from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

doc = Document()

# ──────────────────────────────────────────────
# PAGE SETUP: A4, margins
# ──────────────────────────────────────────────
section = doc.sections[0]
section.page_width  = Inches(8.27)
section.page_height = Inches(11.69)
section.left_margin   = Inches(1.0)
section.right_margin  = Inches(1.0)
section.top_margin    = Inches(1.0)
section.bottom_margin = Inches(1.0)

# ──────────────────────────────────────────────
# COLOUR PALETTE
# ──────────────────────────────────────────────
DARK_BLUE    = RGBColor(0x1A, 0x35, 0x5E)   # deep navy
MED_BLUE     = RGBColor(0x2E, 0x6E, 0xBD)   # heading blue
ACCENT_TEAL  = RGBColor(0x00, 0x86, 0x96)   # teal subheadings
BOX_FILL     = RGBColor(0xE8, 0xF4, 0xFD)   # light blue box bg
WARN_FILL    = RGBColor(0xFF, 0xF3, 0xCD)   # amber for limitations
KEY_FILL     = RGBColor(0xD4, 0xED, 0xDA)   # green for key points
WHITE        = RGBColor(0xFF, 0xFF, 0xFF)
DARK_GRAY    = RGBColor(0x33, 0x33, 0x33)

# ──────────────────────────────────────────────
# BASE STYLE
# ──────────────────────────────────────────────
normal_style = doc.styles["Normal"]
normal_style.font.name = "Arial"
normal_style.font.size = Pt(10.5)
normal_style.font.color.rgb = DARK_GRAY

# ──────────────────────────────────────────────
# HELPER FUNCTIONS
# ──────────────────────────────────────────────

def set_cell_bg(cell, rgb: RGBColor):
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), f'{rgb[0]:02X}{rgb[1]:02X}{rgb[2]:02X}')
    tcPr.append(shd)

def set_cell_border(cell, **kwargs):
    """Add border to a cell. kwargs: top, bottom, left, right = 'single'"""
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    tcBorders = OxmlElement('w:tcBorders')
    for edge, val in kwargs.items():
        border = OxmlElement(f'w:{edge}')
        border.set(qn('w:val'), val)
        border.set(qn('w:sz'), '4')
        border.set(qn('w:space'), '0')
        border.set(qn('w:color'), '2E6EBD')
        tcBorders.append(border)
    tcPr.append(tcBorders)

def add_cover_title(doc, text):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(26)
    run.font.color.rgb = WHITE
    run.font.name = "Arial"
    # paragraph shading
    pPr = p._p.get_or_add_pPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), '1A355E')
    pPr.append(shd)
    p.paragraph_format.space_before = Pt(12)
    p.paragraph_format.space_after  = Pt(12)
    return p

def add_h1(doc, text):
    """Main topic heading - dark blue banner"""
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.LEFT
    run = p.add_run(f"  {text}")
    run.bold = True
    run.font.size = Pt(15)
    run.font.color.rgb = WHITE
    run.font.name = "Arial"
    pPr = p._p.get_or_add_pPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), '1A355E')
    pPr.append(shd)
    p.paragraph_format.space_before = Pt(14)
    p.paragraph_format.space_after  = Pt(4)
    return p

def add_h2(doc, text):
    """Section heading - medium blue"""
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(12.5)
    run.font.color.rgb = MED_BLUE
    run.font.name = "Arial"
    p.paragraph_format.space_before = Pt(10)
    p.paragraph_format.space_after  = Pt(2)
    # bottom border
    pPr = p._p.get_or_add_pPr()
    pBdr = OxmlElement('w:pBdr')
    bottom = OxmlElement('w:bottom')
    bottom.set(qn('w:val'), 'single')
    bottom.set(qn('w:sz'), '4')
    bottom.set(qn('w:space'), '1')
    bottom.set(qn('w:color'), '2E6EBD')
    pBdr.append(bottom)
    pPr.append(pBdr)
    return p

def add_h3(doc, text):
    """Sub-section heading - teal"""
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(11)
    run.font.color.rgb = ACCENT_TEAL
    run.font.name = "Arial"
    p.paragraph_format.space_before = Pt(7)
    p.paragraph_format.space_after  = Pt(2)
    return p

def add_body(doc, text, indent=False):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.font.size = Pt(10.5)
    run.font.color.rgb = DARK_GRAY
    run.font.name = "Arial"
    if indent:
        p.paragraph_format.left_indent = Inches(0.25)
    p.paragraph_format.space_after = Pt(3)
    return p

def add_bullet(doc, text, level=0, bold_prefix=None):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent  = Inches(0.25 + level * 0.25)
    p.paragraph_format.space_after  = Pt(2)
    if bold_prefix:
        r1 = p.add_run(bold_prefix + ": ")
        r1.bold = True
        r1.font.size = Pt(10.5)
        r1.font.name = "Arial"
        r1.font.color.rgb = DARK_GRAY
    r2 = p.add_run(text)
    r2.font.size = Pt(10.5)
    r2.font.name = "Arial"
    r2.font.color.rgb = DARK_GRAY
    return p

def add_box(doc, title, items, fill_rgb=None):
    """A shaded box with a title and bullet items."""
    if fill_rgb is None:
        fill_rgb = BOX_FILL
    tbl = doc.add_table(rows=1, cols=1)
    tbl.style = 'Table Grid'
    cell = tbl.rows[0].cells[0]
    set_cell_bg(cell, fill_rgb)
    # Title
    tp = cell.add_paragraph()
    tr = tp.add_run(title)
    tr.bold = True
    tr.font.size = Pt(11)
    tr.font.color.rgb = DARK_BLUE
    tr.font.name = "Arial"
    tp.paragraph_format.space_after = Pt(3)
    # Items
    for item in items:
        ip = cell.add_paragraph()
        ip.paragraph_format.left_indent = Inches(0.15)
        ir = ip.add_run(f"• {item}")
        ir.font.size = Pt(10)
        ir.font.name = "Arial"
        ir.font.color.rgb = DARK_GRAY
        ip.paragraph_format.space_after = Pt(1)
    # Remove first empty paragraph python-docx adds
    cell.paragraphs[0]._element.getparent().remove(cell.paragraphs[0]._element)
    p_after = doc.add_paragraph()
    p_after.paragraph_format.space_after = Pt(4)
    return tbl

def add_table(doc, headers, rows, header_fill=None):
    if header_fill is None:
        header_fill = MED_BLUE
    ncols = len(headers)
    tbl = doc.add_table(rows=1 + len(rows), cols=ncols)
    tbl.style = 'Table Grid'
    # Header row
    hdr_cells = tbl.rows[0].cells
    for i, h in enumerate(headers):
        set_cell_bg(hdr_cells[i], header_fill)
        p = hdr_cells[i].paragraphs[0]
        run = p.add_run(h)
        run.bold = True
        run.font.size = Pt(10)
        run.font.color.rgb = WHITE
        run.font.name = "Arial"
    # Data rows
    for ri, row_data in enumerate(rows):
        cells = tbl.rows[ri + 1].cells
        for ci, val in enumerate(row_data):
            # alternate shading
            if ri % 2 == 0:
                set_cell_bg(cells[ci], RGBColor(0xF5, 0xF9, 0xFF))
            p = cells[ci].paragraphs[0]
            run = p.add_run(str(val))
            run.font.size = Pt(10)
            run.font.name = "Arial"
            run.font.color.rgb = DARK_GRAY
    p_after = doc.add_paragraph()
    p_after.paragraph_format.space_after = Pt(6)
    return tbl

def add_spacer(doc, height_pt=6):
    p = doc.add_paragraph()
    p.paragraph_format.space_before = Pt(0)
    p.paragraph_format.space_after  = Pt(height_pt)

def add_divider(doc):
    p = doc.add_paragraph()
    pPr = p._p.get_or_add_pPr()
    pBdr = OxmlElement('w:pBdr')
    bottom = OxmlElement('w:bottom')
    bottom.set(qn('w:val'), 'single')
    bottom.set(qn('w:sz'), '6')
    bottom.set(qn('w:space'), '1')
    bottom.set(qn('w:color'), '1A355E')
    pBdr.append(bottom)
    pPr.append(pBdr)
    p.paragraph_format.space_before = Pt(4)
    p.paragraph_format.space_after  = Pt(4)

# ══════════════════════════════════════════════════════════
# COVER PAGE
# ══════════════════════════════════════════════════════════

add_cover_title(doc, "ANAESTHESIA QUICK REVISION GUIDE")

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = p.add_run("Exam-Focused Study Notes | Jan 2025 & Sept 2025 Paper Topics")
r.font.size = Pt(12)
r.font.color.rgb = MED_BLUE
r.font.name = "Arial"
r.italic = True

add_spacer(doc, 8)

# Topic index box
add_box(doc, "TOPICS COVERED", [
    "1.  Opioid Free Anaesthesia (OFA) — Role, Benefits & Limitations",
    "2.  Recent Advances in Anaesthesia for Intrauterine Fetal Surgery",
    "3.  Ultrasound for Airway Assessment and Management",
    "4.  Hospital Acquired Infections & Ventilator Associated Pneumonia (VAP)",
], fill_rgb=RGBColor(0xE8, 0xF4, 0xFD))

add_spacer(doc, 8)

p2 = doc.add_paragraph()
p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
r2 = p2.add_run("Sources: Miller's Anesthesia 10e | Morgan & Mikhail 7e | Barash Clinical Anesthesia 9e | Fishman's Pulmonary Diseases 6e")
r2.font.size = Pt(9)
r2.font.color.rgb = RGBColor(0x66, 0x66, 0x66)
r2.font.name = "Arial"
r2.italic = True

doc.add_page_break()

# ══════════════════════════════════════════════════════════
# TOPIC 1: OPIOID FREE ANAESTHESIA
# ══════════════════════════════════════════════════════════

add_h1(doc, "TOPIC 1: OPIOID FREE ANAESTHESIA (OFA)")

add_h2(doc, "Definition & Background")
add_body(doc, "Opioid Free Anaesthesia (OFA) is an anaesthetic technique in which opioids are completely avoided intraoperatively, relying on a combination of non-opioid analgesics, regional techniques, and adjuvant drugs to achieve analgesia and obtund the surgical stress response.")
add_spacer(doc, 4)
add_body(doc, "Opioid-Sparing Analgesia (OSA) = minimising (not eliminating) opioids. OFA is a subset of the broader OSA movement.")

add_h2(doc, "WHY OFA? — The Rationale")
add_box(doc, "Drivers of the OFA Movement", [
    "Global opioid epidemic — prescription opioid abuse crisis",
    "Opioid-induced hyperalgesia (OIH) — paradoxical pain sensitisation",
    "Postoperative nausea & vomiting (PONV) — opioids are the #1 cause",
    "Respiratory depression — especially in OSA, obese, elderly patients",
    "Postoperative delirium in ICU/elderly patients",
    "Immunosuppressive effects of opioids (NK cell suppression)",
    "Opioid tolerance and dependence risk in naive patients",
    "Delayed return of bowel function (opioid-induced ileus)",
], fill_rgb=BOX_FILL)

add_h2(doc, "Pharmacological Components of OFA")
add_table(doc,
    ["Drug Category", "Agents", "Mechanism"],
    [
        ["Alpha-2 agonists", "Dexmedetomidine, Clonidine", "Presynaptic alpha-2; reduces NE release; sedation + analgesia"],
        ["NMDA antagonists", "Ketamine (S-ketamine), Mg SO4", "Blocks NMDA receptor; prevents central sensitisation"],
        ["IV local anaesthetic", "Systemic Lidocaine infusion", "Na-channel block; anti-hyperalgesic; anti-inflammatory"],
        ["NSAIDs / COX-2i", "Ketorolac, Parecoxib, Celecoxib", "Inhibit prostaglandin synthesis peripherally"],
        ["Alpha-2-delta ligands", "Gabapentin, Pregabalin", "Block voltage-gated Ca2+ channels; reduce glutamate release"],
        ["Glucocorticoids", "Dexamethasone", "Anti-inflammatory; prolongs regional block duration"],
        ["Paracetamol", "IV/oral Acetaminophen", "Central & peripheral COX inhibition; supraspinal action"],
        ["Regional techniques", "Epidural, TAP, PEC blocks, PNBs", "Afferent blockade; prevent central sensitisation"],
        ["Beta-blockers", "Esmolol", "Blunts surgical stress haemodynamic response"],
        ["Volatile agents", "High-dose sevo/desflurane", "MAC-adjusted; provides immobility & some analgesia"],
    ]
)

add_h2(doc, "Benefits of OFA")
add_box(doc, "POTENTIAL BENEFITS", [
    "1. Reduces PONV — bariatric surgery studies show benefit beyond triple antiemetic prophylaxis",
    "2. Avoids respiratory depression — crucial in morbid obesity, OSA, paediatric tonsillectomy",
    "3. Prevents OIH — avoids paradoxical pain sensitisation from high-dose intraoperative opioids",
    "4. Reduces postoperative delirium — modifiable risk factor in elderly/ICU",
    "5. Faster return of bowel function — shorter ileus; supports ERAS protocols",
    "6. Shorter PACU stay and faster discharge",
    "7. Reduced chronic pain risk — less peripheral and central sensitisation",
    "8. Preserves immune function — avoids opioid-induced NK cell suppression",
    "9. No opioid dependence risk in naive patients",
], fill_rgb=KEY_FILL)

add_h2(doc, "Limitations of OFA")
add_box(doc, "LIMITATIONS / RISKS", [
    "1. Haemodynamic instability — large proof-of-concept RCT terminated early due to hypoxia & bradycardia",
    "2. Increased vasopressor requirement (dexmedetomidine causes bradycardia & hypotension)",
    "3. Postoperative sedation and falls (residual dexmedetomidine effect)",
    "4. Inadequate for highly nociceptive procedures without regional anaesthesia",
    "5. Dependence on regional techniques — block failure, haematoma, nerve injury risk",
    "6. Adjuvant drug side effects: Ketamine (dysphoria), NSAIDs (renal/GI), Pregabalin (dizziness)",
    "7. Limited high-quality RCT evidence for major cardiac/thoracic surgery",
    "8. Not universally superior — opioid-sparing approach may be more practical in most patients",
], fill_rgb=WARN_FILL)

add_h2(doc, "OFA vs Opioid-Sparing Analgesia")
add_table(doc,
    ["Feature", "OFA (Opioid Free)", "Opioid-Sparing (OSA)"],
    [
        ["Opioid dose", "Zero intraoperatively", "Reduced (not zero)"],
        ["Evidence base", "Limited RCTs", "Strong, well-established"],
        ["PONV benefit", "Maximum", "Significant"],
        ["Haemodynamic stability", "Potentially compromised", "Better"],
        ["Applicability", "Selected cases", "Near universal"],
        ["ERAS compatibility", "High", "High"],
        ["Typical candidates", "Bariatric, opioid-dependent, OSA", "All surgical patients"],
    ]
)

add_h2(doc, "Clinical Bottom Line")
add_box(doc, "KEY TAKE-HOME MESSAGE", [
    "OFA is NOT a universal solution — it is best reserved for selected patients",
    "Opioid-SPARING multimodal analgesia is the recommended standard for most patients",
    "A large proof-of-concept study was terminated early due to hypoxia and bradycardia (Miller's 10e)",
    "By using a multimodal pharmacological + regional approach, the anaesthesiologist can contribute to combating the opioid crisis while maintaining patient safety",
    "Pre-operative screening for chronic pain, opioid use, and substance abuse is essential",
], fill_rgb=BOX_FILL)

doc.add_page_break()

# ══════════════════════════════════════════════════════════
# TOPIC 2: INTRAUTERINE FETAL SURGERY
# ══════════════════════════════════════════════════════════

add_h1(doc, "TOPIC 2: ANAESTHESIA FOR INTRAUTERINE FETAL SURGERY")

add_h2(doc, "Introduction")
add_body(doc, "Fetal surgery encompasses in utero interventions to correct anatomical malformations causing irreversible harm if untreated. The anaesthesiologist faces a unique DUAL-PATIENT challenge: the pregnant mother AND the fetus. Success depends on multidisciplinary teamwork at a specialised fetal therapy centre. (Miller's Anesthesia 10e, Ch. 59)")

add_h2(doc, "Prerequisites for Fetal Surgery")
add_box(doc, "Criteria (must satisfy ALL)", [
    "Fetal lesion accurately diagnosed on imaging",
    "Progression & severity of anomaly predictable and well-understood",
    "No other severe anomalies contraindicating intervention",
    "Without treatment: fetal demise, irreversible organ damage, or severe neonatal morbidity",
    "Risk to the pregnant patient is acceptably low",
    "Animal model feasibility demonstrated",
    "Ethics committee approval; full informed consent obtained",
    "Specialised multidisciplinary centre (Level II or III)",
], fill_rgb=BOX_FILL)

add_h2(doc, "Classification of Fetal Surgery Procedures")
add_table(doc,
    ["Type", "Technique", "Anaesthesia Used"],
    [
        ["Minimally invasive (FIGS-IT)", "US-guided percutaneous needle procedures", "Local + IV sedation"],
        ["Fetoscopic surgery", "Small scope; percutaneous; US + camera guidance", "Local, sedation, or neuraxial (CSE/epidural)"],
        ["Open fetal surgery", "Maternal laparotomy + hysterotomy", "General anaesthesia (MANDATORY)"],
        ["EXIT procedure", "Delivery while placenta intact; airway secured", "General anaesthesia + epidural"],
    ]
)

add_h2(doc, "Conditions & RCT Evidence")
add_table(doc,
    ["Condition", "Procedure", "Trial / Evidence"],
    [
        ["Twin-to-Twin Transfusion Syndrome (TTTS)", "Fetoscopic laser photocoagulation of placental vessels", "Level I RCT — standard of care"],
        ["Myelomeningocele (spina bifida)", "Open or fetoscopic MMC repair", "MOMS Trial — improved motor function"],
        ["Congenital Diaphragmatic Hernia (CDH)", "Fetal Endoscopic Tracheal Occlusion (FETO)", "TOTAL Trial — survival benefit in severe CDH"],
        ["Lower Urinary Tract Obstruction (LUTO)", "Vesico-amniotic shunt", "PLUTO Trial"],
        ["Sacrococcygeal Teratoma (SCT)", "Debulking for high-output cardiac failure", "Case series; Level III centres"],
        ["CPAM / pulmonary lesions", "Thoraco-amniotic shunt", "Selected cases"],
    ]
)

add_h2(doc, "Anaesthetic Management — Overview")
add_h3(doc, "A. Maternal Anaesthesia")
add_box(doc, "For Open Fetal Surgery", [
    "General anaesthesia REQUIRED",
    "High-dose volatile agent: Desflurane/Sevoflurane at 1.5–2 MAC",
    "  -> Provides: maternal anaesthesia + uterine relaxation (tocolysis) + transplacental fetal anaesthesia",
    "Supplemental IV: propofol, remifentanil infusion",
    "Epidural catheter inserted pre-op for postoperative pain management",
    "Arterial line + large-bore IV + type & crossmatch (haemorrhage risk)",
], fill_rgb=BOX_FILL)
add_box(doc, "For Fetoscopic / Minimally Invasive Procedures", [
    "Neuraxial anaesthesia preferred (spinal or CSE)",
    "OR: local infiltration + IV sedation (fentanyl + midazolam)",
    "No need for uterine relaxation agents in most cases",
    "Less maternal physiological derangement",
], fill_rgb=KEY_FILL)

add_h3(doc, "B. Fetal Anaesthesia and Analgesia")
add_body(doc, "Fetal pain perception: nociceptive pathways present by 24–28 weeks gestation. Fetal hormonal & haemodynamic stress responses to noxious stimuli are well-documented — direct fetal opioid analgesia attenuates these responses.")
add_spacer(doc, 4)
add_table(doc,
    ["Route", "Drugs", "Indications"],
    [
        ["Transplacental (maternal IV/inhalational)", "Volatile agents, opioids, benzodiazepines", "All open fetal surgery"],
        ["Intramuscular (IM into fetus)", "Fentanyl 10–20 mcg/kg + Atropine 20 mcg/kg + Vecuronium", "Fetoscopic procedures"],
        ["Intra-umbilical vein injection", "Fentanyl, atropine, muscle relaxant", "When IM access difficult"],
    ]
)

add_h3(doc, "C. Uterine Relaxation (Tocolysis)")
add_box(doc, "Tocolytic Strategy", [
    "INTRAOPERATIVE: High-dose volatile agents (primary; dose-dependent uterine relaxation)",
    "INTRAOPERATIVE ADJUNCT: IV Nitroglycerin (rapid onset, short duration)",
    "PERIOPERATIVE: IV Magnesium sulphate",
    "POSTOPERATIVE: Nifedipine (Ca-channel blocker) or Indomethacin (PG inhibitor)",
    "Indometacin caution: avoid after 32 weeks (premature ductal closure)",
], fill_rgb=BOX_FILL)

add_h3(doc, "D. Fetal Monitoring")
add_box(doc, "Fetal Monitoring Methods", [
    "Continuous fetal echocardiography / fetal heart rate monitoring throughout procedure",
    "Umbilical artery Doppler — detects flow abnormalities (sign of fetal compromise)",
    "Fetal pulse oximetry (limited; used on exteriorised limb in open surgery)",
    "Fetal scalp electrode (when applicable)",
    "Immediate access to fetal resuscitation drugs: atropine, epinephrine",
], fill_rgb=BOX_FILL)

add_h2(doc, "Recent Advances (Exam High-Yield)")
add_table(doc,
    ["Advance", "Key Points"],
    [
        ["Fetoscopic MMC Repair", "3-port technique; CSE anaesthesia; reduced maternal morbidity vs open surgery"],
        ["FETO for CDH (TOTAL Trial)", "Balloon at 27–30 wks; removed at 34 wks; neuraxial/local anaesthesia; benefit in liver-up CDH with o/e LHR < 25%"],
        ["EXIT Procedure", "High-dose volatile; uterus kept relaxed; airway secured on placental bypass before cord cut"],
        ["Fetal Cardiac Interventions", "Aortic/pulmonary valvuloplasty; US-guided percutaneous; fetal IM injection; 60–70% technical success"],
        ["Neurodevelopmental Safety", "FDA 2016 warning re: anaesthetics & developing brain; GAS trial: single short exposure = minimal risk"],
        ["Three-Level Fetal Centres", "Level I: low risk; Level II: ICU capable; Level III: all open + all complications"],
        ["Bioethics & Counselling", "Termination, watchful waiting, or intervention — all must be offered; informed consent paramount"],
    ]
)

add_h2(doc, "Complications & Management")
add_table(doc,
    ["Complication", "Management"],
    [
        ["Fetal bradycardia", "Atropine IM/IV into fetus; adjust volatile conc; maternal ephedrine"],
        ["PPROM (most common)", "Most frequent complication; conservative or delivery based on GA"],
        ["Preterm labour", "Tocolysis: magnesium, nifedipine; monitor CTG 24–48 h post-op"],
        ["Maternal haemorrhage", "Blood products; uterotonics after fetus delivered"],
        ["Mirror syndrome", "Severe preeclampsia mimic; delivery usually required"],
        ["Fetal demise", "Emergency caesarean or expectant management based on GA"],
    ]
)

doc.add_page_break()

# ══════════════════════════════════════════════════════════
# TOPIC 3: ULTRASOUND FOR AIRWAY
# ══════════════════════════════════════════════════════════

add_h1(doc, "TOPIC 3: ULTRASOUND FOR AIRWAY ASSESSMENT & MANAGEMENT")

add_h2(doc, "Introduction")
add_body(doc, "Point-of-care ultrasound (POCUS) provides real-time, dynamic, objective anatomical information of the airway without radiation. It has transformed from a supplementary tool to an integral component of modern airway practice — for pre-operative planning, intubation guidance, ETT confirmation, and emergency airway rescue. (Morgan & Mikhail 7e; Miller's Anesthesia 10e)")

add_h2(doc, "Ultrasound Anatomy of the Airway")
add_table(doc,
    ["Structure", "US Appearance", "Clinical Relevance"],
    [
        ["Thyroid cartilage", "Echogenic; inverted V-shape anteriorly", "Landmark for CTM identification"],
        ["Cricothyroid membrane (CTM)", "Hypoechoic gap between thyroid & cricoid", "Surgical airway landmark"],
        ["Cricoid cartilage", "Echogenic ring; inferior to CTM", "Defines subglottic space"],
        ["Tracheal rings", "Hyperechoic anterior walls; posterior acoustic shadow", "Counting rings for tracheostomy level"],
        ["Trachea (lumen)", "Anechoic lumen behind rings; 'snowstorm' artifact from air", "Confirms tracheal vs oesophageal intubation"],
        ["Thyroid gland", "Bilateral echogenic; flanks trachea", "Avoidance during tracheostomy"],
        ["Oesophagus", "Posterior & lateral to trachea (usually left)", "Identifies oesophageal intubation"],
        ["Vocal cords", "Coronal view through thyroid cartilage; symmetrical hyperechoic bands", "Vocal cord mobility assessment"],
    ]
)

add_h2(doc, "Probe & Views")
add_table(doc,
    ["View", "Probe", "Frequency", "Best Used For"],
    [
        ["Transverse (cross-section)", "Linear", "7.5–15 MHz", "Trachea, CTM, oesophagus, ETT position"],
        ["Longitudinal (sagittal)", "Linear", "7.5–15 MHz", "Tracheal ring counting; tracheostomy planning"],
        ["Coronal (through thyroid cartilage)", "Linear", "7.5–15 MHz", "Vocal cord movement"],
        ["Subglottic transverse", "Linear", "7.5–15 MHz", "Tracheal diameter; ETT size selection"],
    ]
)

add_h2(doc, "Application 1: Pre-operative Airway Assessment")
add_box(doc, "Predicting Difficult Airway with Ultrasound", [
    "Pre-tracheal soft tissue thickness: >28 mm skin-to-trachea predicts difficult laryngoscopy (obese patients)",
    "Tongue base thickness: hyoid-to-mental distance correlates with Mallampati class",
    "Sublingual space (hyoid to floor of mouth): reduced in obesity — predicts difficult mask ventilation",
    "Anterior neck fat: quantifiable; relevant for bag-mask ventilation difficulty",
    "Neck circumference: identified on US; > 43 cm associated with difficult intubation",
], fill_rgb=BOX_FILL)

add_h2(doc, "Application 2: Cricothyroid Membrane (CTM) Identification")
add_box(doc, "Why Ultrasound CTM Identification Matters", [
    "Palpation-based CTM identification FAILS in up to 65% of cases — especially in obese & female patients",
    "Ultrasound reliably identifies CTM by the hypoechoic gap between thyroid and cricoid cartilages",
    "USEFUL Protocol: systematic scanning from thyroid notch to cricoid for CTM marking",
    "Pre-operative US marking of CTM recommended in anticipated difficult airways BEFORE induction",
    "Directly improves success rate of emergency cricothyrotomy in 'can't intubate, can't oxygenate' scenarios",
], fill_rgb=WARN_FILL)

add_h2(doc, "Application 3: ETT Placement Confirmation")
add_table(doc,
    ["Scenario", "US Finding", "Interpretation"],
    [
        ["Tracheal intubation", "Single 'double-tract sign' in trachea (hyperechoic lines)", "CORRECT — tracheal placement"],
        ["Oesophageal intubation", "Two 'double-tract signs': one in trachea + one in oesophagus (posterior-lateral)", "INCORRECT — pull back immediately"],
        ["Dynamic real-time view", "ETT tip visible passing through tracheal rings as hyperechoic area", "Real-time intubation confirmation"],
    ]
)
add_body(doc, "Sensitivity of ultrasound for detecting oesophageal intubation: 97–100%. Faster than clinical auscultation in noisy environments (ED, ICU).", indent=True)
add_body(doc, "Note: Capnography remains the GOLD STANDARD — ultrasound is a rapid adjunct, not a replacement.", indent=True)

add_h2(doc, "Application 4: Bilateral Lung Ventilation Confirmation")
add_box(doc, "Lung Ultrasound for Ventilation", [
    "Lung sliding sign (B-mode): pleural line shimmering bilaterally = bilateral ventilation confirmed",
    "Absent lung sliding on one side = endobronchial intubation or pneumothorax",
    "M-mode: SEASHORE SIGN = normal ventilation; BARCODE SIGN = no ventilation",
    "Sensitivity for endobronchial intubation: ~95%",
    "Diaphragm assessment: bilateral dome excursion confirms symmetric ventilation",
], fill_rgb=BOX_FILL)

add_h2(doc, "Application 5: ETT Size Selection (Subglottic Diameter)")
add_bullet(doc, "Transverse US view at subglottic level measures air-mucosa interface diameter")
add_bullet(doc, "ETT outer diameter should be ≤80% of tracheal internal diameter")
add_bullet(doc, "Especially useful in paediatric patients — reduces post-extubation stridor")
add_bullet(doc, "Reduces need for ETT exchange due to size mismatch")

add_h2(doc, "Application 6: Percutaneous Tracheostomy Guidance")
add_box(doc, "Ultrasound-Guided Percutaneous Tracheostomy", [
    "Identifies pre-tracheal vessels — avoids thyroid vessels and innominate artery puncture",
    "Confirms needle insertion between tracheal rings (not into thyroid or vessels)",
    "Real-time guidance for Seldinger wire placement",
    "Confirms intraluminal wire position before dilation",
    "Reduces pneumothorax, haemorrhage, and false passage complications",
], fill_rgb=BOX_FILL)

add_h2(doc, "Advantages vs Limitations")
add_table(doc,
    ["Advantages", "Limitations"],
    [
        ["Non-invasive, no radiation", "Operator dependent — needs training"],
        ["Real-time dynamic imaging", "Obesity/subcutaneous emphysema degrades image quality"],
        ["Bedside — OR, ICU, ED", "Cannot visualise larynx beyond vocal cords"],
        ["Detects oesophageal intubation (97–100%)", "Does NOT replace capnography (gold standard)"],
        ["CTM identification in obese patients", "Real-time intubation technically challenging"],
        ["Detects endobronchial intubation rapidly", "Limited evidence for difficult airway prediction vs clinical scoring"],
        ["No sedation or patient cooperation required", "Equipment cost and availability variable"],
    ]
)

add_h2(doc, "Summary Algorithm: Ultrasound in Airway Management")
add_box(doc, "STEP-BY-STEP APPROACH", [
    "PRE-OP: Assess anterior neck soft tissue; identify CTM; measure subglottic diameter",
    "  -> In obese/difficult airway: mark CTM under US before induction",
    "DURING INTUBATION: Real-time transverse neck view to confirm ETT in trachea",
    "POST-INTUBATION: Bilateral lung sliding to confirm bilateral ventilation",
    "IF DOUBT: Two-point scan (neck + lungs) takes < 30 seconds",
    "FOR TRACHEOSTOMY: Pre-procedural vessel mapping; real-time needle guidance",
    "EMERGENCY: Pre-marked CTM guides surgical airway in CICO scenario",
], fill_rgb=RGBColor(0xE8, 0xF4, 0xFD))

doc.add_page_break()

# ══════════════════════════════════════════════════════════
# TOPIC 4: HAI & VAP
# ══════════════════════════════════════════════════════════

add_h1(doc, "TOPIC 4: HOSPITAL ACQUIRED INFECTIONS & VENTILATOR ASSOCIATED PNEUMONIA")

add_h2(doc, "Hospital Acquired Infections (HAI) — Overview")
add_box(doc, "Definition of HAI (Nosocomial Infection)", [
    "Infection NOT present or incubating at time of hospital admission",
    "Develops 48 hours or more after admission",
    "May manifest up to 30 days post-discharge (or 1 year for implant-related infections)",
    "Types: VAP, CAUTI, CLABSI, SSI, C. difficile infection",
], fill_rgb=BOX_FILL)

add_table(doc,
    ["HAI Type", "Definition", "Common Organism"],
    [
        ["VAP", "Pneumonia ≥48 h after intubation", "S. aureus, Pseudomonas, Klebsiella"],
        ["HAP (non-ventilated)", "Pneumonia ≥48 h after admission (non-intubated)", "Same as VAP"],
        ["CAUTI", "UTI with urinary catheter in situ", "E. coli, Klebsiella, Candida"],
        ["CLABSI", "BSI with central venous catheter", "CoNS, S. aureus, Candida"],
        ["SSI", "Surgical site infection within 30 days", "S. aureus, E. coli, Enterococcus"],
    ]
)

add_h2(doc, "VENTILATOR ASSOCIATED PNEUMONIA (VAP)")

add_h3(doc, "Definition")
add_box(doc, "VAP — Clinical Definition", [
    "Pneumonia diagnosed 48 hours or more after endotracheal intubation",
    "Clinical criteria: New/progressive lung infiltrate PLUS 2 of the following:",
    "  1. Hyperthermia (>38°C) or hypothermia (<36°C)",
    "  2. WBC > 10,000/mm³ or leucopenia",
    "  3. Purulent tracheal secretions",
    "  4. Worsening oxygenation (rising FiO2 / falling SpO2)",
    "Early VAP: < 4 days — likely community-sensitive organisms",
    "Late VAP:  ≥ 5 days — higher risk of MDR organisms",
], fill_rgb=BOX_FILL)

add_h3(doc, "Epidemiology (High-Yield Numbers)")
add_box(doc, "Key Statistics to Memorise", [
    "VAP = most common HAI in ICU; accounts for 28% of ALL HAIs",
    "Mechanical ventilation increases pneumonia risk 20-FOLD",
    "~10% of mechanically ventilated patients develop VAP",
    "VAP rate: 14.8 cases per 1000 ventilator days (Canadian multicentre study)",
    "ICU mortality: 24.8%; In-hospital mortality: 31.9%",
    "Attributable ICU LOS increase: 4–13 days",
    "Additional hospitalisation cost: ~$39,828 per patient",
], fill_rgb=WARN_FILL)

add_h3(doc, "Pathophysiology / Causes")
add_body(doc, "Primary route: Aspiration of microorganisms colonising the oropharynx/aerodigestive tract into the lower respiratory tract in a host with impaired immunity.")
add_spacer(doc, 4)
add_box(doc, "Why Does Colonisation Increase in Hospitalised Patients?", [
    "Altered gastric pH from PPIs/H2-blockers (stress ulcer prophylaxis) -> gastric overgrowth",
    "Contaminated respiratory equipment and hospital water systems",
    "Healthcare worker hand transmission (most preventable route)",
    "Respiratory droplet spread of MDR organisms",
    "Disruption of normal oropharyngeal flora by broad-spectrum antibiotics",
    "Impaired host immunity: severity of illness, immunosuppression, malnutrition",
], fill_rgb=BOX_FILL)

add_h3(doc, "Microbiology (NHSN 2015–2017 Data)")
add_table(doc,
    ["Pathogen", "% Isolates", "Rank", "Key Note"],
    [
        ["Staphylococcus aureus (MRSA incl.)", "28.8%", "1st", "Most common; MRSA needs vancomycin/linezolid"],
        ["Pseudomonas aeruginosa", "12.9%", "2nd", "MDR common; anti-pseudomonal coverage needed"],
        ["Klebsiella species", "10.1%", "3rd", "ESBL possible; carbapenems if resistant"],
        ["Enterobacter species", "8.4%", "4th", "Inducible AmpC resistance"],
        ["Haemophilus influenzae", "5.9%", "5th", "Sensitive organisms; early VAP"],
        ["Escherichia coli", "5.6%", "7th", "ESBL strains increasing"],
        ["Acinetobacter species", "3.2%", "10th", "Highly MDR; outbreak risk in ICU"],
    ]
)
add_body(doc, "16.8% of all VAP isolates show resistance to ≥3 antibiotic classes (MDR).", indent=True)

add_h3(doc, "Risk Factors for VAP")
add_table(doc,
    ["Patient-Related Risk Factors", "Procedure/Environment-Related"],
    [
        ["Age > 60 years", "Duration of mechanical ventilation (most important)"],
        ["Altered consciousness / sedation", "Supine positioning (flat bed)"],
        ["Chronic lung disease (COPD, bronchiectasis)", "Nasotracheal intubation (vs orotracheal)"],
        ["ARDS prior to VAP", "Reintubation"],
        ["Immunosuppression / steroids", "Nasogastric tube (promotes aspiration)"],
        ["Prior IV antibiotics within 90 days", "Frequent ventilator circuit handling"],
        ["Septic shock at VAP onset", "Inadequate nurse-to-patient ratio"],
        ["Acute renal replacement therapy", "Indwelling vascular/urinary catheters"],
    ]
)

add_h2(doc, "PREVENTION OF VAP")

add_h3(doc, "VAP Prevention Bundle (IHI Ventilator Bundle)")
add_body(doc, "Bundle = simultaneous implementation of ALL measures (synergistic effect greater than individual interventions)")
add_table(doc,
    ["Prevention Strategy", "Evidence", "Notes"],
    [
        ["Semierect positioning (HOB 30–45°)", "Level 1 RCT", "Reduces micro-aspiration"],
        ["Oral chlorhexidine decontamination", "Level 1 RCT", "0.12% or 0.2% twice daily"],
        ["Orotracheal (not nasotracheal) intubation", "Level 1 RCT", "Nasotracheal promotes sinusitis + VAP"],
        ["Subglottic secretion drainage", "Level 1 RCT", "Special ETT with suction port above cuff"],
        ["Polyurethane ETT cuff (not PVC)", "Level 1 RCT", "Reduces micro-aspiration around cuff"],
        ["Silver-coated ETT", "Level 1 RCT", "Anti-biofilm; reduces early VAP"],
        ["Closed ETT suctioning system", "Level 1 RCT", "Prevents VAP from open suctioning"],
        ["Heat-moisture exchanger (HME)", "Level 1 RCT", "Replaces heated humidifier"],
        ["Rotational / kinetic beds", "Level 1 RCT", "Prevents secretion pooling"],
        ["Non-invasive ventilation (NIV) where possible", "Level 1 RCT", "Avoids intubation entirely"],
        ["Daily SAT + SBT protocol (minimise vent days)", "Level 1 RCT", "Every day on vent = VAP risk"],
        ["Daily sedation vacation (SAT)", "Level 2", "Allows neuro assessment; speeds extubation"],
        ["Avoid reintubation", "Level 2", "Each reintubation recontaminates airway"],
        ["Orogastric (not nasogastric) feeding tube", "Level 2", "Reduces sinusitis and aspiration"],
        ["Restricted blood transfusion", "Level 2", "Immunosuppressive effects of transfusion"],
    ]
)

add_box(doc, "NOT RECOMMENDED for VAP Prevention", [
    "Routine ventilator circuit changes (increases VAP risk by disturbing biofilm)",
    "Chest physiotherapy (no benefit for VAP prevention)",
    "Early tracheostomy (no VAP benefit; only improves patient comfort)",
    "Routine antibiotic cycling/rotation (promotes MDR selection)",
    "Routine antibiotic prophylaxis (causes MDR organisms)",
    "Specific stress ulcer prophylaxis regimen over another",
], fill_rgb=WARN_FILL)

add_h2(doc, "MANAGEMENT OF VAP")

add_h3(doc, "Step 1: Diagnosis")
add_box(doc, "CPIS Score (Clinical Pulmonary Infection Score) — Score > 6 suggests VAP", [
    "Temperature: 36.5–38.4°C = 0; 38.5–38.9°C = 1; ≥39 or ≤36 = 2",
    "WBC: 4000–11000 = 0; <4000 or >11000 = 1; + band forms >50% = +1",
    "Tracheal secretions: none = 0; non-purulent = 1; purulent = 2",
    "Oxygenation (PaO2/FiO2): >240 or ARDS = 0; ≤240 and no ARDS = 2",
    "Chest X-ray: no infiltrate = 0; diffuse = 1; localised = 2",
    "Culture of tracheal aspirate: negative = 0; positive = 1 or 2",
], fill_rgb=BOX_FILL)

add_h3(doc, "Microbiological Sampling (Quantitative Culture Thresholds)")
add_table(doc,
    ["Method", "CFU Threshold", "Notes"],
    [
        ["Bronchoscopic BAL", "≥10⁴ CFU/mL", "Gold standard; highest specificity"],
        ["Protected Specimen Brush (PSB)", "≥10³ CFU/mL", "Bronchoscopic; reduces contamination"],
        ["Non-bronchoscopic (mini) BAL", "≥10⁴ CFU/mL", "Bedside; no bronchoscopy needed"],
        ["Endotracheal aspirate", "≥10⁵–10⁶ CFU/mL", "Most available; lower specificity"],
    ]
)

add_h3(doc, "Step 2: Empirical Antibiotic Selection")
add_body(doc, "FIRST: Assess risk for MDR organisms", indent=False)
add_spacer(doc,3)
add_box(doc, "Risk Factors for MDR VAP", [
    "Prior IV antibiotics within 90 days",
    "Hospitalisation ≥ 5 days at time of VAP",
    "Septic shock at VAP onset",
    "ARDS prior to VAP onset",
    "Acute renal replacement therapy",
    "Residence in LTAC / skilled nursing facility",
], fill_rgb=WARN_FILL)
add_spacer(doc,4)
add_table(doc,
    ["Risk Category", "Antibiotic Regimen"],
    [
        ["Low MDR risk (early VAP, no risk factors)", "Monotherapy: Piperacillin-tazobactam OR Cefepime OR Levofloxacin OR Meropenem"],
        ["High MDR risk (late VAP / risk factors present)", "MRSA coverage: Vancomycin OR Linezolid\nPLUS Anti-pseudomonal beta-lactam: Pip-tazo / Cefepime / Carbapenem\nPLUS (if double GN needed): Aminoglycoside OR Ciprofloxacin"],
        ["MRSA-confirmed or high local prevalence", "Vancomycin (trough 15–20 mg/L) OR Linezolid 600 mg BD"],
    ]
)
add_body(doc, "KEY: Failure to initiate APPROPRIATE antibiotics promptly = independent predictor of mortality. Regimen change needed in 43.7% of VAP cases in one large Spanish multicentre study.", indent=True)

add_h3(doc, "Step 3: Duration & De-escalation")
add_box(doc, "Antibiotic Duration Principles", [
    "7–8 day course is as effective as 14–21 days for most VAP (IDSA/ATS 2016)",
    "Procalcitonin-guided de-escalation reduces antibiotic duration without worsening outcomes",
    "After 48–72 h: review cultures; NARROW to targeted therapy",
    "De-escalation reduces MDR emergence, costs, and adverse effects",
    "Prolonged therapy only for: Pseudomonas, Acinetobacter, non-fermenting GNB (10–14 days)",
], fill_rgb=KEY_FILL)

add_h3(doc, "Step 4: Supportive Management")
add_bullet(doc, "Lung-protective ventilation: TV 6 mL/kg IBW; plateau pressure < 30 cmH2O")
add_bullet(doc, "Prone positioning if concurrent ARDS (> 12 h/day)")
add_bullet(doc, "Continue VAP prevention bundle measures throughout ICU stay")
add_bullet(doc, "Nutritional support: enteral feeding preferred; avoid parenteral")
add_bullet(doc, "Glycaemic control: target 140–180 mg/dL (avoid hypoglycaemia)")
add_bullet(doc, "DVT prophylaxis: LMWH or UFH; compression stockings")

add_h2(doc, "Quick Summary: VAP at a Glance")
add_table(doc,
    ["Parameter", "Value / Key Point"],
    [
        ["Definition", "Pneumonia ≥48 h after intubation"],
        ["Most common pathogen", "Staphylococcus aureus (28.8%)"],
        ["Incidence", "~10% of ventilated patients; 14.8/1000 vent-days"],
        ["Most important risk factor", "Duration of mechanical ventilation"],
        ["Most important prevention", "Minimise ventilator days (daily SBT + SAT)"],
        ["Best diagnostic sample", "Bronchoscopic BAL (≥10⁴ CFU/mL)"],
        ["Antibiotic duration", "7–8 days (most cases)"],
        ["Attributable mortality", "1–27% (wide range; confounded by severity)"],
        ["Additional cost per case", "~$39,828 USD"],
        ["IDSA/ATS Guideline Year", "2016 (most recent major guideline)"],
    ]
)

add_spacer(doc, 12)
add_divider(doc)

# Footer note
p_footer = doc.add_paragraph()
p_footer.alignment = WD_ALIGN_PARAGRAPH.CENTER
r_footer = p_footer.add_run("Sources: Miller's Anesthesia 10e | Morgan & Mikhail's Clinical Anesthesiology 7e | Barash Clinical Anesthesia 9e | Fishman's Pulmonary Diseases & Disorders 6e | IDSA/ATS VAP Guidelines 2016")
r_footer.font.size = Pt(8.5)
r_footer.font.color.rgb = RGBColor(0x88, 0x88, 0x88)
r_footer.font.name = "Arial"
r_footer.italic = True

# ──────────────────────────────────────────────
# SAVE
# ──────────────────────────────────────────────
out_path = "/tmp/workspace/anaesthesia-study-guide/Anaesthesia_Quick_Revision_Guide.docx"
doc.save(out_path)
print(f"Saved: {out_path}")