
 "Reduced hospital-acquired infection and thromboembolism risk (early mobilisation)",
 "Lower overall healthcare cost vs inpatient stay",
 "Improved bed utilisation and efficient OT throughput",
 "Greater patient satisfaction - recovery in familiar home environment",
 "Reduced psychological stress in children and elderly patients",
 "Shorter waiting lists; predictable scheduling",
 "Reduced separation of family units and less disruption to routine",
]
bullet_slide("Benefits of Ambulatory Surgery", benefits, size=18, slide_no=4)

# ================= SLIDE 5: FACILITIES TABLE =================
fac_data = [
 ["Model", "Description", "Typical Use"],
 ["Hospital-Integrated", "Shares OT suite, staff and resources with inpatient hospital", "Complex cases needing backup of full hospital services"],
 ["Hospital Self-Contained", "Dedicated day-surgery unit within hospital campus, separate staff/theatres", "Standard day-case mix with on-site emergency backup"],
 ["Freestanding (ASC)", "Independent ambulatory surgery centre, not physically attached to a hospital", "High-volume, low-risk elective procedures"],
 ["Office-Based", "Procedure performed in physician's office/procedure room", "Minor procedures under local/sedation; strict safety standards required"],
]
table_slide("Facilities for Ambulatory Surgery", fac_data, col_widths=[2.3,5.5,4.3], slide_no=5,
            font_size=13, table_h=4.2)

# ================= SLIDE 6: PATIENT SELECTION - SURGICAL =================
s = add_slide(); set_bg(s); header(s, "Patient Selection Criteria - Surgical Factors", slide_no=6)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(1.6), [
 "Procedure should carry low risk of major bleeding, severe postoperative pain, or need for prolonged IV therapy.",
 "Anticipated postoperative course should be manageable at home (oral analgesia, minimal nursing care).",
 "Increasingly complex procedures (laparoscopic, arthroscopic, spine, robotic) now performed on ambulatory basis due to minimally invasive techniques.",
], size=15)
ex_data = [
 ["Specialty", "Examples of Procedures (Table 68.1, Miller's)"],
 ["General Surgery", "Laparoscopic cholecystectomy, inguinal/umbilical hernia repair, breast lumpectomy"],
 ["Orthopaedics", "Knee/shoulder arthroscopy, ACL reconstruction, carpal tunnel release, minor hand/foot surgery"],
 ["ENT", "Tonsillectomy, myringotomy, septoplasty, sinus surgery"],
 ["Gynaecology", "Laparoscopic sterilisation, hysteroscopy, D&C"],
 ["Ophthalmology", "Cataract extraction, strabismus surgery"],
 ["Urology", "Cystoscopy, TURBT (limited), circumcision"],
 ["Dental/Oral", "Dental extractions under GA, minor maxillofacial procedures"],
]
add_table(s, Inches(0.7), Inches(3.3), Inches(11.9), Inches(3.7), ex_data, col_widths=[2.2,9.7],
          font_size=12.5, header_font_size=13)
footer_note(s)

# ================= SLIDE 7: PATIENT SELECTION - MEDICAL =================
s = add_slide(); set_bg(s); header(s, "Patient Selection Criteria - Medical Factors", slide_no=7)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(5.85), Inches(5.3), [
 "Obstructive Sleep Apnea (OSA):",
 (1,"Not an absolute contraindication; use STOP-BANG screening"),
 (1,"Optimise with CPAP; ensure adequate post-op monitoring before discharge"),
 "Age and Frailty:",
 (1,"Chronological age alone is NOT a valid exclusion criterion"),
 (1,"Clinical Frailty Scale (Box 68.1) is a better predictor of outcome than age"),
 (1,"Frail elderly need careful pre-op optimisation and escort at discharge"),
], size=16)
add_bullets(s, Inches(6.75), Inches(1.55), Inches(5.85), Inches(5.3), [
 "Cardiovascular Disease:",
 (1,"Stable, well-controlled CVD (including compensated heart failure, stable angina) can be managed as day case"),
 (1,"Recent MI/unstable angina/decompensated HF - defer"),
 "General principle:",
 (1,"ASA physical status I-III are generally suitable"),
 (1,"Select ASA III/IV patients if medically optimised and comorbidity is stable"),
 (1,"Obesity (BMI) alone should not exclude patients from ambulatory surgery"),
], size=16)
footer_note(s)

# ================= SLIDE 8: PATIENT SELECTION - SOCIAL =================
social = [
 "A responsible, competent adult escort must accompany the patient home",
 "Adult supervision at home for the first 24 hours postoperatively",
 "Reasonable travel distance to a hospital/emergency facility",
 "Availability of a telephone and means to return if complications arise",
 "Adequate home conditions - sanitation, warmth, ability to follow instructions",
 "Patient's comprehension of and agreement with the day-case pathway",
]
bullet_slide("Patient Selection Criteria - Social Factors", social, size=19, slide_no=8)

# ================= SLIDE 9: PREOPERATIVE ASSESSMENT =================
s = add_slide(); set_bg(s); header(s, "Preoperative Assessment", slide_no=9)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(2.0), [
 "Aim: identify, optimise and prepare patients ahead of the day of surgery - central to safe, efficient ambulatory care.",
 "Can be performed via nurse-led clinics, telephone/tele-assessment, questionnaires, or in-person visits depending on complexity.",
 "Timing: ideally well in advance of surgery to allow optimisation, but close enough to reflect current status.",
], size=16)
inv_data = [
 ["Investigation", "Recommendation in Ambulatory Setting"],
 ["Routine bloods/ECG/CXR", "NOT required routinely - based on comorbidity and procedure risk only"],
 ["Pregnancy testing", "Consider in women of childbearing age per local policy"],
 ["HbA1c / glucose", "For known/at-risk diabetics undergoing anaesthesia"],
 ["Targeted testing", "Directed by history, examination and specific risk factors, not age alone"],
]
add_table(s, Inches(0.7), Inches(3.75), Inches(11.9), Inches(2.7), inv_data, col_widths=[3.8,8.1],
          font_size=14, header_font_size=15)
footer_note(s)

# ================= SLIDE 10: FASTING & PREMEDICATION =================
s = add_slide(); set_bg(s); header(s, "Fasting & Premedication", slide_no=10)
fast_data = [
 ["Intake", "Minimum Fasting Time"],
 ["Clear fluids", "2 hours"],
 ["Breast milk", "4 hours"],
 ["Light meal / infant formula", "6 hours"],
 ["Fatty / fried meal", "8 hours"],
]
add_text(s, Inches(0.7), Inches(1.5), Inches(5.7), Inches(0.4), "Preoperative Fasting Guidelines", size=16, bold=True, color=NAVY)
add_table(s, Inches(0.7), Inches(1.95), Inches(5.7), Inches(2.7), fast_data, col_widths=[3.2,2.5],
          font_size=13.5, header_font_size=14)
add_text(s, Inches(6.7), Inches(1.5), Inches(5.9), Inches(0.4), "Premedication Principles", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(6.7), Inches(1.95), Inches(5.9), Inches(4.8), [
 "Anxiolysis: short-acting benzodiazepine (e.g. low-dose midazolam) if needed - avoid prolonging recovery",
 "Analgesic premedication: paracetamol +/- NSAID given preoperatively (multimodal, opioid-sparing)",
 "Antacid/gastrokinetic premedication: reserved for patients at risk of aspiration (e.g. obesity, reflux, difficult airway)",
 "Provision of clear written and verbal information reduces anxiety and improves compliance with fasting/discharge instructions",
], size=15)
footer_note(s)

# ================= SLIDE 11: ANAESTHETIC TECHNIQUES OVERVIEW =================
s = add_slide(); set_bg(s); header(s, "Anaesthetic Techniques - Overview", slide_no=11)
tech_data = [
 ["Technique", "Key Features for Ambulatory Use"],
 ["General Anaesthesia (TIVA/Inhalational)", "Rapid onset/offset agents; propofol induction +/- maintenance; low-solubility volatiles (sevoflurane, desflurane)"],
 ["Regional Anaesthesia", "Peripheral nerve blocks preferred over neuraxial for faster ambulation; excellent postoperative analgesia"],
 ["Neuraxial (Spinal/Epidural)", "Low-dose, short-acting local anaesthetics (e.g. low-dose spinal) to permit early ambulation and voiding"],
 ["Sedation / MAC", "Titrated sedative-analgesic combination with local anaesthesia by surgeon; continuum from minimal sedation to GA"],
 ["Local Anaesthesia Alone", "Fastest recovery; ideal where surgically feasible"],
]
add_table(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(4.3), tech_data, col_widths=[3.4,8.5],
          font_size=13.5, header_font_size=14)
footer_note(s)

# ================= SLIDE 12: GA - IV & INHALED =================
s = add_slide(); set_bg(s); header(s, "General Anaesthesia: IV & Inhaled Agents", slide_no=12)
add_text(s, Inches(0.7), Inches(1.5), Inches(5.8), Inches(0.4), "Intravenous Agents", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(0.7), Inches(1.95), Inches(5.8), Inches(4.6), [
 "Propofol - agent of choice for induction and TIVA maintenance:",
 (1,"Rapid, clear-headed recovery; lower incidence of PONV"),
 (1,"Antiemetic properties even at sub-hypnotic doses"),
 (1,"TCI (target-controlled infusion) allows smooth titration"),
], size=15)
add_text(s, Inches(6.75), Inches(1.5), Inches(5.9), Inches(0.4), "Inhaled Agents", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(6.75), Inches(1.95), Inches(5.9), Inches(4.6), [
 "Sevoflurane - smooth non-irritant induction (mask induction feasible in children); low blood/gas solubility",
 "Desflurane - lowest blood/gas solubility of volatiles in use -> fastest emergence, useful in longer procedures",
 "Both permit rapid, titratable emergence suited to fast-track recovery",
 "Choice guided by PONV risk, cost and case duration",
], size=15)
footer_note(s)

# ================= SLIDE 13: SEDATION CONTINUUM (flowchart-style) =================
s = add_slide(); set_bg(s); header(s, "The Continuum of Sedation to General Anaesthesia", slide_no=13)
add_text(s, Inches(0.7), Inches(1.5), Inches(11.9), Inches(0.5),
          "Sedation is a continuum - depth can shift rapidly; the same vigilance for airway/ventilation applies throughout.",
          size=15, color=GREY, italic=True)
stages = ["Minimal Sedation\n(Anxiolysis)", "Moderate Sedation\n(\"Conscious Sedation\")",
          "Deep Sedation", "General\nAnaesthesia"]
descs = ["Normal response to\nverbal stimuli", "Purposeful response to\nverbal/tactile stimuli",
         "Purposeful response only\nto repeated/painful stimuli", "Unarousable even\nwith painful stimuli"]
x0 = Inches(0.7); w = Inches(2.85); gap = Inches(0.25); y0 = Inches(2.6); h = Inches(1.3)
for i in range(4):
    x = x0 + i*(w+gap)
    add_box(s, x, y0, w, h, stages[i], fill=TEAL if i<3 else NAVY, size=15)
    add_text(s, x, y0+h+Inches(0.15), w, Inches(1.0), descs[i], size=12.5, color=DARK, align=PP_ALIGN.CENTER)
    if i < 3:
        add_arrow(s, x+w, y0+h/2, x+w+gap, y0+h/2, color=ACCENT, width=2.5)
add_rect(s, Inches(0.7), Inches(5.4), Inches(11.9), Inches(1.55), LIGHT_TEAL)
add_bullets(s, Inches(0.95), Inches(5.55), Inches(11.4), Inches(1.3), [
 "Midazolam: reliable anxiolysis + amnesia; slower/variable recovery with repeat dosing",
 "Propofol sedation: rapid recovery, minimal residual effect, but can abruptly progress to apnoea/GA - requires airway-trained provider",
], size=14)
footer_note(s)

# ================= SLIDE 14: MONITORING =================
mon = [
 "Standard intraoperative monitoring: ECG, NIBP, SpO2, EtCO2, temperature - as for any anaesthetic",
 "Depth-of-anaesthesia monitoring (processed EEG - BIS, Entropy) helps titrate agents precisely, reducing drug overuse and speeding recovery",
 "Cerebral oximetry (NIRS) may be used selectively in patients at risk of cerebral hypoperfusion",
 "Target-controlled infusion (TCI) systems permit reproducible plasma/effect-site concentrations for TIVA",
 "Goal: avoid both under- and over-dosing to enable rapid, clear-headed emergence",
]
bullet_slide("Intraoperative Monitoring", mon, size=17, slide_no=14)

# ================= SLIDE 15: FLOWCHART - OT PATIENT FLOW =================
s = add_slide(); set_bg(s)
header(s, "Ambulatory Surgery Patient Flow - From OT Booking to Home Discharge", slide_no=15)
boxes = [
 "Pre-Admission\nAssessment Clinic\n(selection, optimisation,\ninformation, fasting\ninstructions)",
 "Day of Surgery\nAdmission\n(re-check fitness,\nconsent, marking,\nescort confirmed)",
 "Operating Theatre\n(GA / Regional /\nSedation-MAC;\nmultimodal analgesia\n+ antiemetics)",
 "Phase I Recovery\n(PACU)\nModified Aldrete\nScore \u2265 9",
 "Phase II Recovery /\nStep-Down\n(fast-track eligible\nbypass Phase I)",
 "Discharge Readiness\nAssessment\nPADSS \u2265 9 /\nBrigham criteria met",
 "Home with Escort\n+ Written Instructions\n+ 24h Follow-up call",
]
n = len(boxes)
box_w = Inches(1.62); box_h = Inches(1.55)
total_w = Inches(12.1)
gap = Emu(int((total_w - box_w*n) / (n-1)))
x = Inches(0.6); y = Inches(2.3)
colors = [TEAL, TEAL, NAVY, ACCENT, TEAL, ACCENT, NAVY]
for i in range(n):
    add_box(s, x, y, box_w, box_h, boxes[i], fill=colors[i], size=10.5)
    if i < n-1:
        add_arrow(s, x+box_w, y+box_h/2, x+box_w+gap, y+box_h/2, color=DARK, width=2.25)
    x = x + box_w + gap
# branch note for fast-track bypass
add_text(s, Inches(0.6), Inches(4.15), Inches(12.1), Inches(0.5),
          "Fast-track pathway: patients recovering from local anaesthesia, sedation, or low-dose spinal may bypass Phase I and enter Phase II directly.",
          size=13, italic=True, color=GREY, align=PP_ALIGN.CENTER)
add_rect(s, Inches(0.6), Inches(4.9), Inches(12.1), Inches(2.0), LIGHT_TEAL)
add_text(s, Inches(0.85), Inches(5.0), Inches(11.6), Inches(0.35), "Discharge is patient-ready, not time-based:", size=14, bold=True, color=NAVY)
add_bullets(s, Inches(0.85), Inches(5.4), Inches(11.6), Inches(1.4), [
 "Stable vital signs, oriented mental status, ability to ambulate and dress",
 "Pain and PONV controlled with oral medication; minimal surgical bleeding",
 "Able to tolerate oral fluids (where indicated) and voided (case-dependent)",
 "Responsible adult escort present with transport arranged",
], size=13)
footer_note(s)

# ================= SLIDE 16: RECOVERY PHASES =================
s = add_slide(); set_bg(s); header(s, "Recovery Phases After Ambulatory Anaesthesia", slide_no=16)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(2.0), [
 "Early (Phase I) recovery: immediate post-anaesthesia period - airway, breathing, circulation, consciousness recovering; occurs in PACU.",
 "Second-stage (Phase II) recovery: patient is awake and stable, working toward discharge criteria - can be a step-down unit or the day-ward.",
 "Fast-track recovery: selected patients bypass Phase I and go directly to Phase II, freeing PACU resources - appropriate after local anaesthesia, sedation, and low-dose spinal, and increasingly after GA with modern rapid-offset agents.",
], size=16)
footer_note(s)

# ================= SLIDE 17: ALDRETE SCORE TABLE =================
aldrete = [
 ["Parameter", "2 points", "1 point", "0 points"],
 ["Activity", "Moves 4 extremities voluntarily", "Moves 2 extremities", "Unable to move extremities"],
 ["Respiration", "Breathes deeply, coughs freely", "Dyspnoea / limited breathing", "Apnoeic"],
 ["Circulation", "BP within 20% of baseline", "BP 20-49% from baseline", "BP \u226550% from baseline"],
 ["Consciousness", "Fully awake", "Arousable on calling", "Not responding"],
 ["Oxygenation", "SpO2 >92% on room air", "Needs O2 to keep SpO2 >90%", "SpO2 <90% even with O2"],
]
table_slide("Modified Aldrete Recovery Score (Table 68.5)", aldrete,
            col_widths=[2.2,3.6,3.4,3.1], slide_no=17, font_size=12.5, header_font_size=13.5,
            caption="Maximum score = 10. Patients scoring \u22659 are fit for discharge from Phase I recovery.")

# ================= SLIDE 18: POSTOPERATIVE PAIN =================
s = add_slide(); set_bg(s); header(s, "Postoperative Pain - Multimodal Analgesia", slide_no=18)
pain_data = [
 ["Component", "Role"],
 ["Acetaminophen (Paracetamol)", "Baseline opioid-sparing analgesic; given pre- or intra-operatively"],
 ["NSAIDs", "Effective for somatic/visceral pain; reduce opioid requirement - caution with bleeding risk"],
 ["Gabapentinoids", "Reduce hyperalgesia and opioid consumption in select procedures"],
 ["Dexamethasone", "Dual benefit - analgesia and potent antiemetic effect"],
 ["Local/Regional Blocks", "Site-specific analgesia, reduces systemic opioid need"],
 ["Rescue Analgesia", "Short-acting opioid reserved for breakthrough pain only"],
]
add_table(s, Inches(0.7), Inches(1.55), Inches(11.9), Inches(4.1), pain_data, col_widths=[3.2,8.7],
          font_size=13, header_font_size=14)
footer_note(s)

# ================= SLIDE 19: PAIN AT HOME =================
home_pain = [
 "Written, patient-friendly analgesia schedule provided at discharge (multimodal - scheduled, not PRN, for first 24-48h)",
 "Combination of paracetamol + NSAID as first line; opioids reserved for breakthrough/rescue only",
 "Educate patient/family on managing opioid side effects: nausea, constipation, sedation, and safe storage/disposal",
 "Continuous peripheral nerve catheters or single-shot long-acting blocks (e.g. liposomal bupivacaine) can extend analgesia at home",
 "Clear instructions on when to seek help (uncontrolled pain, bleeding, signs of infection)",
]
bullet_slide("Pain Management at Home & Managing Opioid Complications", home_pain, size=16, slide_no=19)

# ================= SLIDE 20: PONV - APFEL SCORE =================
apfel = [
 ["Risk Factor", "Point"],
 ["Female sex", "1"],
 ["History of PONV or motion sickness", "1"],
 ["Non-smoker", "1"],
 ["Use of postoperative opioids", "1"],
]
apfel_risk = [
 ["Number of risk factors", "Predicted PONV risk"],
 ["0", "~10%"], ["1", "~20%"], ["2", "~40%"], ["3", "~60%"], ["4", "~80%"],
]
s = add_slide(); set_bg(s); header(s, "PONV Risk Assessment - Apfel Score (Table 68.6)", slide_no=20)
add_table(s, Inches(0.7), Inches(1.6), Inches(6.0), Inches(3.0), apfel, col_widths=[4.2,1.8],
           font_size=13.5, header_font_size=14)
add_table(s, Inches(7.0), Inches(1.6), Inches(5.6), Inches(3.5), apfel_risk, col_widths=[3.5,3.0],
           font_size=13.5, header_font_size=14)
add_text(s, Inches(0.7), Inches(4.85), Inches(11.9), Inches(1.6),
          "Simplified Apfel score: each risk factor scores 1 point (max 4). Score correlates directly with predicted incidence of postoperative nausea and vomiting, guiding the intensity of prophylactic antiemetic strategy (0-1 factors: minimal prophylaxis; \u22652 factors: multimodal prophylaxis).",
          size=14.5, color=DARK)
footer_note(s)

# ================= SLIDE 21: PDNV & ANTIEMETICS =================
s = add_slide(); set_bg(s); header(s, "Postdischarge Nausea & Vomiting (PDNV) and Antiemetic Strategy", slide_no=21)
add_bullets(s, Inches(0.7), Inches(1.55), Inches(5.85), Inches(4.9), [
 "PDNV (Table 68.7) risk factors:",
 (1,"Female sex"), (1,"Age <50 years"), (1,"History of PONV"),
 (1,"Opioid use in PACU"), (1,"Nausea present in PACU"),
 "Risk rises steeply as more factors are present - PDNV can occur after the patient is already home, hence prevention before discharge matters.",
], size=15)
add_bullets(s, Inches(6.75), Inches(1.55), Inches(5.9), Inches(4.9), [
 "Antiemetic classes:",
 (1,"5-HT3 antagonists (e.g. ondansetron) - first line"),
 (1,"Corticosteroids (dexamethasone) - given at induction"),
 (1,"NK-1 antagonists (e.g. aprepitant) - useful for high-risk, longer-lasting prophylaxis"),
 (1,"First-generation agents (droperidol, metoclopramide) - adjuncts"),
 "Multimodal prophylaxis (2 or more agents from different classes) recommended for moderate-high risk patients; use TIVA with propofol to reduce baseline risk.",
], size=15)
footer_note(s)

# ================= SLIDE 22: ERAS =================
eras = [
 "Enhanced Recovery After Surgery (ERAS) principles apply strongly to ambulatory pathways",
 "Preoperative: patient education, carbohydrate loading, avoidance of prolonged fasting",
 "Intraoperative: opioid-sparing multimodal anaesthesia, normothermia, euvolaemia, minimally invasive technique",
 "Postoperative: early mobilisation, early oral intake, scheduled multimodal analgesia and antiemetics",
 "Goal: faster functional recovery, fewer complications, and higher same-day discharge rates even for increasingly complex procedures",
]
bullet_slide("Enhanced Recovery After Surgery (ERAS) in Ambulatory Practice", eras, size=17, slide_no=22)

# ================= SLIDE 23: SPECIAL AREAS =================
s = add_slide(); set_bg(s); header(s, "Special Areas: Office-Based & Non-OR Anaesthesia", slide_no=23)
add_text(s, Inches(0.7), Inches(1.5), Inches(5.8), Inches(0.4), "Office-Based Practice", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(0.7), Inches(1.95), Inches(5.8), Inches(4.6), [
 "Same safety standards as hospital-based ambulatory surgery - cannot be relaxed for cost/convenience",
 "Requires appropriate equipment, resuscitation drugs, trained staff, and a clear emergency transfer protocol",
 "Accreditation and regular safety audits are essential",
], size=15)
add_text(s, Inches(6.75), Inches(1.5), Inches(5.9), Inches(0.4), "Non-OR / Remote-Location Anaesthesia", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(6.75), Inches(1.95), Inches(5.9), Inches(4.6), [
 "Includes endoscopy suites, radiology/IR, cardiac catheterisation labs",
 "Hazards: unfamiliar layout, limited access to the patient, poor lighting, lack of immediate backup (Table 68.8)",
 "Requires the same monitoring standards and a pre-checked emergency plan as the main OT",
], size=15)
footer_note(s)

# ================= SLIDE 24: DISCHARGE - PADSS TABLE =================
padss = [
 ["Category", "Assessment"],
 ["Vital Signs", "Within 20% of preoperative baseline"],
 ["Activity & Mental Status", "Steady gait, no dizziness, oriented consistent with preoperative level"],
 ["Pain, Nausea, Vomiting", "Controlled and manageable with oral medication"],
 ["Surgical Bleeding", "Minimal, consistent with expected postoperative course"],
 ["Intake and Output", "Able to tolerate oral fluids; voided (where clinically relevant)"],
]
table_slide("Postanesthetic Discharge Scoring System - PADSS (Box 68.4)", padss,
            col_widths=[3.2,8.7], slide_no=24, font_size=13.5, header_font_size=14.5, table_h=4.2)

# ================= SLIDE 25: DISCHARGE CRITERIA (Brigham) =================
brigham = [
 "Stable vital signs for at least 30-60 minutes",
 "Patient oriented to person, place and time",
 "Able to ambulate (age/procedure appropriate) without excessive dizziness",
 "Minimal nausea, vomiting or dizziness",
 "Pain controlled with oral analgesics",
 "Minimal bleeding or wound drainage",
 "Voided urine, if applicable to the procedure/anaesthetic",
 "Responsible adult escort present and transportation confirmed",
 "Written discharge and follow-up instructions given and understood",
]
bullet_slide("Criteria for Facility Discharge (Box 68.3, Brigham & Women's Hospital)", brigham,
             size=15.5, slide_no=25, two_col=True)

# ================= SLIDE 26: ADVERSE EFFECTS & OUTCOMES =================
s = add_slide(); set_bg(s); header(s, "Adverse Effects & Outcome Measures", slide_no=26)
add_text(s, Inches(0.7), Inches(1.5), Inches(5.8), Inches(0.4), "Common Adverse Effects", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(0.7), Inches(1.95), Inches(5.8), Inches(4.7), [
 "Postoperative nausea and vomiting", "Pain inadequately controlled at home",
 "Sore throat, drowsiness, dizziness", "Unplanned hospital admission (rare - <1-2%)",
 "Surgical site bleeding or infection", "Urinary retention (especially after spinal anaesthesia)",
], size=15)
add_text(s, Inches(6.75), Inches(1.5), Inches(5.9), Inches(0.4), "Outcome Indicators (Table 68.9, IAAS)", size=16, bold=True, color=NAVY)
add_bullets(s, Inches(6.75), Inches(1.95), Inches(5.9), Inches(4.7), [
 "Unplanned overnight admission rate", "Unplanned return to hospital/ED within 30 days",
 "Postoperative pain and PONV scores", "Patient satisfaction scores",
 "Surgical complication and mortality rates", "Time to return to normal activity/work",
], size=15)
footer_note(s)

# ================= SLIDE 27: SUMMARY =================
summary = [
 "Ambulatory anaesthesia is now the default pathway for most elective surgery - selection is based on individualised risk, not arbitrary cut-offs for age, BMI, or ASA class",
 "Thorough preoperative assessment and optimisation underpins safe same-day discharge",
 "Short-acting, opioid- and PONV-sparing multimodal anaesthetic techniques (propofol/TIVA, low-solubility volatiles, regional blocks) enable fast, clear-headed recovery",
 "Structured recovery pathways (fast-track, PADSS/Aldrete scoring) standardise safe, patient-ready discharge - not merely time-based discharge",
 "Multimodal analgesia and antiemetic prophylaxis (Apfel-score guided) are essential to a comfortable post-discharge course",
 "Continuous outcome audit (readmission, satisfaction, complications) drives quality improvement in ambulatory programs",
]
bullet_slide("Key Takeaways", summary, size=16.5, slide_no=27)

# ================= SLIDE 28: REFERENCES =================
s = add_slide(); set_bg(s); header(s, "References", slide_no=28)
add_bullets(s, Inches(0.7), Inches(1.6), Inches(11.9), Inches(4.5), [
 "Gropper MA, et al. Miller's Anesthesia, 10th Edition. Chapter 68: Ambulatory Anesthesia. Elsevier, 2024.",
 "Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia, 9th Edition - sections on ambulatory laparoscopic, hip and knee surgery.",
 "Brunicardi F, et al. Schwartz's Principles of Surgery, 11th Edition - Ambulatory Surgery and Ambulatory Surgery Centers.",
 "Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology - Specific Patient Conditions & Ambulatory Surgery.",
], size=16)
footer_note(s, "Prepared for MD Seminar - Department of Anaesthesiology")

prs.save("/tmp/workspace/ambulatory_anaesthesia/Ambulatory_Anaesthesia_MD_Seminar.pptx")
print("Saved. Total slides:", len(prs.slides.__iter__.__self__._sldIdLst))

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/ambulatory_anaesthesia/build_ppt.py'