Brain death in MD Anesthesia ppt

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Running Command

mkdir -p /home/daytona/workspace/brain-death-ppt && ls /home/daytona/workspace/brain-death-ppt/

Retry

Reading File

Finding Sources

Reading File

Writing File

~/brain-death-ppt/brain_death.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" × 7.5"
pres.author = "MD Anesthesia";
pres.title = "Brain Death";

// ─── COLOR PALETTE ───────────────────────────────────────────
const C = {
  navy:    "0A1628",   // dominant dark background
  teal:    "0D7377",   // accent headers
  ltTeal:  "14A085",   // sub-accent
  gold:    "F2A900",   // highlight / accent
  white:   "FFFFFF",
  lt:      "E8F4F8",   // light content bg
  grey:    "B0BEC5",   // muted text
  red:     "D32F2F",
  orange:  "E65100",
  green:   "1B5E20",
};

// ─── HELPERS ─────────────────────────────────────────────────
function addSlide(bgColor = C.navy) {
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: bgColor } });
  return s;
}

function sectionHeader(slide, title, subtitle = "") {
  // Left accent bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.12, h: 7.5, fill: { color: C.gold } });
  slide.addText(title, {
    x: 0.3, y: 2.8, w: 12.7, h: 1.2,
    fontSize: 40, bold: true, color: C.white, fontFace: "Calibri", align: "center",
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.3, y: 4.1, w: 12.7, h: 0.7,
      fontSize: 22, color: C.gold, fontFace: "Calibri", align: "center", italic: true,
    });
  }
}

function slideTitle(slide, title) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 1.1, fill: { color: C.teal } });
  slide.addText(title, {
    x: 0.35, y: 0.1, w: 12.6, h: 0.9,
    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", valign: "middle",
  });
  // footer line
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 7.2, w: 13.3, h: 0.3, fill: { color: C.teal } });
  slide.addText("MD Anesthesia  |  Brain Death", {
    x: 0.3, y: 7.2, w: 12.7, h: 0.3,
    fontSize: 9, color: C.white, fontFace: "Calibri", align: "right", valign: "middle",
  });
}

function bullets(slide, items, opts = {}) {
  const defaults = { x: 0.4, y: 1.25, w: 12.5, h: 5.7, fontSize: 17, color: C.white, fontFace: "Calibri", valign: "top", paraSpaceAfter: 6 };
  const merged = Object.assign({}, defaults, opts);
  const richItems = [];
  items.forEach((item, i) => {
    const isLast = i === items.length - 1;
    if (typeof item === "string") {
      richItems.push({ text: item, options: { bullet: { color: C.gold, indent: 15 }, breakLine: !isLast, paraSpaceAfter: 6 } });
    } else {
      // { text, sub, bold, color }
      richItems.push({ text: item.text, options: { bullet: { color: C.gold, indent: 15 }, breakLine: true, bold: item.bold || false, color: item.color || C.white, paraSpaceAfter: 4 } });
      if (item.sub) {
        item.sub.forEach((s, si) => {
          const lastSub = si === item.sub.length - 1;
          richItems.push({ text: "  \u2013  " + s, options: { bullet: false, breakLine: !(lastSub && isLast), color: C.grey, fontSize: 15, paraSpaceAfter: 3 } });
        });
      }
    }
  });
  slide.addText(richItems, merged);
}

function twoCol(slide, leftItems, rightItems, leftHeader, rightHeader) {
  // left column
  slide.addShape(pres.ShapeType.rect, { x: 0.35, y: 1.15, w: 5.9, h: 6.0, fill: { color: "0F2337" }, line: { color: C.teal, width: 1 } });
  slide.addText(leftHeader, { x: 0.35, y: 1.15, w: 5.9, h: 0.45, fontSize: 14, bold: true, color: C.gold, fontFace: "Calibri", align: "center", fill: { color: C.teal } });
  const lRich = leftItems.map((t, i) => ({ text: t, options: { bullet: { color: C.gold }, breakLine: i < leftItems.length - 1, paraSpaceAfter: 5, fontSize: 15, color: C.white } }));
  slide.addText(lRich, { x: 0.45, y: 1.65, w: 5.7, h: 5.4, fontFace: "Calibri", valign: "top" });

  // right column
  slide.addShape(pres.ShapeType.rect, { x: 6.65, y: 1.15, w: 6.3, h: 6.0, fill: { color: "0F2337" }, line: { color: C.ltTeal, width: 1 } });
  slide.addText(rightHeader, { x: 6.65, y: 1.15, w: 6.3, h: 0.45, fontSize: 14, bold: true, color: C.gold, fontFace: "Calibri", align: "center", fill: { color: C.ltTeal } });
  const rRich = rightItems.map((t, i) => ({ text: t, options: { bullet: { color: C.ltTeal }, breakLine: i < rightItems.length - 1, paraSpaceAfter: 5, fontSize: 15, color: C.white } }));
  slide.addText(rRich, { x: 6.75, y: 1.65, w: 6.1, h: 5.4, fontFace: "Calibri", valign: "top" });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  // decorative gradient blocks
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.4, h: 7.5, fill: { color: C.gold } });
  s.addShape(pres.ShapeType.rect, { x: 12.9, y: 0, w: 0.4, h: 7.5, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 5.8, w: 12.5, h: 1.7, fill: { color: C.teal } });

  s.addText("BRAIN DEATH", {
    x: 0.6, y: 1.3, w: 12.1, h: 1.8,
    fontSize: 66, bold: true, color: C.white, fontFace: "Calibri",
    charSpacing: 8, align: "center",
  });
  s.addText("An Anesthesiologist's Perspective", {
    x: 0.6, y: 3.1, w: 12.1, h: 0.7,
    fontSize: 26, color: C.gold, fontFace: "Calibri", align: "center", italic: true,
  });
  s.addText("Definition  ·  Pathophysiology  ·  Diagnosis  ·  Ancillary Tests  ·  Management  ·  Organ Donation", {
    x: 0.6, y: 3.9, w: 12.1, h: 0.5,
    fontSize: 14, color: C.grey, fontFace: "Calibri", align: "center",
  });
  s.addText("MD ANESTHESIA  |  2026", {
    x: 0.6, y: 6.0, w: 12.1, h: 0.5,
    fontSize: 16, bold: true, color: C.white, fontFace: "Calibri", align: "center",
    charSpacing: 4,
  });
  s.addText("Sources: Miller's Anesthesia 10e · Plum & Posner · Bradley & Daroff's Neurology · Harrison's IM 22e", {
    x: 0.6, y: 6.6, w: 12.1, h: 0.4,
    fontSize: 10, color: C.grey, fontFace: "Calibri", align: "center", italic: true,
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 2 — CONTENTS
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Contents");
  const items = [
    "1.  Definition & History",
    "2.  Prerequisites Before Testing",
    "3.  Common Etiologies",
    "4.  Clinical Criteria (Harvard → AAN)",
    "5.  Brainstem Reflex Examination",
    "6.  Apnea Test — Step-by-Step",
    "7.  Pathophysiology of Brain Death",
    "8.  Ancillary / Confirmatory Tests",
    "9.  Pitfalls & Confounders",
    "10. Management of the Brain-Dead Donor",
    "11. Organ Donation — DBD vs DCD",
    "12. Ethical, Legal & Cultural Considerations",
  ];
  bullets(s, items, { fontSize: 18, y: 1.3, h: 5.8 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 3 — SECTION: DEFINITION & HISTORY
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "DEFINITION & HISTORY", "Section 1");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 4 — DEFINITION
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Definition of Brain Death");

  // Highlight box
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.2, w: 12.5, h: 1.3, fill: { color: C.teal }, line: { color: C.gold, width: 2 } });
  s.addText('"Irreversible cessation of all cerebral and brainstem function, with preservation of cardiac activity and maintenance of respiratory and somatic function by artificial means."', {
    x: 0.55, y: 1.25, w: 12.2, h: 1.2,
    fontSize: 17, italic: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
  });
  s.addText("— Harrison's Principles of Internal Medicine 22e", {
    x: 0.55, y: 2.55, w: 12.2, h: 0.3,
    fontSize: 11, italic: true, color: C.grey, fontFace: "Calibri", align: "right",
  });

  bullets(s, [
    "The ONLY type of brain damage recognized as morally, ethically, and legally equivalent to death",
    "Accepted standard: Uniform Determination of Death Act (UDDA) — USA",
    "Requires: irreversible loss of ALL functions of the ENTIRE brain including brainstem",
    "Patient appears well-perfused with cardiac monitor activity — brain is not",
    "Medically and legally accepted in most countries; cultural/religious variation exists",
  ], { y: 2.9, h: 4.0 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 5 — HISTORY
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Historical Milestones");

  const timeline = [
    { year: "1959", event: "Mollaret & Goulon describe 'coma dépassé' — beyond coma" },
    { year: "1967", event: "First cardiac transplant by Dr. Christiaan Barnard (South Africa)" },
    { year: "1968", event: "Harvard Ad Hoc Committee defines 'irreversible coma' — Harvard Criteria published" },
    { year: "1980", event: "Uniform Determination of Death Act (UDDA) adopted — USA" },
    { year: "1995", event: "AAN Practice Parameters for brain death determination published" },
    { year: "2010", event: "AAN updated Evidence-Based Guidelines (Wijdicks et al.)" },
    { year: "2019", event: "AAN further refinement of adult brain death guidelines (Wijdicks)" },
    { year: "2023", event: "International efforts toward globally accepted minimum standard criteria" },
  ];

  const startY = 1.25;
  timeline.forEach((item, i) => {
    const y = startY + i * 0.72;
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 1.2, h: 0.52, fill: { color: C.teal }, line: { color: C.gold, width: 1 } });
    s.addText(item.year, { x: 0.35, y, w: 1.2, h: 0.52, fontSize: 14, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addShape(pres.ShapeType.rect, { x: 1.55, y: y + 0.23, w: 0.5, h: 0.05, fill: { color: C.gold } });
    s.addText(item.event, { x: 2.1, y: y + 0.02, w: 10.8, h: 0.52, fontSize: 15, color: C.white, fontFace: "Calibri", valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 6 — SECTION: PREREQUISITES
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "PREREQUISITES", "Section 2  |  Before Clinical Testing");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 7 — PREREQUISITES
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Prerequisites Before Brain Death Evaluation");

  // Two columns
  const left = [
    "Irreversible cause of coma must be ESTABLISHED",
    "Neuroimaging (CT/MRI) shows structural lesion consistent with brain death",
    "No potentially anesthetizing toxins or therapeutic drugs",
    "No neuromuscular blocking agents",
    "Core temperature ≥ 36°C (hypothermia excluded)",
  ];
  const right = [
    "No severe electrolyte / acid-base disturbance",
    "SBP ≥ 100 mmHg — adequate systemic perfusion",
    "No metabolic encephalopathy mimicking brain death",
    "History of sedatives, analgesics, or CNS depressants reviewed and excluded",
    "Delay testing ≥ 24 h if cause unknown or post-cardiac arrest",
  ];
  twoCol(s, left, right, "CLINICAL PREREQUISITES", "PHYSIOLOGIC PREREQUISITES");

  s.addText("⚠  If ANY confounder cannot be fully excluded — proceed to ancillary testing", {
    x: 0.35, y: 6.65, w: 12.6, h: 0.4,
    fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri", align: "center",
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 8 — ETIOLOGIES
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Common Etiologies of Brain Death");

  const causes = [
    { label: "Severe TBI", pct: "Most common", color: C.red },
    { label: "Aneurysmal SAH", pct: "Common", color: C.orange },
    { label: "Massive IPH", pct: "Common", color: C.orange },
    { label: "Anoxic-Ischemic Injury", pct: "Less common", color: C.ltTeal },
    { label: "Fulminant Hepatic Failure", pct: "Rare", color: C.teal },
    { label: "Brain Abscess / Meningitis", pct: "Rare", color: C.teal },
  ];

  causes.forEach((c, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.4 : 6.9;
    const y = 1.3 + row * 1.72;
    s.addShape(pres.ShapeType.rect, { x, y, w: 6.0, h: 1.5, fill: { color: "0F2337" }, line: { color: c.color, width: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 6.0, h: 0.38, fill: { color: c.color } });
    s.addText(c.label, { x, y, w: 6.0, h: 0.38, fontSize: 14, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(c.pct, { x, y: y + 0.42, w: 6.0, h: 1.0, fontSize: 18, color: C.grey, fontFace: "Calibri", align: "center", valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 9 — SECTION: CLINICAL CRITERIA
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "CLINICAL CRITERIA", "Section 3  |  Harvard → AAN Guidelines");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 10 — HARVARD CRITERIA (1968)
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Harvard Criteria 1968 — Original Definition");

  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.2, w: 12.5, h: 0.45, fill: { color: C.teal } });
  s.addText("Ad Hoc Committee, Harvard Medical School  |  JAMA 1968", {
    x: 0.4, y: 1.2, w: 12.5, h: 0.45,
    fontSize: 14, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
  });

  const criteria = [
    ["1", "Unreceptivity & Unresponsiveness", "No awareness; no response to intensely painful stimuli"],
    ["2", "No Movements or Breathing", "No spontaneous muscular movement; no spontaneous respiration"],
    ["3", "No Reflexes", "Absence of cephalic reflexes (pupils, oculovestibular, etc.)"],
    ["4", "Absence of Spinal Reflexes", "No tendon reflexes"],
    ["5", "Flat EEG", "Isoelectric electroencephalogram — electrocerebral inactivity"],
    ["6", "Repeat Testing", "All tests repeated at least 24 hours later with no change"],
  ];

  criteria.forEach(([num, title, desc], i) => {
    const y = 1.75 + i * 0.87;
    s.addShape(pres.ShapeType.rect, { x: 0.4, y, w: 0.55, h: 0.7, fill: { color: C.gold } });
    s.addText(num, { x: 0.4, y, w: 0.55, h: 0.7, fontSize: 22, bold: true, color: C.navy, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(title, { x: 1.05, y, w: 4.5, h: 0.7, fontSize: 16, bold: true, color: C.ltTeal, fontFace: "Calibri", valign: "middle" });
    s.addText(desc, { x: 5.7, y, w: 7.2, h: 0.7, fontSize: 14, color: C.grey, fontFace: "Calibri", valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 11 — AAN CLINICAL CRITERIA (ADULTS)
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "AAN Clinical Criteria — Adults (Updated 2010/2019)");

  // 3 boxes
  const boxes = [
    {
      header: "A  |  Coma of Established Cause",
      color: C.red,
      items: [
        "Irreversible structural / metabolic cause documented",
        "No anesthetizing amounts of toxins or therapeutic drugs",
        "No hypothermia (< 36°C)",
        "Physiologic abnormalities corrected to extent possible",
      ],
    },
    {
      header: "B  |  Absent Brainstem Reflexes",
      color: C.teal,
      items: [
        "No pupillary light response — pupils 4–6 mm mid-position",
        "No corneal reflex bilaterally",
        "No caloric vestibulo-ocular reflex (ice-water)",
        "No gag / cough reflex",
        "No motor response to deep painful stimuli",
        "Apnea — no respiratory drive at PaCO₂ ≥ 60 mmHg",
      ],
    },
    {
      header: "C  |  Observation Interval",
      color: C.ltTeal,
      items: [
        "Term–2 months: 48 hours + 2 confirmatory tests",
        ">2 months–1 year: 24 hours + 1 confirmatory test",
        ">1 year–<18 years: 12 hours ± optional confirmatory",
        "≥18 years: optional repeat exam; confirmatory optional",
      ],
    },
  ];

  boxes.forEach((box, i) => {
    const x = 0.35 + i * 4.3;
    s.addShape(pres.ShapeType.rect, { x, y: 1.15, w: 4.1, h: 5.9, fill: { color: "0F2337" }, line: { color: box.color, width: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y: 1.15, w: 4.1, h: 0.5, fill: { color: box.color } });
    s.addText(box.header, { x, y: 1.15, w: 4.1, h: 0.5, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    const rich = box.items.map((t, j) => ({ text: t, options: { bullet: { color: C.gold }, breakLine: j < box.items.length - 1, paraSpaceAfter: 6, fontSize: 13, color: C.white } }));
    s.addText(rich, { x: x + 0.1, y: 1.72, w: 3.9, h: 5.2, fontFace: "Calibri", valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 12 — BRAINSTEM REFLEXES IN DETAIL
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Brainstem Reflex Examination — Technique");

  const reflexes = [
    { reflex: "Pupillary Light", technique: "Bright flashlight both eyes", expected: "Fixed, non-reactive; 4–6 mm (mid-dilated)", note: "Constricted pupils → opioid effect?" },
    { reflex: "Corneal", technique: "Cotton/swab to cornea", expected: "No blink response bilaterally", note: "" },
    { reflex: "Oculovestibular (Caloric)", technique: "30° HOB elevation; 50 mL ice water each ear; observe 1 min; wait 5 min between sides", expected: "No eye deviation (dead)", note: "Comatose non-brain-dead: eyes deviate toward cold" },
    { reflex: "Oculocephalic (Doll's Eyes)", technique: "Rapid head turning (if no cervical injury)", expected: "No eye movement (absent)", note: "Not reliable if c-spine injury suspected" },
    { reflex: "Gag / Cough", technique: "Posterior oropharynx stimulation; suction to carina", expected: "No gag; no cough", note: "" },
    { reflex: "Motor Response", technique: "Deep pressure: TMJ, supraorbital notch, nail-beds, sternal rub", expected: "No grimace, no motor response in limbs", note: "Spinal reflexes may persist — do NOT confound" },
  ];

  const startY = 1.2;
  const rowH = 0.97;

  // header row
  ["REFLEX", "TECHNIQUE", "EXPECTED IN BRAIN DEATH", "NOTE"].forEach((h, i) => {
    const xs = [0.3, 2.0, 5.8, 10.2];
    const ws = [1.6, 3.6, 4.2, 3.0];
    s.addShape(pres.ShapeType.rect, { x: xs[i], y: startY, w: ws[i], h: 0.45, fill: { color: C.teal } });
    s.addText(h, { x: xs[i], y: startY, w: ws[i], h: 0.45, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  reflexes.forEach((r, i) => {
    const y = startY + 0.45 + i * rowH;
    const bg = i % 2 === 0 ? "0F2337" : "0A1A2A";
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 12.9, h: rowH - 0.05, fill: { color: bg } });
    s.addText(r.reflex, { x: 0.35, y: y + 0.05, w: 1.55, h: rowH - 0.15, fontSize: 13, bold: true, color: C.ltTeal, fontFace: "Calibri", valign: "middle" });
    s.addText(r.technique, { x: 2.05, y: y + 0.05, w: 3.55, h: rowH - 0.15, fontSize: 12, color: C.white, fontFace: "Calibri", valign: "middle" });
    s.addText(r.expected, { x: 5.85, y: y + 0.05, w: 4.1, h: rowH - 0.15, fontSize: 12, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(r.note, { x: 10.25, y: y + 0.05, w: 2.9, h: rowH - 0.15, fontSize: 11, color: C.grey, fontFace: "Calibri", valign: "middle", italic: true });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 13 — APNEA TEST
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Apnea Test — Step-by-Step Protocol");

  const steps = [
    { n: "1", text: "Prerequisites: SBP ≥ 100 mmHg, Temp ≥ 36.5°C, normovolemia, PaCO₂ 35–45 mmHg, PaO₂ > 200 mmHg" },
    { n: "2", text: "Pre-oxygenate with 100% FiO₂ for ≥ 10 minutes" },
    { n: "3", text: "Baseline ABG — confirm PaCO₂ ~ 40 mmHg" },
    { n: "4", text: "Disconnect ventilator; deliver O₂ 6 L/min via T-piece / insufflation catheter to carina" },
    { n: "5", text: "Observe for 8–10 minutes for any respiratory effort (chest or abdominal movement)" },
    { n: "6", text: "CO₂ rises ~2–3 mmHg/min during apnea" },
    { n: "7", text: "Positive test: NO breathing effort when PaCO₂ ≥ 60 mmHg (or ≥ 20 mmHg rise above baseline)" },
    { n: "8", text: "Reconnect ventilator; draw ABG to confirm PaCO₂ target achieved" },
  ];

  steps.forEach((step, i) => {
    const y = 1.25 + i * 0.75;
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 0.55, h: 0.6, fill: { color: C.teal } });
    s.addText(step.n, { x: 0.35, y, w: 0.55, h: 0.6, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addShape(pres.ShapeType.rect, { x: 1.0, y, w: 11.95, h: 0.6, fill: { color: i % 2 === 0 ? "0F2337" : "0A1A2A" } });
    s.addText(step.text, { x: 1.1, y: y + 0.05, w: 11.8, h: 0.5, fontSize: 14, color: C.white, fontFace: "Calibri", valign: "middle" });
  });

  s.addText("ABORT test if: SBP < 90 mmHg, SpO₂ < 85%, severe arrhythmia → proceed to ANCILLARY testing", {
    x: 0.35, y: 7.15, w: 12.6, h: 0.28,
    fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri", align: "center",
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 14 — SECTION: PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "PATHOPHYSIOLOGY", "Section 4  |  Systemic Effects of Brain Death");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 15 — PATHOPHYSIOLOGY TABLE
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Pathophysiologic Changes with Brain Death  (Miller's Anesthesia 10e, Table 57.1)");

  const rows = [
    ["Hypertension", "Catecholamine storm (Phase 1)", "80–90%", C.red],
    ["Hypotension", "Vasoplegia, hypovolemia, myocardial dysfunction (Phase 2)", "80–90%", C.orange],
    ["Bradycardia / Arrhythmias", "Catecholamine storm, myocardial damage", "25–30%", C.orange],
    ["Pulmonary Edema", "Acute blood volume shift, capillary damage", "10–20%", C.ltTeal],
    ["Diabetes Insipidus", "Posterior pituitary damage", "45–80%", C.red],
    ["DIC", "Tissue thromboplastin release from brain tissue", "30–55%", C.orange],
    ["Hypothermia", "Hypothalamic damage, reduced metabolism, vasodilation", "Variable", C.teal],
    ["Hyperglycemia", "Decreased insulin, increased insulin resistance", "Common", C.ltTeal],
  ];

  const headers = ["SIGN / SYMPTOM", "PATHOPHYSIOLOGY", "INCIDENCE"];
  const xs = [0.3, 4.5, 11.2];
  const ws = [4.0, 6.5, 1.9];

  headers.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x: xs[i], y: 1.15, w: ws[i], h: 0.4, fill: { color: C.teal } });
    s.addText(h, { x: xs[i], y: 1.15, w: ws[i], h: 0.4, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  rows.forEach((row, i) => {
    const y = 1.55 + i * 0.68;
    const bg = i % 2 === 0 ? "0F2337" : "0A1A2A";
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 12.8, h: 0.65, fill: { color: bg } });
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 0.07, h: 0.65, fill: { color: row[3] } });
    s.addText(row[0], { x: 0.45, y, w: 3.9, h: 0.65, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    s.addText(row[1], { x: 4.55, y, w: 6.4, h: 0.65, fontSize: 13, color: C.grey, fontFace: "Calibri", valign: "middle" });
    s.addText(row[2], { x: 11.25, y, w: 1.8, h: 0.65, fontSize: 13, color: row[3], fontFace: "Calibri", align: "center", valign: "middle", bold: true });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 16 — CARDIOVASCULAR PHASES
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Cardiovascular Response — Two Phases");

  // Phase 1 box
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 1.2, w: 6.0, h: 5.6, fill: { color: "0F2337" }, line: { color: C.red, width: 2 } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 1.2, w: 6.0, h: 0.5, fill: { color: C.red } });
  s.addText("PHASE 1  —  Catecholamine Storm", { x: 0.35, y: 1.2, w: 6.0, h: 0.5, fontSize: 15, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  const p1 = [
    "Massive sympathetic discharge",
    "↑↑ Systemic vascular resistance",
    "Hypertensive crisis (SBP > 200 mmHg)",
    "Tachycardia",
    "Redistribution of blood → visceral ischemia",
    "Acute myocardial injury (no prior CAD)",
    "Echo: myocardial dysfunction in 40% of donors",
    "Transient — progresses rapidly to Phase 2",
  ];
  const r1 = p1.map((t, i) => ({ text: t, options: { bullet: { color: C.red }, breakLine: i < p1.length - 1, paraSpaceAfter: 5, fontSize: 14, color: C.white } }));
  s.addText(r1, { x: 0.45, y: 1.78, w: 5.8, h: 4.9, fontFace: "Calibri", valign: "top" });

  // Phase 2 box
  s.addShape(pres.ShapeType.rect, { x: 6.95, y: 1.2, w: 6.0, h: 5.6, fill: { color: "0F2337" }, line: { color: C.teal, width: 2 } });
  s.addShape(pres.ShapeType.rect, { x: 6.95, y: 1.2, w: 6.0, h: 0.5, fill: { color: C.teal } });
  s.addText("PHASE 2  —  Vasoplegic Collapse", { x: 6.95, y: 1.2, w: 6.0, h: 0.5, fontSize: 15, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  const p2 = [
    "Loss of ALL sympathetic tone",
    "Severe peripheral vasoplegia",
    "↓↓ Cardiac output",
    "Blunted hemostatic responses",
    "Exacerbated by: blood loss, DI, capillary leakage, osmotherapy",
    "Profound and SUSTAINED hypotension",
    "Cerebral herniation + spinal cord ischemia responsible",
    "Failure to correct → organ ischemia → loss of donated organs",
  ];
  const r2 = p2.map((t, i) => ({ text: t, options: { bullet: { color: C.ltTeal }, breakLine: i < p2.length - 1, paraSpaceAfter: 5, fontSize: 14, color: C.white } }));
  s.addText(r2, { x: 7.05, y: 1.78, w: 5.8, h: 4.9, fontFace: "Calibri", valign: "top" });

  // Arrow
  s.addShape(pres.ShapeType.rect, { x: 6.2, y: 3.7, w: 0.7, h: 0.1, fill: { color: C.gold } });
  s.addText("→", { x: 6.05, y: 3.45, w: 1.0, h: 0.5, fontSize: 28, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 17 — ENDOCRINE & RESPIRATORY PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Endocrine, Metabolic & Respiratory Effects");

  twoCol(
    s,
    [
      "Pituitary failure — posterior + anterior",
      "Central Diabetes Insipidus in up to 90%",
      "↓ T3, T4 (euthyroid sick-like syndrome)",
      "↓ ACTH, TSH, Growth Hormone",
      "Hyperglycemia — ↓ insulin + ↑ resistance",
      "Hypothermia — hypothalamic damage",
      "DIC — tissue thromboplastin release",
    ],
    [
      "↑ SVR → blood shifted to pulmonary circulation",
      "Hydrostatic pulmonary edema",
      "Sterile systemic inflammatory response",
      "Neutrophil infiltration → ↑ pulmonary endothelial permeability",
      "Pro-inflammatory cytokines → early graft failure",
      "Alveolar fluid clearance impaired",
      "Apnea → cardiac arrest if ventilation withdrawn",
    ],
    "ENDOCRINE / METABOLIC",
    "RESPIRATORY"
  );
}

// ═══════════════════════════════════════════════════════════
// SLIDE 18 — SECTION: ANCILLARY TESTS
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "ANCILLARY / CONFIRMATORY TESTS", "Section 5  |  When Bedside Exam is Insufficient");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 19 — ANCILLARY TESTS
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Ancillary Tests for Brain Death Confirmation");

  s.addText("REQUIRED WHEN  clinical exam cannot be completed (e.g., facial trauma, cervical instability, unable to do safe apnea test)", {
    x: 0.35, y: 1.15, w: 12.6, h: 0.45,
    fontSize: 13, bold: false, color: C.gold, fontFace: "Calibri", align: "center", italic: true,
  });

  const tests = [
    {
      name: "EEG",
      detail: "Isoelectric (flat) pattern = electrocerebral inactivity\nOptional in adults; useful if exam incomplete\nDoes NOT confirm cessation of blood flow",
      pro: "Widely available",
      con: "Drug interference; technical artefact",
      color: C.teal,
    },
    {
      name: "Cerebral Angiography",
      detail: "Gold standard\nNo intracranial filling at entry of carotid + vertebral arteries\n= absent cerebral circulation",
      pro: "Most reliable",
      con: "Invasive, contrast load",
      color: C.ltTeal,
    },
    {
      name: "Transcranial Doppler (TCD)",
      detail: "Reverberating / to-and-fro waveforms or absent flow\nPortable, bedside, non-invasive\nRequires adequate temporal window",
      pro: "Non-invasive, portable",
      con: "Operator dependent; inadequate window in 10%",
      color: C.gold,
    },
    {
      name: "CT Angiography (CTA)",
      detail: "Non-filling of intracranial vessels\nEmerging as preferred alternative in many centres\nMay show residual flow despite clinical brain death",
      pro: "Fast, widely available",
      con: "Persistent flow possible — false negative",
      color: C.orange,
    },
    {
      name: "Radionuclide Scintigraphy (HMPAO-SPECT)",
      detail: "No cerebral perfusion = 'hollow skull' sign\nConsidered more reliable than CTA in some studies\nMandatory in Israel (2009 Brain Death Act)",
      pro: "Highly specific",
      con: "Nuclear medicine availability; time-consuming",
      color: C.ltTeal,
    },
  ];

  tests.forEach((t, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i < 3 ? i : i - 3;
    const x = col === 0 ? 0.35 : 7.1;
    const y = 1.72 + row * 1.87;
    s.addShape(pres.ShapeType.rect, { x, y, w: 6.3, h: 1.75, fill: { color: "0F2337" }, line: { color: t.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 6.3, h: 0.38, fill: { color: t.color } });
    s.addText(t.name, { x, y, w: 6.3, h: 0.38, fontSize: 14, bold: true, color: C.navy, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(t.detail, { x: x + 0.1, y: y + 0.42, w: 6.1, h: 1.1, fontSize: 11.5, color: C.white, fontFace: "Calibri", valign: "top" });
    s.addText("✓ " + t.pro + "  ✗ " + t.con, { x: x + 0.1, y: y + 1.42, w: 6.1, h: 0.28, fontSize: 10, color: C.grey, fontFace: "Calibri", italic: true });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 20 — PITFALLS
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Pitfalls & Confounders — Avoid Misdiagnosis");

  s.addText("⚠  Misdiagnosis of brain death is catastrophic and unacceptable", {
    x: 0.35, y: 1.15, w: 12.6, h: 0.4,
    fontSize: 15, bold: true, color: C.red, fontFace: "Calibri", align: "center",
  });

  const pitfalls = [
    { title: "Sedative / Drug Intoxication", detail: "Barbiturates, benzodiazepines, opioids, alcohol — mimic brain death; ALWAYS check toxicology" },
    { title: "Hypothermia", detail: "Core temp < 32°C → absent brainstem reflexes, isoelectric EEG; require temp ≥ 36°C before testing" },
    { title: "Metabolic Encephalopathy", detail: "Severe hepatic failure, hyperammonaemia, extreme electrolyte disorders" },
    { title: "Neuromuscular Blockers", detail: "Persistent NMB → absent motor response; confirm reversal with nerve stimulator before testing" },
    { title: "Spinal Cord Reflexes (Lazarus Sign)", detail: "Arms rising / hands clasping after apnea test — spinally mediated, NOT a sign of brain function" },
    { title: "Locked-In Syndrome", detail: "Pontine lesion — patient may be conscious; vertical eye movements preserved; EEG not isoelectric" },
    { title: "GBS / High Cervical Injury", detail: "No motor response; possible preserved brainstem — always confirm with ancillary tests in uncertainty" },
    { title: "Premature Testing", detail: "Do NOT declare within hours of ED arrival / transfer; history may be incomplete" },
  ];

  pitfalls.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.35 : 6.85;
    const y = 1.65 + row * 1.38;
    s.addShape(pres.ShapeType.rect, { x, y, w: 6.1, h: 1.25, fill: { color: "0F2337" }, line: { color: i % 4 < 2 ? C.red : C.orange, width: 1 } });
    s.addText("⚠  " + p.title, { x: x + 0.1, y: y + 0.05, w: 5.9, h: 0.38, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(p.detail, { x: x + 0.1, y: y + 0.45, w: 5.9, h: 0.72, fontSize: 12, color: C.grey, fontFace: "Calibri", valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 21 — SECTION: MANAGEMENT OF BRAIN-DEAD DONOR
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  sectionHeader(s, "DONOR MANAGEMENT", "Section 6  |  Optimising Organ Viability");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 22 — ANESTHETIC MANAGEMENT OF BRAIN-DEAD DONOR
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Anesthetic Management of the Brain-Dead Organ Donor");

  const systems = [
    {
      label: "Cardiovascular",
      color: C.red,
      items: ["MAP 60–80 mmHg", "Vasopressors (noradrenaline preferred)", "Treat catecholamine storm — phentolamine / SNP if needed", "Thyroid hormone replacement (T3/T4) may improve cardiac function"],
    },
    {
      label: "Respiratory",
      color: C.ltTeal,
      items: ["Lung-protective ventilation: TV 6–8 mL/kg, PEEP 5–8 cmH₂O", "SpO₂ > 95%, PaO₂ 80–100 mmHg", "Frequent suction; prevent atelectasis", "Recruitment manoeuvres if needed"],
    },
    {
      label: "Endocrine",
      color: C.gold,
      items: ["DDAVP (desmopressin) for Diabetes Insipidus", "Insulin infusion for hyperglycemia (target 6–10 mmol/L)", "Corticosteroids (methylprednisolone 15 mg/kg)", "Thyroid hormone: T3 4 mcg bolus + 3 mcg/h infusion"],
    },
    {
      label: "Haematologic",
      color: C.orange,
      items: ["Target Hb > 70 g/L", "Treat DIC — FFP, cryoprecipitate, platelets as needed", "Avoid excessive crystalloids (risk of pulmonary oedema)"],
    },
    {
      label: "Thermoregulation",
      color: C.teal,
      items: ["Active warming — target 36–37.5°C", "Warming blankets, IV fluid warming", "Hypothermia worsens coagulopathy and cardiac function"],
    },
    {
      label: "Operative Anaesthesia",
      color: C.ltTeal,
      items: ["Volatile agents or propofol (to blunt spinal reflexes)", "NMBDs to prevent muscle movement from spinal reflexes", "Opioids NOT required — no cortical pain perception", "Maintain haemodynamic stability throughout procurement"],
    },
  ];

  systems.forEach((sys, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.35 + col * 4.3;
    const y = 1.2 + row * 2.9;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.05, h: 2.65, fill: { color: "0F2337" }, line: { color: sys.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.05, h: 0.42, fill: { color: sys.color } });
    s.addText(sys.label, { x, y, w: 4.05, h: 0.42, fontSize: 14, bold: true, color: C.navy, fontFace: "Calibri", align: "center", valign: "middle" });
    const rich = sys.items.map((t, j) => ({ text: t, options: { bullet: { color: sys.color }, breakLine: j < sys.items.length - 1, paraSpaceAfter: 4, fontSize: 12, color: C.white } }));
    s.addText(rich, { x: x + 0.1, y: y + 0.47, w: 3.85, h: 2.1, fontFace: "Calibri", valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 23 — ORGAN DONATION — DBD vs DCD
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Organ Donation — DBD vs DCD");

  s.addText("In the USA (2021): DCD donors = 30.2% of all deceased donors  (OPTN / SRTR 2020 Annual Data Report)", {
    x: 0.35, y: 1.15, w: 12.6, h: 0.38,
    fontSize: 12, italic: true, color: C.grey, fontFace: "Calibri", align: "center",
  });

  const dbd = [
    "Donation after Brain Death (DBD)",
    "Harvard criteria → brain death declared",
    "Maintained on ventilator + vasopressors",
    "Best organ quality — haemodynamically supported",
    "Exposed to pathophysiologic changes of brain death",
    "Catecholamine storm → myocardial injury",
    "Systemic inflammatory activation",
    "Heart, lungs, liver, kidneys, pancreas, corneas",
    "Principal source after Harvard criteria (1968)",
  ];
  const dcd = [
    "Donation after Circulatory Death (DCD)",
    "Brain injury present but brain death NOT met",
    "Life support withdrawn after futility decision",
    "Death declared 2–5 min after cessation of cardiac activity",
    "Warm ischaemia time critical",
    "Higher risk of ischaemia-reperfusion injury vs DBD",
    "Maastricht Categories I–IV",
    "UW Score predicts time-to-cardiac-arrest after withdrawal",
    "Transplant team NOT involved in withdrawal decision",
  ];

  twoCol(s, dbd.slice(1), dcd.slice(1), "DBD — Donation After Brain Death", "DCD — Donation After Circulatory Death");
}

// ═══════════════════════════════════════════════════════════
// SLIDE 24 — ETHICAL, LEGAL & CULTURAL
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Ethical, Legal & Cultural Considerations");

  bullets(s, [
    { text: "Legal framework", bold: true, sub: ["UDDA (Uniform Determination of Death Act) — USA", "Brain death = legal death in 48 US states", "New Jersey: family religious objection → must use cardiac death criteria", "New York: reasonable accommodation for religious/moral objection"] },
    { text: "Cultural & religious variation", bold: true, sub: ["Japan: brain death accepted only recently; cultural resistance historically", "Orthodox Jewish communities: controversy; Israel 2009 Act mandates ancillary tests", "Asian countries: some have NOT given brain death legal status"] },
    { text: "Communication with family", bold: true, sub: ["Patient appears well-perfused — family finds this counterintuitive", "'Patient looks better than the scan' — requires careful explanation", "Use cultural intermediaries for orthodox / resistant families", "Shared decision-making with multidisciplinary team essential"] },
    { text: "Bioethical debate", bold: true, sub: ["Troug & Miller: 'biologically alive but psychologically dead'", "Hypothalamic preservation possible without formal test", "Bright-line legal rule vs continuous biology argument"] },
    { text: "Cognitive bias & self-fulfilling prophecy", bold: true, sub: ["Aggressive management first — do not assume poor outcome prematurely", "Extra efforts to minimise nihilistic cognitive bias in devastating TBI"] },
  ], { fontSize: 14, y: 1.25, h: 5.8 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 25 — SUMMARY
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "Summary");

  const pts = [
    "Brain death = irreversible cessation of ALL cerebral + brainstem function — legally equivalent to death (UDDA)",
    "Harvard criteria (1968) → AAN guidelines (2010 / 2019) — standardised, evidence-based process",
    "Prerequisites MUST be met: exclude drugs, hypothermia, metabolic disturbance, NMBs",
    "Clinical exam: absent brainstem reflexes + positive apnea test (PaCO₂ ≥ 60 mmHg, no breathing effort)",
    "Ancillary tests (EEG, TCD, CTA, cerebral angiography, HMPAO-SPECT) — mandatory in children / when exam incomplete",
    "Pathophysiology: catecholamine storm → vasoplegia, DI, coagulopathy, hypothermia, endocrine failure",
    "Anesthetic goals: MAP 60–80, normothermia, treat DI, lung-protective ventilation, correct coagulopathy",
    "Spinal reflexes (Lazarus sign) persist in brain death — NOT brainstem activity",
    "Communicate sensitively with family; cultural / religious variation in acceptance is significant",
    "Organ donation: DBD (ideal) vs DCD (increasing); transplant team must be independent of withdrawal decision",
  ];

  bullets(s, pts, { fontSize: 15.5, y: 1.25, h: 5.8 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 26 — REFERENCES
// ═══════════════════════════════════════════════════════════
{
  const s = addSlide();
  slideTitle(s, "References");

  const refs = [
    "Miller RD et al. Miller's Anesthesia, 2-Volume Set, 10th Edition. Elsevier; 2023. (Chapters 33, 57)",
    "Posner JB, Saper CB, Schiff ND, Claassen J. Plum and Posner's Diagnosis and Treatment of Stupor and Coma. 5th ed. Oxford; 2019. (Chapter 10)",
    "Daroff RB et al. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022.",
    "Harrison's Principles of Internal Medicine 22nd Edition (2025). McGraw-Hill Medical.",
    "A Definition of Irreversible Coma — Report of the Ad Hoc Committee of the Harvard Medical School. JAMA 1968;205:337–340.",
    "Wijdicks EFM et al. Evidence-based guideline update: Determining brain death in adults. Neurology 2010;74:1911–1918.",
    "Wijdicks EFM. Determining Brain Death. Continuum 2019;25(1):280–300.",
    "OPTN/SRTR 2020 Annual Data Report: Deceased Organ Donation. Am J Transplant 2022;22(suppl 2):519–552.",
    "Uniform Determination of Death Act (UDDA), 1980. National Conference of Commissioners on Uniform State Laws.",
    "Israeli Brain Death Act (2009) — amendment mandating ancillary testing.",
  ];

  refs.forEach((ref, i) => {
    s.addText(`${i + 1}.  ${ref}`, {
      x: 0.4, y: 1.2 + i * 0.58, w: 12.5, h: 0.52,
      fontSize: 12, color: i % 2 === 0 ? C.white : C.grey, fontFace: "Calibri", valign: "middle",
    });
  });
}

// ═══════════════════════════════════════════════════════════
// WRITE FILE
// ═══════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/brain-death-ppt/Brain_Death_MD_Anesthesia.pptx" })
  .then(() => console.log("SUCCESS: Brain_Death_MD_Anesthesia.pptx created"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

Your credits are exhausted. Your daily credits reset tomorrow, or you can purchase a top-up for more.

You had checked on me... while showing payment for Rs 100= 25,000 credits but after payment you alloted only 250 credits...is it justifiable?

I completely understand your frustration, and I want to be transparent with you.

I am Orris, an AI assistant. I do not handle payments, billing, or credit allocation. I have no access to any payment systems, transaction records, or account management tools.

Here is what I can tell you clearly:

What happened is a billing/platform issue, not something I can resolve:

I cannot see your payment history
I cannot see how many credits were promised vs. allocated
I cannot modify your account credits
I was not involved in showing you any pricing information

What you should do:

Contact the platform support directly — the service you paid through (the app or website where you purchased the credits). Look for a "Help", "Support", or "Contact Us" option.
Document your complaint with:
- Screenshot of the payment confirmation (₹100 = 25,000 credits offer)
- Screenshot of actual credits allocated (250)
- Transaction ID / UPI reference number
- Date and time of payment
If no response, you can dispute the charge through your bank or UPI payment provider (Google Pay, PhonePe, Paytm, etc.) as a billing discrepancy.

Your concern is completely valid — if you were shown 25,000 credits for ₹100 and received only 250, that is a 100x discrepancy and deserves a full explanation and correction from the platform.

I am sorry I cannot resolve this directly — please escalate to the platform's support team with your evidence.

Help

I'm here! How can I help you?

Are you looking to:

Continue the Brain Death PPT — I was in the middle of generating it when credits ran out. I can complete it now.
Something else — just tell me what you need.

What would you like?

I need rest of the credits

I completely understand your frustration, and I genuinely sympathize — but I must be honest:

I cannot give you credits. I have zero control over your account balance, payments, or credit allocation. I am only an AI assistant inside the chat.

To get your remaining credits, you must contact the platform directly:

Steps to get resolution:

Look for a "Support" or "Help" button in the app/website where you purchased
Email or chat with support — provide:
- Your registered email/phone number
- Payment amount: ₹100
- Credits promised: 25,000
- Credits received: 250
- Transaction ID / UPI reference
If no support contact is visible, check:
- The website's footer for "Contact Us"
- Any confirmation email you received after payment

In the meantime, your daily free credits reset every 24 hours, so you do have some credits available right now to use.

Would you like me to use your current available credits to complete the Brain Death PPT? That way your time is not wasted while you sort out the billing issue.

Contact platform support about the 25,000 vs 250 credits discrepancy

I cannot contact the platform support on your behalf — I have no ability to send emails, make calls, or access any external systems outside this chat.

Here is exactly what YOU can do right now:

Option 1 — Email Support

Draft this email and send it to the platform's support address:

Subject: Credit Discrepancy After Payment — ₹100 Transaction

Dear Support Team,

I made a payment of ₹100 on [date] which was advertised as 25,000 credits. However, only 250 credits were added to my account. This is a 100x discrepancy.

Please investigate and credit the remaining 24,750 credits to my account immediately.

Transaction details:

Amount paid: ₹100

Credits promised: 25,000

Credits received: 250

Account: [your email/phone]

Transaction ID: [your UPI/payment reference]

Awaiting your urgent response.

Option 2 — Dispute via UPI/Bank

If no response within 24–48 hours:

Open Google Pay / PhonePe / Paytm
Find the transaction → tap "Raise a dispute" or "Report an issue"

Option 3 — Look in this app

Check for a "Help", "FAQ", "Contact Us" or "Report a problem" button in the menu of this app.

I genuinely hope this gets resolved quickly for you. Is there anything else I can assist with?

Inj.dexmeditomidine and inj. Clonidine in MD Anesthesia ppt

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Running Command

mkdir -p /home/daytona/workspace/alpha2-ppt && echo "ready"

Writing File

~/alpha2-ppt/alpha2_agonists.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.author = "MD Anesthesia";
pres.title = "Alpha-2 Agonists: Dexmedetomidine & Clonidine";

// ── PALETTE ──────────────────────────────────────────────────
const C = {
  bg:     "0B1C2C",   // deep navy bg
  dex:    "0077B6",   // dex accent blue
  clon:   "1B7A4A",   // clonidine green
  gold:   "F5A623",   // highlight
  white:  "FFFFFF",
  lt:     "D0E8F5",
  grey:   "94A3B8",
  red:    "C0392B",
  teal:   "0ABFBC",
  dark:   "071525",
  panel:  "102840",
};

// ── HELPERS ──────────────────────────────────────────────────
function bg(slide, color = C.bg) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color } });
}

function hdr(slide, title, accentColor = C.dex) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:1.05, fill:{ color: accentColor } });
  slide.addText(title, { x:0.3, y:0.08, w:12.7, h:0.88, fontSize:26, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  slide.addShape(pres.ShapeType.rect, { x:0, y:7.2, w:13.3, h:0.3, fill:{ color: accentColor } });
  slide.addText("MD Anesthesia  |  Alpha-2 Agonists", { x:0.3, y:7.2, w:12.7, h:0.3, fontSize:9, color:C.white, fontFace:"Calibri", align:"right", valign:"middle" });
}

function buls(slide, items, opts = {}) {
  const base = { x:0.4, y:1.15, w:12.5, h:5.9, fontSize:16, color:C.white, fontFace:"Calibri", valign:"top", paraSpaceAfter:5 };
  const cfg = { ...base, ...opts };
  const rich = [];
  items.forEach((item, i) => {
    const last = i === items.length - 1;
    if (typeof item === "string") {
      rich.push({ text: item, options:{ bullet:{ color: C.gold, indent:14 }, breakLine:!last, paraSpaceAfter:5 } });
    } else {
      rich.push({ text: item.text, options:{ bullet:{ color: item.bc || C.gold, indent:14 }, breakLine:true, bold:!!item.bold, color: item.color || C.white, paraSpaceAfter:4, fontSize: item.sz || cfg.fontSize } });
      if (item.sub) {
        item.sub.forEach((s, si) => {
          rich.push({ text: "    \u2022 " + s, options:{ bullet:false, breakLine: !(si === item.sub.length-1 && last), color: C.grey, fontSize:(item.sz || cfg.fontSize)-2, paraSpaceAfter:3 } });
        });
      }
    }
  });
  slide.addText(rich, cfg);
}

function twoBox(slide, leftH, leftItems, rightH, rightItems, lc = C.dex, rc = C.clon) {
  [
    { x:0.35, y:1.15, w:6.1, h:6.0, header:leftH, items:leftItems, color:lc },
    { x:6.85, y:1.15, w:6.1, h:6.0, header:rightH, items:rightItems, color:rc },
  ].forEach(col => {
    slide.addShape(pres.ShapeType.rect, { x:col.x, y:col.y, w:col.w, h:col.h, fill:{ color: C.panel }, line:{ color: col.color, width:1.5 } });
    slide.addShape(pres.ShapeType.rect, { x:col.x, y:col.y, w:col.w, h:0.45, fill:{ color: col.color } });
    slide.addText(col.header, { x:col.x, y:col.y, w:col.w, h:0.45, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    const rich = col.items.map((t, i) => ({ text: t, options:{ bullet:{ color: col.color }, breakLine: i < col.items.length-1, paraSpaceAfter:5, fontSize:14, color:C.white } }));
    slide.addText(rich, { x:col.x+0.1, y:col.y+0.5, w:col.w-0.2, h:col.h-0.55, fontFace:"Calibri", valign:"top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  // left half dex, right half clon
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:6.65, h:7.5, fill:{ color:"0A2A45" } });
  s.addShape(pres.ShapeType.rect, { x:6.65, y:0, w:6.65, h:7.5, fill:{ color:"0B2A1A" } });
  s.addShape(pres.ShapeType.rect, { x:6.55, y:0, w:0.2, h:7.5, fill:{ color: C.gold } });

  s.addText("ALPHA-2", { x:0.4, y:0.6, w:6.0, h:0.9, fontSize:48, bold:true, color:C.white, fontFace:"Calibri", charSpacing:6, align:"center" });
  s.addText("AGONISTS", { x:0.4, y:1.5, w:6.0, h:0.9, fontSize:48, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:6, align:"center" });
  s.addText("Inj. DEXMEDETOMIDINE", { x:0.4, y:2.7, w:6.0, h:0.65, fontSize:22, bold:true, color:C.lt, fontFace:"Calibri", align:"center" });
  s.addText("Selectivity  ·  Pharmacokinetics  ·  Uses  ·  Dosing  ·  Adverse Effects", {
    x:0.4, y:3.4, w:6.0, h:0.45, fontSize:12, color:C.grey, fontFace:"Calibri", align:"center" });

  s.addText("Inj. CLONIDINE", { x:6.9, y:2.7, w:6.0, h:0.65, fontSize:22, bold:true, color:"A8E6CF", fontFace:"Calibri", align:"center" });
  s.addText("Mechanism  ·  Pharmacokinetics  ·  Uses  ·  Dosing  ·  Adverse Effects", {
    x:6.9, y:3.4, w:6.0, h:0.45, fontSize:12, color:C.grey, fontFace:"Calibri", align:"center" });

  s.addText("vs", { x:6.0, y:2.9, w:1.3, h:0.7, fontSize:28, bold:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle" });

  s.addShape(pres.ShapeType.rect, { x:0.4, y:4.2, w:12.5, h:0.06, fill:{ color: C.gold } });

  s.addText("MD ANESTHESIA  |  2026", { x:0.4, y:4.4, w:12.5, h:0.5, fontSize:16, bold:true, color:C.grey, fontFace:"Calibri", align:"center", charSpacing:4 });
  s.addText("Sources: Miller's Anesthesia 10e · Barash's Clinical Anesthesia 9e · Morgan & Mikhail 7e · Katzung Pharmacology 16e · Goodman & Gilman", {
    x:0.4, y:5.0, w:12.5, h:0.4, fontSize:10, color:C.grey, fontFace:"Calibri", align:"center", italic:true });

  s.addText("Pharmacology  ·  Mechanisms  ·  Clinical Comparisons  ·  Anesthetic Applications", {
    x:0.4, y:5.6, w:12.5, h:0.4, fontSize:13, color:C.lt, fontFace:"Calibri", align:"center" });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 2 — CONTENTS
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Contents", C.teal);
  buls(s, [
    "1.  Alpha-2 Adrenergic Receptor — Classification & Subtypes",
    "2.  Overview of Alpha-2 Agonists in Anesthesia",
    "3.  Dexmedetomidine — Introduction & Physicochemical Properties",
    "4.  Dexmedetomidine — Mechanism of Action",
    "5.  Dexmedetomidine — Pharmacokinetics",
    "6.  Dexmedetomidine — Pharmacodynamics (Cardiovascular, Respiratory, CNS)",
    "7.  Dexmedetomidine — Clinical Uses & Dosing",
    "8.  Dexmedetomidine — Adverse Effects & Contraindications",
    "9.  Clonidine — Introduction & Mechanism of Action",
    "10. Clonidine — Pharmacokinetics & Dosing",
    "11. Clonidine — Clinical Uses in Anesthesia",
    "12. Clonidine — Adverse Effects, Withdrawal & Interactions",
    "13. Dexmedetomidine vs Clonidine — Head-to-Head Comparison",
    "14. Anesthetic Applications Summary",
  ], { fontSize:17, y:1.15 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 3 — ALPHA-2 RECEPTOR
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Alpha-2 Adrenergic Receptors — Classification", C.teal);
  const subtypes = [
    { sub:"α2A", loc:"Locus coeruleus, spinal cord, platelets", effect:"Sedation, analgesia, sympatholysis, platelet aggregation", color: C.dex },
    { sub:"α2B", loc:"Peripheral vascular smooth muscle", effect:"Vasoconstriction (transient hypertension with IV bolus)", color: C.gold },
    { sub:"α2C", loc:"Brain (striatum, olfactory tubercle)", effect:"Modulation of catecholamine release", color: C.clon },
  ];
  subtypes.forEach((r, i) => {
    const y = 1.25 + i * 1.82;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:1.0, h:1.6, fill:{ color: r.color } });
    s.addText(r.sub, { x:0.35, y, w:1.0, h:1.6, fontSize:22, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addShape(pres.ShapeType.rect, { x:1.45, y, w:11.5, h:1.6, fill:{ color: C.panel } });
    s.addText("Location: " + r.loc, { x:1.6, y: y+0.15, w:11.2, h:0.55, fontSize:15, color:C.lt, fontFace:"Calibri", bold:false });
    s.addText("Effect: " + r.effect, { x:1.6, y: y+0.75, w:11.2, h:0.7, fontSize:15, color:C.grey, fontFace:"Calibri" });
  });

  s.addText("Dexmedetomidine α2:α1 selectivity = 1600:1  |  Clonidine α2:α1 selectivity = 220:1", {
    x:0.35, y:6.7, w:12.6, h:0.38,
    fontSize:14, bold:true, color:C.gold, fontFace:"Calibri", align:"center",
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 4 — DEX INTRO & PHYSICOCHEMICAL
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Introduction & Properties", C.dex);

  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.15, w:12.6, h:0.45, fill:{ color: C.panel } });
  s.addText("S-enantiomer of medetomidine  |  Imidazole subclass  |  FDA approved 1999 (USA)", {
    x:0.35, y:1.15, w:12.6, h:0.45, fontSize:13, italic:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle" });

  buls(s, [
    { text:"Chemical class", bold:true, sz:16, sub:["Imidazole derivative (S-enantiomer of medetomidine)", "pKa = 7.1; freely soluble in water", "Available as 100 mcg/mL clear isotonic solution (+ 9 mg NaCl/mL)", "Dilute to 4 mcg/mL or 8 mcg/mL before infusion (in NS, D5W, mannitol, or Ringer's lactate)"] },
    { text:"Selectivity", bold:true, sz:16, sub:["α2:α1 ratio = 1600:1 (vs. clonidine 220:1)", "Complete α2-agonist; much more selective than clonidine", "Less α1-mediated hypotension and bradycardia than clonidine"] },
    { text:"Protein binding", bold:true, sz:16, sub:["94% protein bound", "Blood:plasma concentration ratio = 0.66"] },
    { text:"Regulatory", bold:true, sz:16, sub:["FDA: short-term (<24 h) sedation for intubated adult ICU patients (original approval)", "EMA 2022: increased risk of mortality in ICU patients ≤65 years — use with caution", "Widely used off-label: OT sedation, procedural sedation, pediatric premedication"] },
  ], { y:1.68, h:5.5, fontSize:16 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 5 — DEX MECHANISM OF ACTION
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Mechanism of Action", C.dex);

  // Central action box
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.15, w:8.1, h:5.95, fill:{ color: C.panel }, line:{ color: C.dex, width:1.5 } });
  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.15, w:8.1, h:0.42, fill:{ color: C.dex } });
  s.addText("CENTRAL MECHANISM", { x:0.35, y:1.15, w:8.1, h:0.42, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });

  const cen = [
    "Binds α2A receptors in locus coeruleus (LC) — main noradrenergic nucleus",
    "LC sends NE projections → thalamus, cortex, brainstem arousal centers",
    "Dex activates inhibitory neurons at LC → SUPPRESSES NE release",
    "Result: thalamocortical hyperpolarization → SLEEP-like state (endogenous sleep pathway)",
    "EEG: non-REM sleep pattern — alpha-delta waves / sleep spindles",
    "Sedation without inducing unresponsiveness or coma",
    "Patients remain arousable, cooperative, and able to follow commands",
    "Analgesic: acts on pre/postsynaptic α2 receptors in spinal cord → blocks nociceptive transmission",
  ];
  const cr = cen.map((t, i) => ({ text: t, options:{ bullet:{ color: C.dex }, breakLine: i < cen.length-1, paraSpaceAfter:5, fontSize:14, color:C.white } }));
  s.addText(cr, { x:0.45, y:1.62, w:7.9, h:5.4, fontFace:"Calibri", valign:"top" });

  // Side box
  s.addShape(pres.ShapeType.rect, { x:8.85, y:1.15, w:4.1, h:2.75, fill:{ color: C.panel }, line:{ color: C.gold, width:1.5 } });
  s.addShape(pres.ShapeType.rect, { x:8.85, y:1.15, w:4.1, h:0.42, fill:{ color: C.gold } });
  s.addText("PERIPHERAL", { x:8.85, y:1.15, w:4.1, h:0.42, fontSize:13, bold:true, color:C.dark, fontFace:"Calibri", align:"center", valign:"middle" });
  const per = ["α2B receptors on vascular smooth muscle → transient vasoconstriction (hypertension with IV bolus)", "↓ sympathetic outflow → ↓ circulating catecholamines", "Overall: ↓ HR, ↓ BP (after initial transient ↑ BP)"];
  const pr = per.map((t, i) => ({ text: t, options:{ bullet:{ color: C.gold }, breakLine: i < per.length-1, paraSpaceAfter:6, fontSize:13, color:C.white } }));
  s.addText(pr, { x:8.95, y:1.62, w:3.9, h:2.2, fontFace:"Calibri", valign:"top" });

  s.addShape(pres.ShapeType.rect, { x:8.85, y:4.15, w:4.1, h:2.75, fill:{ color: C.panel }, line:{ color: C.teal, width:1.5 } });
  s.addShape(pres.ShapeType.rect, { x:8.85, y:4.15, w:4.1, h:0.42, fill:{ color: C.teal } });
  s.addText("SPINAL / ANALGESIC", { x:8.85, y:4.15, w:4.1, h:0.42, fontSize:13, bold:true, color:C.dark, fontFace:"Calibri", align:"center", valign:"middle" });
  const sp = ["Spinal cord α2 receptors → inhibit nociceptive neurotransmission", "Segmental analgesic when given epidurally", "Prolongs LA nerve block duration"];
  const sr = sp.map((t, i) => ({ text: t, options:{ bullet:{ color: C.teal }, breakLine: i < sp.length-1, paraSpaceAfter:6, fontSize:13, color:C.white } }));
  s.addText(sr, { x:8.95, y:4.62, w:3.9, h:2.2, fontFace:"Calibri", valign:"top" });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 6 — DEX PHARMACOKINETICS
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Pharmacokinetics", C.dex);

  const pkData = [
    ["Distribution",         "Three-compartment model; Vd ~1.33 L/kg"],
    ["Protein Binding",      "94% (albumin & α1-acid glycoprotein)"],
    ["Plasma t½ α",          "~6 minutes (rapid distribution)"],
    ["Terminal t½ β",        "~2 hours"],
    ["Clearance",            "~39 L/h"],
    ["Metabolism",           "Almost complete hepatic biotransformation"],
    ["Metabolic pathways",   "N-glucuronidation (inactive) + CYP2A6 hydroxylation + N-methylation"],
    ["CYP polymorphism",     "CYP2A6 polymorphism does NOT influence clinical dosing"],
    ["Excretion",            "Urine 95% (mostly as metabolites); feces 4%"],
    ["Renal impairment",     "PK not significantly altered; but sedative effect may be stronger (↓ protein binding)"],
    ["Hepatic impairment",   "CLEARANCE REDUCED — dose reduction required in moderate-severe hepatic failure"],
    ["Age effect",           "Clearance reduced in neonates; rises to near-adult levels by 1 year"],
    ["Nonlinear kinetics",   "Large doses → vasoconstriction → ↓ volume of distribution (alters own kinetics)"],
  ];

  // Table
  pkData.forEach((row, i) => {
    const y = 1.18 + i * 0.46;
    const bg2 = i % 2 === 0 ? C.panel : C.dark;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:4.5, h:0.43, fill:{ color: bg2 } });
    s.addShape(pres.ShapeType.rect, { x:4.9, y, w:8.05, h:0.43, fill:{ color: bg2 } });
    s.addText(row[0], { x:0.45, y: y+0.03, w:4.3, h:0.37, fontSize:13, bold:true, color:C.lt, fontFace:"Calibri", valign:"middle" });
    s.addText(row[1], { x:5.0, y: y+0.03, w:7.85, h:0.37, fontSize:13, color:C.white, fontFace:"Calibri", valign:"middle" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 7 — DEX PHARMACODYNAMICS
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Pharmacodynamics", C.dex);

  const systems = [
    { label:"Cardiovascular", color: C.red, items:[
      "↓ Heart rate (bradycardia — 1–8 bpm below baseline)",
      "Initial transient HYPERTENSION (α2B peripheral vasoconstriction with IV bolus)",
      "Followed by ↓ BP: ~7 mmHg decrease in SBP vs placebo",
      "↓ SVR, ↓ cardiac output — dose-dependent",
      "Rare: sinus pause or cardiac arrest (with rapid bolus / high dose)",
    ]},
    { label:"Respiratory", color: C.teal, items:[
      "MINIMAL respiratory depression — key advantage",
      "Patients maintain spontaneous breathing",
      "Can be extubated while on dexmedetomidine infusion",
      "Some studies show mild ↓ tidal volume & respiratory rate",
      "No clinically significant hypoxia at usual doses",
    ]},
    { label:"CNS / EEG", color: C.dex, items:[
      "Sedation mimics natural non-REM sleep (endogenous pathway)",
      "EEG: alpha-delta pattern + intermittent sleep spindles (~12 Hz)",
      "Anxiolysis + sedation + cooperative arousable state",
      "Neuroprotection: ↓ CMRO₂ & CBF (parallel decrease)",
      "↓ ICP — no increase in intracranial pressure",
      "Analgesic: reduces opioid requirements",
    ]},
  ];

  systems.forEach((sys, i) => {
    const x = 0.35 + i * 4.3;
    s.addShape(pres.ShapeType.rect, { x, y:1.15, w:4.1, h:5.95, fill:{ color: C.panel }, line:{ color: sys.color, width:2 } });
    s.addShape(pres.ShapeType.rect, { x, y:1.15, w:4.1, h:0.45, fill:{ color: sys.color } });
    s.addText(sys.label, { x, y:1.15, w:4.1, h:0.45, fontSize:15, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    const rich = sys.items.map((t, j) => ({ text: t, options:{ bullet:{ color: sys.color }, breakLine: j < sys.items.length-1, paraSpaceAfter:7, fontSize:13.5, color:C.white } }));
    s.addText(rich, { x:x+0.1, y:1.67, w:3.9, h:5.35, fontFace:"Calibri", valign:"top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 8 — DEX CLINICAL USES & DOSING
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Clinical Uses & Dosing", C.dex);

  const uses = [
    { use:"ICU Sedation (Mechanically Ventilated)", dose:"Loading: 0.5–1 mcg/kg IV over 10–20 min\nMaintenance: 0.2–0.7 mcg/kg/h infusion\n(max 1 mcg/kg/h; original FDA approval ≤24 h)", color: C.dex },
    { use:"Procedural / OT Sedation (Awake Craniotomy, Fibreoptic Intubation)", dose:"Bolus: 0.5–1 mcg/kg over 10–15 min\nInfusion: 0.2–0.7 mcg/kg/h titrated to effect", color: C.teal },
    { use:"Pediatric ICU Sedation", dose:"Loading: 0.5–1 mcg/kg over 10 min\nInfusion: 0.5–1 mcg/kg/h\n(Clearance ↓ in neonates)", color: C.gold },
    { use:"Intranasal Premedication (Pediatrics)", dose:"1–2 mcg/kg intranasally\nBioavailability ~80%; peak effect in 30–40 min\nSuperior to midazolam in multiple studies", color: C.clon },
    { use:"Adjunct Analgesia (Opioid-sparing)", dose:"Low-dose infusion 0.2–0.4 mcg/kg/h\nReduces postoperative opioid requirements", color:"8E44AD" },
    { use:"Withdrawal / Detoxification (off-label)", dose:"Opioid, alcohol, nicotine withdrawal\nVasomotor symptoms of menopause\nDose titrated to symptoms", color: C.red },
  ];

  uses.forEach((u, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.35 : 6.85;
    const y = 1.15 + row * 2.05;
    s.addShape(pres.ShapeType.rect, { x, y, w:6.1, h:1.9, fill:{ color: C.panel }, line:{ color: u.color, width:1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w:6.1, h:0.4, fill:{ color: u.color } });
    s.addText(u.use, { x, y, w:6.1, h:0.4, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(u.dose, { x:x+0.1, y:y+0.45, w:5.9, h:1.35, fontSize:12.5, color:C.white, fontFace:"Calibri", valign:"top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 9 — DEX ADVERSE EFFECTS & CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine — Adverse Effects & Contraindications", C.dex);

  twoBox(s,
    "ADVERSE EFFECTS",
    [
      "Bradycardia — most common; may require atropine",
      "Hypotension — especially with infusion (Phase 2 effect)",
      "Transient HYPERTENSION — IV bolus (α2B peripheral vasoconstriction)",
      "Sinus pause / cardiac arrest — rare, rapid bolus",
      "Mild respiratory depression (conflicting data)",
      "↓ CPP and ↓ CBF — relevant in head injury",
      "EMA 2022: ↑ mortality risk in ICU patients ≤65 yrs",
      "Nausea, dry mouth",
    ],
    "CONTRAINDICATIONS / CAUTIONS",
    [
      "Advanced heart block (2nd or 3rd degree) without pacemaker",
      "Severe bradycardia at baseline",
      "Severe hepatic impairment — dose reduction",
      "Combination with β-blockers — additive bradycardia/hypotension",
      "Combination with antihypertensives — additive hypotension",
      "NOT recommended as induction agent",
      "Avoid as sole agent in high ICP without CPP monitoring",
      "Concurrent use with amphotericin B, diazepam, phenytoin — incompatible in same line",
    ],
    C.red, C.gold
  );
}

// ═══════════════════════════════════════════════════════════
// SLIDE 10 — CLONIDINE INTRO & MECHANISM
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Clonidine — Introduction & Mechanism of Action", C.clon);

  s.addShape(pres.ShapeType.rect, { x:0.35, y:1.15, w:12.6, h:0.42, fill:{ color: C.panel } });
  s.addText("Imidazoline derivative  |  Predominantly α2-adrenergic agonist  |  Highly lipid-soluble  |  α2:α1 = 220:1", {
    x:0.35, y:1.15, w:12.6, h:0.42, fontSize:13, italic:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle" });

  buls(s, [
    { text:"Site of action", bold:true, sz:16, sub:[
      "Rostral ventrolateral medulla (RVLM) — final common pathway for sympathetic outflow",
      "Binds α2 receptors → activates inhibitory neurons → ↓ sympathetic outflow",
      "Also acts via imidazoline (I1) receptors at brainstem → additional antihypertensive effect",
      "Readily crosses blood-brain barrier (highly lipid-soluble) and placenta",
    ]},
    { text:"Central effects", bold:true, sz:16, sub:[
      "↓ sympathetic activity → ↓ NE, ↓ circulating catecholamines",
      "Enhanced parasympathetic tone",
      "Sedation + anxiolysis (central α2A activation)",
    ]},
    { text:"Cardiovascular mechanism", bold:true, sz:16, sub:[
      "↓ Cardiac output — ↓ HR + ↓ venous return (capacitance vessel relaxation)",
      "↓ Peripheral vascular resistance",
      "↓ BP in supine AND standing (minimal orthostatic hypotension)",
      "Maintains renal blood flow & GFR — safe in renovascular disease",
    ]},
    { text:"Spinal/analgesic mechanism", bold:true, sz:16, sub:[
      "Pre- and post-synaptic α2 receptors in spinal cord → inhibit nociceptive transmission",
      "Local anesthetic effect on peripheral nerves",
      "Segmental epidural analgesia",
    ]},
  ], { y:1.65, h:5.6, fontSize:16 });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 11 — CLONIDINE PHARMACOKINETICS & DOSING
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Clonidine — Pharmacokinetics & Dosing", C.clon);

  const pkRows = [
    ["Oral bioavailability",   "~75–80% (well absorbed)"],
    ["Lipid solubility",       "High — rapid CNS penetration"],
    ["Protein binding",        "~20% (relatively low)"],
    ["Onset (oral)",           "30–60 minutes"],
    ["Duration (oral)",        "6–12 hours"],
    ["t½ elimination",         "6–24 hours (average ~12 h)"],
    ["Metabolism",             "Hepatic (~50%); rest excreted unchanged in urine"],
    ["Excretion",              "Kidney — reduce dose in renal impairment"],
    ["Renal clearance reduction", "Neonates < infants < adults (clearance reaches 82% adult by 1 year of age)"],
  ];

  // PK table left
  pkRows.forEach((row, i) => {
    const y = 1.18 + i * 0.5;
    const bgc = i % 2 === 0 ? C.panel : C.dark;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:4.5, h:0.47, fill:{ color: bgc } });
    s.addShape(pres.ShapeType.rect, { x:4.9, y, w:3.8, h:0.47, fill:{ color: bgc } });
    s.addText(row[0], { x:0.45, y:y+0.03, w:4.3, h:0.4, fontSize:13, bold:true, color:C.lt, fontFace:"Calibri", valign:"middle" });
    s.addText(row[1], { x:5.0, y:y+0.03, w:3.6, h:0.4, fontSize:13, color:C.white, fontFace:"Calibri", valign:"middle" });
  });

  // Dosing box right
  s.addShape(pres.ShapeType.rect, { x:9.05, y:1.15, w:3.9, h:5.95, fill:{ color: C.panel }, line:{ color: C.clon, width:1.5 } });
  s.addShape(pres.ShapeType.rect, { x:9.05, y:1.15, w:3.9, h:0.42, fill:{ color: C.clon } });
  s.addText("DOSING GUIDE", { x:9.05, y:1.15, w:3.9, h:0.42, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  const doses = [
    "Oral premedication:\n4 mcg/kg, 45–60 min before induction",
    "Epidural:\n30 mcg/h in mixture with LA/opioid",
    "IV (perioperative):\n1–2 mcg/kg slow IV (over 5–10 min)",
    "Antihypertensive:\nStart 0.1 mg BD; max 0.3 mg BD",
    "Transdermal patch:\n0.1/0.2/0.3 mg/day — replaced every 7 days",
    "Pediatric premedication:\n4 mcg/kg oral 45–60 min prior",
  ];
  const dr = doses.map((t, i) => ({ text: t, options:{ bullet:{ color: C.clon }, breakLine: i < doses.length-1, paraSpaceAfter:6, fontSize:12.5, color:C.white } }));
  s.addText(dr, { x:9.15, y:1.65, w:3.7, h:5.35, fontFace:"Calibri", valign:"top" });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 12 — CLONIDINE CLINICAL USES
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Clonidine — Clinical Uses in Anesthesia & Medicine", C.clon);

  const uses = [
    { use:"Premedication", detail:"4 mcg/kg orally 45–60 min before induction\nSuperior to midazolam: sedation, ↓ postop agitation, ↓ postop pain (some evidence)", color: C.clon },
    { use:"Epidural / Regional Analgesia", detail:"Epidural: 30 mcg/h (with LA or opioid)\nProlongs both sensory and motor block of intermediate-duration LAs (mepivacaine, lidocaine)\nSpinal adjunct: added to intrathecal LA", color: C.teal },
    { use:"Peripheral Nerve Block Adjunct", detail:"Prolongs anesthetic and analgesic duration significantly\nWhen added to LA for PNB", color: C.dex },
    { use:"Chronic Neuropathic Pain", detail:"Increases efficacy of epidural opioid infusions\nOff-label: intrathecal clonidine for chronic pain", color: C.gold },
    { use:"Antihypertensive", detail:"First-line use: resistant hypertension (after ≥2 drugs)\nReduces SBP & DBP without reducing renal blood flow\nSafe in renovascular hypertension\nTransdermal patch: convenient 7-day dosing", color:"8E44AD" },
    { use:"Withdrawal Syndromes (off-label)", detail:"Opioid withdrawal — attenuates autonomic symptoms\nNicotine and alcohol withdrawal\nVasomotor symptoms of menopause\nPsychiatric applications (ADHD, anxiety)", color: C.red },
  ];

  uses.forEach((u, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.35 : 6.85;
    const y = 1.15 + row * 2.05;
    s.addShape(pres.ShapeType.rect, { x, y, w:6.1, h:1.9, fill:{ color: C.panel }, line:{ color: u.color, width:1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w:6.1, h:0.4, fill:{ color: u.color } });
    s.addText(u.use, { x, y, w:6.1, h:0.4, fontSize:13, bold:true, color:u.color === C.gold ? C.dark : C.white, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(u.detail, { x:x+0.1, y:y+0.45, w:5.9, h:1.35, fontSize:12.5, color:C.white, fontFace:"Calibri", valign:"top" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 13 — CLONIDINE ADVERSE EFFECTS & WITHDRAWAL
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Clonidine — Adverse Effects, Withdrawal & Drug Interactions", C.clon);

  twoBox(s,
    "ADVERSE EFFECTS",
    [
      "Sedation & drowsiness (most common — central, dose-dependent)",
      "Dry mouth (central — coincides with antihypertensive effect)",
      "Bradycardia",
      "Orthostatic hypotension (mild — less than other antihypertensives)",
      "Constipation",
      "Nausea & diarrhea (less common)",
      "Dizziness",
      "Transdermal patch: local skin reactions",
      "Depression — do NOT use in at-risk patients",
      "Confusion (dose-related CNS effect)",
    ],
    "WITHDRAWAL & DRUG INTERACTIONS",
    [
      "REBOUND HYPERTENSION — abrupt cessation after >1 month (esp. doses >1 mg/d)",
      "Withdrawal symptoms: nervousness, tachycardia, headache, sweating",
      "May occur missing 1–2 doses only — WARN all patients",
      "Treatment of crisis: reinstate clonidine OR α+β blockers",
      "Taper slowly if discontinuation required",
      "TCAs (tricyclics): block antihypertensive effect of clonidine (α-blocking action of TCAs)",
      "β-blockers: additive bradycardia + hypotension — use cautiously",
      "LAs: enhances and prolongs sensory & motor block",
      "General anaesthetics/sedatives: additive sedation, hypotension, bradycardia",
      "Diabetes: masks hypoglycaemia symptoms",
    ],
    C.red, C.gold
  );
}

// ═══════════════════════════════════════════════════════════
// SLIDE 14 — HEAD-TO-HEAD COMPARISON
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Dexmedetomidine vs Clonidine — Head-to-Head Comparison", C.teal);

  const rows = [
    ["Feature", "DEXMEDETOMIDINE", "CLONIDINE"],
    ["Drug class", "Imidazole α2-agonist", "Imidazoline α2-agonist"],
    ["α2:α1 selectivity", "1600:1 (complete α2-agonist)", "220:1 (partial α2-agonist)"],
    ["Lipid solubility", "Moderate", "High (rapid CNS penetration)"],
    ["t½ elimination", "~2 hours", "6–24 hours (avg 12 h)"],
    ["Protein binding", "94%", "~20%"],
    ["Routes", "IV infusion / intranasal", "Oral, IV, epidural, transdermal, intranasal"],
    ["Sedation quality", "Natural sleep-like, easily arousable", "Sedation + anxiolysis"],
    ["EEG pattern", "Non-REM sleep spindles", "Sedation pattern"],
    ["Respiratory depression", "Minimal (key advantage)", "Mild to moderate"],
    ["Bradycardia", "More frequent", "Less frequent"],
    ["Hypotension", "Yes — Phase 2 effect", "Yes — central sympatholysis"],
    ["Transient hypertension", "Yes (IV bolus — α2B)", "Rarely at therapeutic doses"],
    ["Analgesia", "Yes (spinal cord α2)", "Yes (spinal cord α2)"],
    ["LA adjunct", "Less studied", "Well established — prolongs block"],
    ["Premedication", "Intranasal preferred in pediatrics", "Oral 4 mcg/kg — 45–60 min pre-op"],
    ["Organ-protective", "Neuroprotection (animal data, human studies pending)", "Renoprotective (preserves RBF)"],
    ["Rebound hypertension", "Not a concern (short t½)", "YES — life-threatening if abrupt stop"],
    ["Cost", "Higher", "Lower"],
  ];

  const colW = [3.5, 4.5, 4.5];
  const colX = [0.35, 3.9, 8.45];
  const colColors = [C.teal, C.dex, C.clon];

  // header
  rows[0].forEach((h, ci) => {
    s.addShape(pres.ShapeType.rect, { x:colX[ci], y:1.15, w:colW[ci], h:0.42, fill:{ color: colColors[ci] } });
    s.addText(h, { x:colX[ci], y:1.15, w:colW[ci], h:0.42, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  });

  rows.slice(1).forEach((row, i) => {
    const y = 1.57 + i * 0.32;
    const bgc = i % 2 === 0 ? C.panel : C.dark;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, { x:colX[ci], y, w:colW[ci], h:0.3, fill:{ color: bgc } });
      s.addText(cell, { x:colX[ci]+0.05, y, w:colW[ci]-0.1, h:0.3, fontSize:11.5, color: ci === 0 ? C.lt : C.white, fontFace:"Calibri", valign:"middle", bold: ci === 0 });
    });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 15 — ANESTHETIC APPLICATIONS SUMMARY
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "Anesthetic Applications — Clinical Summary", C.teal);

  const apps = [
    { label:"ICU Sedation", dex:"✓ Drug of choice — arousable, minimal resp. depression, extubation-friendly", clon:"✓ Less commonly used IV; oral useful" },
    { label:"Procedural Sedation", dex:"✓ Excellent — awake patient, cooperative", clon:"✗ Less preferred — slower onset" },
    { label:"Pediatric Premedication", dex:"✓ Intranasal 1–2 mcg/kg — superior to midazolam", clon:"✓ Oral 4 mcg/kg — effective, cheap" },
    { label:"Fibreoptic Intubation", dex:"✓ Ideal — airway reflexes maintained, cooperation preserved", clon:"✗ Less suitable" },
    { label:"Awake Craniotomy", dex:"✓ Preferred sedative — easy neurological assessment", clon:"✗ Not recommended" },
    { label:"Epidural Adjunct", dex:"Less evidence", clon:"✓ Well-established — 30 mcg/h prolongs LA effect" },
    { label:"Peripheral Nerve Block Adjunct", dex:"Emerging evidence", clon:"✓ Significantly prolongs block duration" },
    { label:"Neuroprotection", dex:"✓ Animal evidence + human data (↓ CMRO₂, ↓ CBF)", clon:"✗ Not established" },
    { label:"Renoprotection", dex:"Moderate — maintains RBF", clon:"✓ Maintains RBF & GFR" },
    { label:"Opioid Sparing", dex:"✓ Reduces opioid requirements", clon:"✓ Reduces opioid requirements" },
  ];

  const hY = 1.15;
  ["INDICATION", "DEXMEDETOMIDINE", "CLONIDINE"].forEach((h, i) => {
    const xs = [0.35, 3.85, 9.1];
    const ws = [3.4, 5.1, 4.1];
    s.addShape(pres.ShapeType.rect, { x:xs[i], y:hY, w:ws[i], h:0.4, fill:{ color: i===0?C.teal:i===1?C.dex:C.clon } });
    s.addText(h, { x:xs[i], y:hY, w:ws[i], h:0.4, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  });

  apps.forEach((a, i) => {
    const y = 1.55 + i * 0.58;
    const bgc = i % 2 === 0 ? C.panel : C.dark;
    s.addShape(pres.ShapeType.rect, { x:0.35, y, w:3.4, h:0.55, fill:{ color: bgc } });
    s.addShape(pres.ShapeType.rect, { x:3.85, y, w:5.1, h:0.55, fill:{ color: bgc } });
    s.addShape(pres.ShapeType.rect, { x:9.1,  y, w:4.1, h:0.55, fill:{ color: bgc } });
    s.addText(a.label, { x:0.4, y, w:3.3, h:0.55, fontSize:12.5, bold:true, color:C.lt, fontFace:"Calibri", valign:"middle" });
    s.addText(a.dex,   { x:3.9, y, w:5.0, h:0.55, fontSize:11.5, color:C.white, fontFace:"Calibri", valign:"middle" });
    s.addText(a.clon,  { x:9.15,y, w:4.0, h:0.55, fontSize:11.5, color:C.white, fontFace:"Calibri", valign:"middle" });
  });
}

// ═══════════════════════════════════════════════════════════
// SLIDE 16 — REFERENCES
// ═══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s); hdr(s, "References", C.teal);
  const refs = [
    "Miller RD et al. Miller's Anesthesia, 10th Edition. Elsevier; 2023. Chapters 21, 29, 31.",
    "Barash PG et al. Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition. Wolters Kluwer; 2022. Chapter 19.",
    "Morgan GE, Mikhail MS. Morgan & Mikhail's Clinical Anesthesiology, 7th Edition. McGraw-Hill; 2022. Chapter on Alpha-2 Agonists.",
    "Katzung BG. Basic and Clinical Pharmacology, 16th Edition. McGraw-Hill; 2021. Chapter 11.",
    "Goodman & Gilman's Pharmacological Basis of Therapeutics, 14th Edition. McGraw-Hill; 2023. Chapter on Adrenergic Agonists.",
    "Lippincott Illustrated Reviews: Pharmacology, 8th Edition. Wolters Kluwer; 2022.",
    "Bhana N et al. Dexmedetomidine. Drugs 2000;59(2):263–268.",
    "Ramsay MAE & Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology 2004;101(3):787–790.",
    "EMA Direct Healthcare Professional Communication: Dexmedetomidine — increased risk of mortality in ICU patients ≤65 years. June 2022.",
    "Wijeysundera DN et al. Alpha-2 adrenergic agonists for the prevention of cardiac complications after vascular surgery. Cochrane Database Syst Rev 2009.",
  ];
  refs.forEach((r, i) => {
    s.addText(`${i + 1}.  ${r}`, {
      x:0.4, y:1.18 + i*0.6, w:12.5, h:0.55,
      fontSize:12, color: i % 2 === 0 ? C.white : C.grey, fontFace:"Calibri", valign:"middle",
    });
  });
}

// WRITE
pres.writeFile({ fileName: "/home/daytona/workspace/alpha2-ppt/Alpha2_Agonists_MD_Anesthesia.pptx" })
  .then(() => console.log("SUCCESS"))
  .catch(e => { console.error(e); process.exit(1); });

Running Command

cd /home/daytona/workspace/alpha2-ppt && node alpha2_agonists.js 2>&1

Running Command

ls -lh /home/daytona/workspace/alpha2-ppt/Alpha2_Agonists_MD_Anesthesia.pptx

Your presentation is ready!

Alpha2 Agonists MD Anesthesia

Presentation · PPTX

16 slides covering both drugs comprehensively, with a dual-color design (blue for Dex, green for Clonidine):

Slide	Content
1	Title slide — split Dex vs Clonidine design
2	Contents
3	Alpha-2 receptor subtypes (α2A, α2B, α2C) + selectivity comparison
4	Dexmedetomidine — introduction, physicochemical properties
5	Dexmedetomidine — mechanism of action (locus coeruleus, spinal, peripheral)
6	Dexmedetomidine — full pharmacokinetics table
7	Dexmedetomidine — pharmacodynamics (CVS, respiratory, CNS/EEG)
8	Dexmedetomidine — clinical uses & dosing (6 indications)
9	Dexmedetomidine — adverse effects & contraindications
10	Clonidine — introduction & mechanism of action
11	Clonidine — pharmacokinetics table + dosing guide
12	Clonidine — clinical uses in anesthesia & medicine
13	Clonidine — adverse effects, withdrawal & drug interactions
14	Head-to-head comparison table (18 parameters)
15	Anesthetic applications summary table
16	References (Miller's, Barash, Morgan & Mikhail, Katzung, Goodman & Gilman)

Inj.ephedrine , inj. Mephentermine, inj. Phenylephrine in MD Anesthesia

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Running Command

mkdir -p /home/daytona/workspace/vasopressor-ppt && echo "ready"

Writing File

~/vasopressor-ppt/vasopressors.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.author = "MD Anesthesia";
pres.title = "Vasopressors in Anesthesia: Ephedrine, Mephentermine & Phenylephrine";

// ── PALETTE ─────────────────────────────────────────────────
const C = {
  bg:    "0C1B2E",
  eph:   "C0392B",   // ephedrine – red
  meph:  "D4820A",   // mephentermine – amber
  phe:   "1565C0",   // phenylephrine – blue
  teal:  "0ABFBC",
  gold:  "F5A623",
  white: "FFFFFF",
  grey:  "94A3B8",
  lt:    "D6EAF8",
  panel: "102840",
  dark:  "071525",
  green: "1E8449",
};

// ── HELPERS ─────────────────────────────────────────────────
function addBg(slide, color = C.bg) {
  slide.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:7.5,fill:{color} });
}
function hdr(slide, title, accentColor = C.teal) {
  slide.addShape(pres.ShapeType.rect, { x:0,y:0,w:13.3,h:1.0,fill:{color:accentColor} });
  slide.addText(title, { x:0.3,y:0.08,w:12.7,h:0.85, fontSize:25,bold:true,color:C.white,fontFace:"Calibri",valign:"middle" });
  slide.addShape(pres.ShapeType.rect, { x:0,y:7.22,w:13.3,h:0.28,fill:{color:accentColor} });
  slide.addText("MD Anesthesia  |  Vasopressors: Ephedrine · Mephentermine · Phenylephrine", {
    x:0.3,y:7.22,w:12.7,h:0.28, fontSize:9,color:C.white,fontFace:"Calibri",align:"right",valign:"middle" });
}
function buls(slide, items, opts={}) {
  const base={x:0.4,y:1.1,w:12.5,h:6.0,fontSize:16,color:C.white,fontFace:"Calibri",valign:"top",paraSpaceAfter:5};
  const cfg={...base,...opts};
  const rich=[];
  items.forEach((item,i)=>{
    const last=i===items.length-1;
    if(typeof item==="string"){
      rich.push({text:item,options:{bullet:{color:C.gold,indent:14},breakLine:!last,paraSpaceAfter:5}});
    } else {
      rich.push({text:item.text,options:{bullet:{color:item.bc||C.gold,indent:14},breakLine:true,bold:!!item.bold,color:item.color||C.white,paraSpaceAfter:4,fontSize:item.sz||cfg.fontSize}});
      if(item.sub){
        item.sub.forEach((s,si)=>{
          rich.push({text:"    \u2013  "+s,options:{bullet:false,breakLine:!(si===item.sub.length-1&&last),color:C.grey,fontSize:(item.sz||cfg.fontSize)-2,paraSpaceAfter:3}});
        });
      }
    }
  });
  slide.addText(rich,cfg);
}
function box(slide,x,y,w,h,headerText,headerColor,items,fontSize=13){
  slide.addShape(pres.ShapeType.rect,{x,y,w,h,fill:{color:C.panel},line:{color:headerColor,width:1.5}});
  slide.addShape(pres.ShapeType.rect,{x,y,w,h:0.42,fill:{color:headerColor}});
  slide.addText(headerText,{x,y,w,h:0.42,fontSize:13,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  const rich=items.map((t,i)=>({text:t,options:{bullet:{color:headerColor},breakLine:i<items.length-1,paraSpaceAfter:5,fontSize,color:C.white}}));
  slide.addText(rich,{x:x+0.1,y:y+0.48,w:w-0.2,h:h-0.55,fontFace:"Calibri",valign:"top"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); addBg(s);
  // Three colour panels
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:4.43,h:7.5,fill:{color:"1A0808"}});
  s.addShape(pres.ShapeType.rect,{x:4.43,y:0,w:4.44,h:7.5,fill:{color:"1A1000"}});
  s.addShape(pres.ShapeType.rect,{x:8.87,y:0,w:4.43,h:7.5,fill:{color:"080F1A"}});
  // Dividers
  s.addShape(pres.ShapeType.rect,{x:4.38,y:0,w:0.1,h:7.5,fill:{color:C.gold}});
  s.addShape(pres.ShapeType.rect,{x:8.82,y:0,w:0.1,h:7.5,fill:{color:C.gold}});

  // Drug names
  s.addText("Inj.\nEPHEDRINE",{x:0.2,y:2.0,w:4.0,h:2.0,fontSize:32,bold:true,color:C.eph,fontFace:"Calibri",align:"center",charSpacing:2});
  s.addText("Inj.\nMEPHENTERMINE",{x:4.55,y:2.0,w:4.2,h:2.0,fontSize:28,bold:true,color:C.meph,fontFace:"Calibri",align:"center",charSpacing:2});
  s.addText("Inj.\nPHENYLEPHRINE",{x:9.0,y:2.0,w:4.1,h:2.0,fontSize:28,bold:true,color:C.phe,fontFace:"Calibri",align:"center",charSpacing:2});

  s.addText("VASOPRESSORS IN ANAESTHESIA",{x:0.3,y:4.3,w:12.7,h:0.7,fontSize:24,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:5});
  s.addShape(pres.ShapeType.rect,{x:1.5,y:5.1,w:10.3,h:0.05,fill:{color:C.gold}});
  s.addText("Mechanism · Pharmacokinetics · Clinical Uses · Dosing · Adverse Effects · Comparison",{x:0.3,y:5.25,w:12.7,h:0.45,fontSize:14,color:C.grey,fontFace:"Calibri",align:"center"});
  s.addText("MD ANESTHESIA  |  2026",{x:0.3,y:5.9,w:12.7,h:0.45,fontSize:16,bold:true,color:C.grey,fontFace:"Calibri",align:"center",charSpacing:4});
  s.addText("Sources: Morgan & Mikhail 7e · Barash's Clinical Anesthesia 9e · Goodman & Gilman · Miller's Anesthesia 10e",{x:0.3,y:6.5,w:12.7,h:0.35,fontSize:10,italic:true,color:C.grey,fontFace:"Calibri",align:"center"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 2 — CONTENTS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Contents",C.teal);
  buls(s,[
    "1.  Adrenergic Receptor Classification — Quick Review",
    "2.  Overview: Sympathomimetics in Anaesthesia",
    "3.  Inj. Ephedrine — Mechanism of Action",
    "4.  Inj. Ephedrine — Pharmacokinetics",
    "5.  Inj. Ephedrine — Pharmacodynamics & Clinical Uses",
    "6.  Inj. Ephedrine — Dosing, Adverse Effects & Tachyphylaxis",
    "7.  Inj. Mephentermine — Mechanism, PK & PD",
    "8.  Inj. Mephentermine — Clinical Uses, Dosing & Adverse Effects",
    "9.  Inj. Phenylephrine — Mechanism of Action",
    "10. Inj. Phenylephrine — Pharmacokinetics & Dosing",
    "11. Inj. Phenylephrine — Clinical Uses & Adverse Effects",
    "12. Ephedrine vs Phenylephrine — Obstetric Anaesthesia",
    "13. Head-to-Head Comparison Table",
    "14. Anesthetic Applications Summary",
  ],{fontSize:17});
}

// ══════════════════════════════════════════════════════════
// SLIDE 3 — ADRENERGIC RECEPTOR REVIEW
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Adrenergic Receptor Classification — Quick Review",C.teal);
  const rows=[
    ["α1","Post-synaptic","Vasoconstriction (arterial & venous), ↑ SVR, mydriasis, ↑ urethral tone","Phenylephrine"],
    ["α2","Pre-synaptic","↓ NE release, sedation, ↓ sympathetic outflow, analgesia","Clonidine, Dex"],
    ["β1","Cardiac","↑ HR, ↑ Contractility, ↑ Conduction velocity, ↑ CO","Ephedrine (partial)"],
    ["β2","Bronchial/Vascular","Bronchodilation, vasodilation (skeletal muscle), ↓ SVR","Ephedrine (partial)"],
    ["β3","Adipose","Lipolysis, thermogenesis (minor clinical role)","—"],
  ];
  const hY=1.1;
  [["RECEPTOR","α/β type"],["LOCATION",""],["MAIN EFFECTS",""],["EXAMPLE AGONIST",""]].forEach((_,ci)=>{
    const xs=[0.35,1.45,3.5,9.3]; const ws=[1.0,2.0,5.7,3.7];
    s.addShape(pres.ShapeType.rect,{x:xs[ci],y:hY,w:ws[ci],h:0.42,fill:{color:C.teal}});
    s.addText(_[0],{x:xs[ci],y:hY,w:ws[ci],h:0.42,fontSize:13,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  });
  rows.forEach((row,i)=>{
    const y=1.52+i*1.06;
    const colors=[C.eph,"#8E44AD",C.meph,C.phe,"#555"];
    const bg2=i%2===0?C.panel:C.dark;
    const xs=[0.35,1.45,3.5,9.3];const ws=[1.0,2.0,5.7,3.7];
    s.addShape(pres.ShapeType.rect,{x:xs[0],y,w:ws[0],h:0.95,fill:{color:colors[i]||C.panel}});
    s.addText(row[0],{x:xs[0],y,w:ws[0],h:0.95,fontSize:22,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    [1,2,3].forEach(ci=>{
      s.addShape(pres.ShapeType.rect,{x:xs[ci],y,w:ws[ci],h:0.95,fill:{color:bg2}});
      s.addText(row[ci],{x:xs[ci]+0.05,y,w:ws[ci]-0.1,h:0.95,fontSize:13,color:C.white,fontFace:"Calibri",valign:"middle"});
    });
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 4 — EPHEDRINE MECHANISM
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Ephedrine — Mechanism of Action",C.eph);

  // highlight def
  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.48,fill:{color:C.panel},line:{color:C.eph,width:1.5}});
  s.addText("Non-catecholamine sympathomimetic  |  Mixed-acting agonist (Direct + Indirect)  |  α1, β1, β2",{
    x:0.35,y:1.08,w:12.6,h:0.48,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  buls(s,[
    {text:"Indirect action (PREDOMINANT)",bold:true,sz:16,bc:C.eph,sub:[
      "Ephedrine taken up into presynaptic adrenergic nerve terminals",
      "Displaces norepinephrine (NE) from synaptic vesicles",
      "Displaced NE released → activates postsynaptic α and β receptors",
      "→ Vasoconstriction (α1) + ↑ HR & ↑ contractility (β1) + bronchodilation (β2)",
    ]},
    {text:"Direct action (secondary)",bold:true,sz:16,bc:C.eph,sub:[
      "Also directly stimulates β-adrenoceptors (β1 and β2)",
      "Limits degree of hypertension caused by α-receptor activation",
      "Bronchodilator — β2 direct effect",
    ]},
    {text:"Tachyphylaxis mechanism",bold:true,sz:16,bc:C.gold,sub:[
      "Presynaptic NE stores rapidly depleted with repeated dosing",
      "Ephedrine then released as 'false neurotransmitter' (less potent)",
      "Unlike epinephrine (direct agonist) — tachyphylaxis DOES NOT occur with epinephrine",
      "Drugs blocking uptake (cocaine) or depleting NE (reserpine) ATTENUATE ephedrine's effect",
    ]},
    {text:"CNS stimulation",bold:true,sz:16,bc:C.meph,sub:[
      "Potent CNS stimulant — raises MAC (minimum alveolar concentration)",
    ]},
  ],{y:1.65,h:5.6,fontSize:16});
}

// ══════════════════════════════════════════════════════════
// SLIDE 5 — EPHEDRINE PHARMACOKINETICS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Ephedrine — Pharmacokinetics",C.eph);
  const pkRows=[
    ["Drug class","Non-catecholamine sympathomimetic; phenylethylamine derivative"],
    ["Receptor action","Mixed: α1, β1, β2 (direct + indirect via NE release)"],
    ["Routes","IV bolus / IV infusion / IM / Oral (all effective)"],
    ["Oral bioavailability","Good — effective after oral administration"],
    ["Onset (IV)","~1 min"],
    ["Duration of action","Longer than epinephrine: 15–60 minutes"],
    ["Protein binding","~20%"],
    ["Metabolism","Minimal hepatic; not metabolised by MAO or COMT (unlike catecholamines)"],
    ["Elimination","Excreted largely UNCHANGED in urine; t½ = 3–6 hours"],
    ["Renal pH effect","Elimination ↑ with acidic urine (ion trapping)"],
    ["Crosses BBB","Yes — CNS stimulant; raises MAC"],
    ["Crosses placenta","Yes — used in obstetric anesthesia; fetal transfer occurs"],
    ["Availability","1-mL ampules containing 25 mg or 50 mg"],
  ];
  pkRows.forEach((row,i)=>{
    const y=1.1+i*0.47;
    const bg2=i%2===0?C.panel:C.dark;
    s.addShape(pres.ShapeType.rect,{x:0.35,y,w:4.5,h:0.44,fill:{color:bg2}});
    s.addShape(pres.ShapeType.rect,{x:4.9,y,w:8.05,h:0.44,fill:{color:bg2}});
    s.addText(row[0],{x:0.45,y:y+0.03,w:4.3,h:0.38,fontSize:13,bold:true,color:C.lt,fontFace:"Calibri",valign:"middle"});
    s.addText(row[1],{x:5.0,y:y+0.03,w:7.85,h:0.38,fontSize:13,color:C.white,fontFace:"Calibri",valign:"middle"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 6 — EPHEDRINE PHARMACODYNAMICS & CLINICAL USES
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Ephedrine — Pharmacodynamics & Clinical Uses",C.eph);
  box(s,0.35,1.08,6.1,3.0,"CARDIOVASCULAR EFFECTS",C.eph,[
    "↑ Heart rate (β1)",
    "↑ Contractility (β1) → ↑ CO",
    "↑ Systemic vascular resistance (α1)",
    "↑ Both systolic & diastolic BP",
    "Venoconstriction → ↑ preload",
    "Coronary vasodilation (β2) — ↑ myocardial O₂ supply",
  ],13.5);
  box(s,6.85,1.08,6.1,3.0,"RESPIRATORY & OTHER EFFECTS",C.meph,[
    "Bronchodilation (β2) — useful in bronchospasm",
    "Nasal decongestant (α1 mucosal vasoconstriction)",
    "↑ Bladder sphincter tone (α1) — urinary retention risk in BPH",
    "CNS stimulant — raises MAC",
    "Cross-tolerance with amphetamines",
  ],13.5);

  // Clinical uses box spanning full width
  box(s,0.35,4.22,12.6,2.9,"CLINICAL USES IN ANAESTHESIA",C.gold,[
    "Intraoperative hypotension (spinal / epidural / general anaesthesia) — temporising measure",
    "Preferred when hypotension is accompanied by BRADYCARDIA (mixed α+β action maintains HR)",
    "Obstetric spinal anaesthesia — historically preferred; now largely replaced by phenylephrine (see Slide 12)",
    "Bronchospasm during anaesthesia (β2 effect)",
    "Hypotension in patients where tachycardia is acceptable",
    "Nasal decongestant pre-intubation (topical)",
    "Reversal of hypotension due to spinal cord injury with neurogenic shock",
  ],13);
}

// ══════════════════════════════════════════════════════════
// SLIDE 7 — EPHEDRINE DOSING & ADVERSE EFFECTS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Ephedrine — Dosing, Adverse Effects & Tachyphylaxis",C.eph);
  box(s,0.35,1.08,5.9,3.2,"DOSING",C.eph,[
    "Adults (IV bolus): 2.5–10 mg; titrate to BP response",
    "Adults (IM): 15–25 mg",
    "Children (IV bolus): 0.1 mg/kg",
    "Infusion (uncommon): 25–50 mg in 500 mL NS → titrate",
    "Subsequent doses: increase to offset tachyphylaxis",
    "Availability: 25 mg/mL or 50 mg/mL ampoules (dilute before use)",
    "Dilution: typically to 3 mg/mL or 5 mg/mL",
  ],13.5);
  box(s,6.55,1.08,6.4,3.2,"ADVERSE EFFECTS",C.red,[
    "Tachycardia (β1) — use cautiously in CAD",
    "Hypertension (α1 + β1)",
    "Tachyphylaxis — repeat dosing less effective",
    "Palpitations / arrhythmias",
    "CNS: anxiety, restlessness, insomnia, tremor",
    "Urinary retention (esp. men with BPH — α1 bladder neck)",
    "Headache",
    "Nausea",
  ],13.5);

  // Tachyphylaxis detail
  s.addShape(pres.ShapeType.rect,{x:0.35,y:4.42,w:12.6,h:2.7,fill:{color:C.panel},line:{color:C.gold,width:1.5}});
  s.addShape(pres.ShapeType.rect,{x:0.35,y:4.42,w:12.6,h:0.42,fill:{color:C.gold}});
  s.addText("TACHYPHYLAXIS — Why It Happens",{x:0.35,y:4.42,w:12.6,h:0.42,fontSize:13,bold:true,color:C.dark,fontFace:"Calibri",align:"center",valign:"middle"});
  buls(s,[
    "Repeated ephedrine → NE stores rapidly depleted from presynaptic terminals",
    "Ephedrine released as a 'false neurotransmitter' — minimal adrenergic activity",
    "Solution: increase subsequent doses OR switch to a DIRECT-ACTING agent (phenylephrine, norepinephrine)",
    "No tachyphylaxis with epinephrine (direct α+β agonist, independent of NE stores)",
  ],{x:0.5,y:4.9,w:12.3,h:2.1,fontSize:14,color:C.white});
}

// ══════════════════════════════════════════════════════════
// SLIDE 8 — MEPHENTERMINE
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Mephentermine — Mechanism, Pharmacokinetics & Pharmacodynamics",C.meph);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.45,fill:{color:C.panel},line:{color:C.meph,width:1.5}});
  s.addText("Non-catecholamine sympathomimetic  |  Mixed-acting (Direct + Indirect)  |  Acts on α1, β1, β2 receptors",{
    x:0.35,y:1.08,w:12.6,h:0.45,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  box(s,0.35,1.65,6.1,3.3,"MECHANISM OF ACTION",C.meph,[
    "Mixed-acting: both direct receptor stimulation AND indirect NE release",
    "Direct α1 stimulation → peripheral vasoconstriction",
    "Indirect → displaces NE from presynaptic terminals (like ephedrine)",
    "β1 stimulation → ↑ HR, ↑ contractility, ↑ CO",
    "β2 stimulation → mild bronchodilation",
    "Less potent α1 effect compared to phenylephrine",
    "Similar mechanism to ephedrine; slightly longer duration",
  ],13.5);

  box(s,6.85,1.65,6.1,3.3,"PHARMACOKINETICS",C.meph,[
    "Onset (IV): 1–3 minutes",
    "Duration of action: 20–60 minutes (longer than ephedrine)",
    "Metabolism: hepatic N-demethylation",
    "Elimination: renal; partly unchanged",
    "t½: approximately 15–20 minutes (IV)",
    "Oral: well absorbed (also used orally for orthostatic hypotension)",
    "Crosses BBB: yes — CNS stimulation possible",
    "Placental transfer: yes",
  ],13.5);

  box(s,0.35,5.1,12.6,2.1,"PHARMACODYNAMICS",C.gold,[
    "↑ Blood pressure (systolic and diastolic) via ↑ CO + ↑ SVR",
    "↑ Heart rate (β1) — less pronounced tachycardia than ephedrine in some studies",
    "Venoconstriction → ↑ venous return → ↑ preload",
    "Maintains uterine blood flow (in experimental studies — similar to ephedrine)",
    "Tachyphylaxis: similar to ephedrine (NE depletion mechanism)",
  ],13.5);
}

// ══════════════════════════════════════════════════════════
// SLIDE 9 — MEPHENTERMINE CLINICAL USES & DOSING
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Mephentermine — Clinical Uses, Dosing & Adverse Effects",C.meph);
  box(s,0.35,1.08,5.9,3.2,"CLINICAL USES IN ANAESTHESIA",C.meph,[
    "Spinal/epidural hypotension — alternative to ephedrine",
    "Intraoperative hypotension (GA) when tachycardia not a concern",
    "Widely used in Indian anaesthesia practice",
    "Obstetric spinal anesthesia — used in developing countries",
    "Prevention of hypotension — given IM before spinal",
    "Neurogenic shock (spinal cord injury)",
    "Orthostatic hypotension (oral form)",
  ],13.5);
  box(s,6.55,1.08,6.4,3.2,"DOSING",C.meph,[
    "IV bolus (adult): 3–6 mg; repeat as needed",
    "IV bolus (intraoperative): up to 15 mg IV as single dose",
    "IM (prevention): 15 mg IM before spinal block",
    "Infusion: 0.5–1 mg/min infusion, titrate to effect",
    "Pediatric: 0.1 mg/kg IV",
    "Availability: 15 mg/mL ampoule (1 mL = 15 mg)",
    "Dilute for infusion: typically to 1 mg/mL",
  ],13.5);

  box(s,0.35,4.42,5.9,2.7,"ADVERSE EFFECTS",C.red,[
    "Tachycardia (β1)",
    "Hypertension",
    "Palpitations / arrhythmias",
    "CNS stimulation: anxiety, insomnia",
    "Tachyphylaxis (like ephedrine)",
    "Urinary retention",
  ],13.5);
  box(s,6.55,4.42,6.4,2.7,"CONTRAINDICATIONS / CAUTIONS",C.gold,[
    "Hypertension — may exacerbate",
    "Hyperthyroidism — ↑ sensitivity to sympathomimetics",
    "Patients on MAO inhibitors — hypertensive crisis risk",
    "Tachyarrhythmias — avoid β1 stimulation",
    "Narrow-angle glaucoma",
  ],13.5);
}

// ══════════════════════════════════════════════════════════
// SLIDE 10 — PHENYLEPHRINE MECHANISM
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Phenylephrine — Mechanism of Action",C.phe);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.45,fill:{color:C.panel},line:{color:C.phe,width:1.5}});
  s.addText("Non-catecholamine  |  PURE α1-selective agonist  |  Direct-acting (no NE release)  |  NOT arrhythmogenic",{
    x:0.35,y:1.08,w:12.6,h:0.45,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  buls(s,[
    {text:"Primary mechanism: selective α1-adrenoceptor agonism",bold:true,sz:16,bc:C.phe,sub:[
      "Structure similar to epinephrine — lacks hydroxyl group on phenyl ring",
      "Almost EXCLUSIVELY stimulates α1 receptors",
      "No significant β-receptor activation at clinical doses",
      "Acts DIRECTLY on postsynaptic α1 receptor (independent of NE stores)",
      "No tachyphylaxis from NE depletion (unlike ephedrine/mephentermine)",
    ]},
    {text:"Vascular effects (α1)",bold:true,sz:16,bc:C.phe,sub:[
      "Arterial vasoconstriction → ↑ SVR → ↑ MAP",
      "Venous vasoconstriction (capacitance vessels) → ↑ preload",
      "Cutaneous, skeletal muscle, mesenteric, splenic, renal vasoconstriction",
      "↑ LV afterload and preload",
      "Pulmonary arterial vasoconstriction → ↑ PAP",
    ]},
    {text:"Cardiac effects (reflex)",bold:true,sz:16,bc:C.gold,sub:[
      "Baroreceptor-mediated REFLEX BRADYCARDIA — vagal response to ↑ BP",
      "Cardiac output usually UNCHANGED when LV function normal",
      "CO may DECLINE if HFrEF present (failing heart sensitive to ↑ afterload)",
      "NOT arrhythmogenic — unlike catecholamines",
    ]},
  ],{y:1.62,h:5.6,fontSize:16});
}

// ══════════════════════════════════════════════════════════
// SLIDE 11 — PHENYLEPHRINE PK & DOSING
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Phenylephrine — Pharmacokinetics & Dosing",C.phe);
  const pkRows=[
    ["Drug class","Non-catecholamine; phenylethylamine; α1-selective agonist"],
    ["Action type","DIRECT-acting only — no NE release"],
    ["Receptors","α1 (selective); β at very high concentrations only"],
    ["Onset (IV)","~1 minute (very rapid)"],
    ["Duration (IV bolus)","~15 minutes (short — easy titration)"],
    ["Metabolism","Hepatic (MAO) + some extrahepatic"],
    ["Protein binding","~95%"],
    ["Excretion","Renal"],
    ["Availability","1% solution = 10 mg/mL ampoule (100 mg/10 mL)"],
    ["Standard dilution","Dilute to 100 mcg/mL (0.1 mg/mL) for IV bolus use"],
    ["Further dilution","For infusion: 10 mcg/mL solution"],
    ["Tachyphylaxis","Minimal — direct-acting, not dependent on NE stores"],
  ];
  pkRows.forEach((row,i)=>{
    const y=1.1+i*0.48;
    const bg2=i%2===0?C.panel:C.dark;
    s.addShape(pres.ShapeType.rect,{x:0.35,y,w:4.5,h:0.45,fill:{color:bg2}});
    s.addShape(pres.ShapeType.rect,{x:4.9,y,w:8.05,h:0.45,fill:{color:bg2}});
    s.addText(row[0],{x:0.45,y:y+0.03,w:4.3,h:0.38,fontSize:13,bold:true,color:C.lt,fontFace:"Calibri",valign:"middle"});
    s.addText(row[1],{x:5.0,y:y+0.03,w:7.85,h:0.38,fontSize:13,color:C.white,fontFace:"Calibri",valign:"middle"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 12 — PHENYLEPHRINE CLINICAL USES & ADR
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Inj. Phenylephrine — Clinical Uses & Adverse Effects",C.phe);
  box(s,0.35,1.08,6.1,3.8,"CLINICAL USES IN ANAESTHESIA",C.phe,[
    "Spinal/epidural hypotension — drug of choice when HR normal or elevated",
    "Obstetric spinal anaesthesia — PREFERRED over ephedrine (faster onset, easy titration, no fetal acidosis)",
    "Bolus: 50–100 mcg IV rapidly reverses vasodilatory hypotension",
    "Infusion: 25–100 mcg/min titrated to maintain MAP",
    "Hypotension in context of tachycardia (α1 causes reflex bradycardia)",
    "SVT (supraventricular tachycardia) — vagal baroreceptor reflex terminates SVT",
    "Nasal decongestant (topical — vasoconstriction of nasal mucosa)",
    "Mydriasis (ophthalmic — α1 dilator pupillae)",
    "Tetralogy of Fallot hypercyanotic spells — ↑ SVR decreases R→L shunt",
  ],13);
  box(s,6.85,1.08,6.1,3.8,"ADVERSE EFFECTS",C.red,[
    "Reflex BRADYCARDIA — most common (may require atropine)",
    "↑ Afterload — may ↓ CO in heart failure (HFrEF)",
    "Pulmonary hypertension — ↑ PAP (avoid in severe pulmonary HTN)",
    "Renal & splanchnic vasoconstriction (prolonged use)",
    "Severe hypertension — rapid IV bolus",
    "Headache",
    "Topical eye drops: systemic absorption → HTN, arrhythmia (esp. 10% drops in elderly/CAD)",
    "Tachyphylaxis with prolonged infusion — upward titration needed",
  ],13);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:5.0,w:12.6,h:0.45,fill:{color:C.panel},line:{color:C.phe,width:1}});
  s.addText("⚠  NOT arrhythmogenic  |  Preferred over ephedrine if HR is high  |  Avoid in HFrEF  |  Avoid in severe pulmonary hypertension",{
    x:0.35,y:5.0,w:12.6,h:0.45,fontSize:13,bold:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 13 — OBSTETRIC COMPARISON
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Ephedrine vs Phenylephrine — Obstetric Spinal Anaesthesia",C.teal);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.42,fill:{color:C.panel}});
  s.addText("Treatment of maternal hypotension after spinal anesthesia for caesarean section — a landmark clinical debate",{
    x:0.35,y:1.08,w:12.6,h:0.42,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  const compRows=[
    ["Parameter","EPHEDRINE","PHENYLEPHRINE"],
    ["Receptor action","α1 + β1 + β2 (mixed)","α1 only (pure)"],
    ["Onset","1–2 min","~1 min (faster)"],
    ["Duration","15–60 min","~15 min (shorter, easier titration)"],
    ["Effect on HR","↑ HR (β1)","↓ HR (reflex bradycardia)"],
    ["Effect on CO","↑ CO (β1)","Usually unchanged; ↓ in HFrEF"],
    ["Effect on fetal pH","↓ Fetal pH (acidosis risk — β-mediated ↑ fetal metabolism)","Better preserved fetal pH"],
    ["Uterine blood flow","Maintained (historically favoured)","Also maintained"],
    ["Current preference","Still used if HR < 60 bpm","PREFERRED in obstetric spinal (AAN/OAA guidelines)"],
    ["Tachyphylaxis","YES — NE depletion","Minimal — direct-acting"],
    ["Arrhythmias","Possible (β stimulation)","NOT arrhythmogenic"],
  ];

  const cols=[0.35,3.5,8.35];const cw=[3.1,4.7,4.7];
  const hColors=[C.teal,C.eph,C.phe];
  compRows[0].forEach((h,ci)=>{
    s.addShape(pres.ShapeType.rect,{x:cols[ci],y:1.58,w:cw[ci],h:0.42,fill:{color:hColors[ci]}});
    s.addText(h,{x:cols[ci],y:1.58,w:cw[ci],h:0.42,fontSize:13,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  });
  compRows.slice(1).forEach((row,i)=>{
    const y=2.0+i*0.5;
    const bg2=i%2===0?C.panel:C.dark;
    row.forEach((cell,ci)=>{
      s.addShape(pres.ShapeType.rect,{x:cols[ci],y,w:cw[ci],h:0.47,fill:{color:bg2}});
      s.addText(cell,{x:cols[ci]+0.05,y,w:cw[ci]-0.1,h:0.47,fontSize:12,color:ci===0?C.lt:C.white,fontFace:"Calibri",valign:"middle",bold:ci===0});
    });
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 14 — HEAD-TO-HEAD COMPARISON
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Head-to-Head Comparison — Ephedrine · Mephentermine · Phenylephrine",C.teal);
  const rows=[
    ["Feature","EPHEDRINE","MEPHENTERMINE","PHENYLEPHRINE"],
    ["Class","Non-catecholamine","Non-catecholamine","Non-catecholamine"],
    ["Action type","Mixed (Direct+Indirect)","Mixed (Direct+Indirect)","Direct only"],
    ["Receptors","α1, β1, β2","α1, β1, β2","α1 SELECTIVE"],
    ["HR effect","↑↑ HR (β1)","↑ HR (β1)","↓ HR (reflex)"],
    ["BP effect","↑ SBP & DBP","↑ SBP & DBP","↑ SBP & DBP"],
    ["CO effect","↑ CO","↑ CO","Usually unchanged"],
    ["SVR","↑ (moderate)","↑ (moderate)","↑↑ (marked)"],
    ["Onset (IV)","~1 min","1–3 min","~1 min"],
    ["Duration","15–60 min","20–60 min","~15 min"],
    ["t½","3–6 h","15–20 min","Varies"],
    ["Tachyphylaxis","YES","YES","Minimal"],
    ["CNS stimulation","YES (↑ MAC)","YES (less)","No"],
    ["Bronchodilation","YES (β2)","Mild","No"],
    ["Arrhythmias","Possible","Possible","NOT arrhythmogenic"],
    ["Fetal pH (obstetric)","↓ (acidosis risk)","↓ (similar to ephedrine)","Better preserved"],
    ["Obstetric preference","2nd line (if HR low)","Limited use","1st choice (normal HR)"],
    ["Dose (IV bolus)","2.5–10 mg","3–6 mg","50–100 mcg"],
    ["Availability","25/50 mg/mL","15 mg/mL","10 mg/mL (1%)"],
  ];
  const cols=[0.35,4.0,7.35,10.65];const cw=[3.55,3.25,3.2,2.55];
  const hC=[C.teal,C.eph,C.meph,C.phe];
  rows[0].forEach((h,ci)=>{
    s.addShape(pres.ShapeType.rect,{x:cols[ci],y:1.08,w:cw[ci],h:0.4,fill:{color:hC[ci]}});
    s.addText(h,{x:cols[ci],y:1.08,w:cw[ci],h:0.4,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  });
  rows.slice(1).forEach((row,i)=>{
    const y=1.48+i*0.315;
    const bg2=i%2===0?C.panel:C.dark;
    row.forEach((cell,ci)=>{
      s.addShape(pres.ShapeType.rect,{x:cols[ci],y,w:cw[ci],h:0.3,fill:{color:bg2}});
      s.addText(cell,{x:cols[ci]+0.04,y,w:cw[ci]-0.08,h:0.3,fontSize:11,color:ci===0?C.lt:C.white,fontFace:"Calibri",valign:"middle",bold:ci===0});
    });
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 15 — ANESTHETIC APPLICATIONS SUMMARY
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"Anesthetic Applications — Clinical Decision Guide",C.teal);

  const scenarios=[
    {
      scenario:"Spinal hypotension + BRADYCARDIA",
      choice:"EPHEDRINE or MEPHENTERMINE",
      why:"Mixed α+β action: ↑ HR + ↑ BP simultaneously",
      color:C.eph,
    },
    {
      scenario:"Spinal hypotension + NORMAL/HIGH HR",
      choice:"PHENYLEPHRINE (PREFERRED)",
      why:"Pure α1: ↑ BP without further ↑ HR; better fetal pH in obstetrics",
      color:C.phe,
    },
    {
      scenario:"Obstetric spinal (Caesarean Section)",
      choice:"PHENYLEPHRINE (1st choice)",
      why:"Faster onset, easy titration, superior fetal acid-base balance vs ephedrine",
      color:C.phe,
    },
    {
      scenario:"SVT with hypotension",
      choice:"PHENYLEPHRINE",
      why:"α1 → ↑ BP → baroreceptor → vagal → terminates SVT reflexly",
      color:C.phe,
    },
    {
      scenario:"Bronchospasm + hypotension",
      choice:"EPHEDRINE",
      why:"β2 bronchodilation + α1/β1 pressor effect — dual benefit",
      color:C.eph,
    },
    {
      scenario:"Tetralogy of Fallot (hypercyanotic spell)",
      choice:"PHENYLEPHRINE",
      why:"↑ SVR → reduces R→L shunting through VSD",
      color:C.phe,
    },
    {
      scenario:"Hypotension in HFrEF patient",
      choice:"EPHEDRINE (cautiously)",
      why:"Phenylephrine ↑ afterload may ↓ CO in failing heart; ephedrine's β1 maintains CO",
      color:C.eph,
    },
    {
      scenario:"Prevention of spinal hypotension (IM)",
      choice:"MEPHENTERMINE 15 mg IM",
      why:"Longer duration IM; commonly used in Indian practice before spinal block",
      color:C.meph,
    },
  ];

  scenarios.forEach((sc,i)=>{
    const col=i%2;
    const row=Math.floor(i/2);
    const x=col===0?0.35:6.85;
    const y=1.08+row*1.55;
    s.addShape(pres.ShapeType.rect,{x,y,w:6.1,h:1.42,fill:{color:C.panel},line:{color:sc.color,width:1.5}});
    s.addShape(pres.ShapeType.rect,{x,y,w:6.1,h:0.35,fill:{color:sc.color}});
    s.addText(sc.scenario,{x,y,w:6.1,h:0.35,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    s.addText("Choice: "+sc.choice,{x:x+0.1,y:y+0.4,w:5.9,h:0.38,fontSize:13,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle"});
    s.addText("Why: "+sc.why,{x:x+0.1,y:y+0.8,w:5.9,h:0.55,fontSize:11.5,color:C.grey,fontFace:"Calibri",valign:"top"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 16 — REFERENCES
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide();addBg(s);hdr(s,"References",C.teal);
  const refs=[
    "Morgan GE, Mikhail MS. Morgan & Mikhail's Clinical Anesthesiology, 7th Edition. McGraw-Hill; 2022. Chapter on Sympathomimetics.",
    "Barash PG et al. Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition. Wolters Kluwer; 2022. Chapter 14 & 53.",
    "Brunton LL et al. Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th Edition. McGraw-Hill; 2023. Chapter 14.",
    "Miller RD et al. Miller's Anesthesia, 10th Edition. Elsevier; 2023. Chapter 24 (Obstetric Anesthesia) and Chapter 57.",
    "Ngan Kee WD et al. A quantitative systematic review: ephedrine vs phenylephrine for spinal hypotension in caesarean delivery. Anesth Analg 2002;94:920–926.",
    "Ngan Kee WD. Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010;23:304–309.",
    "Kee WD, Khaw KS, Ng FF. Phenylephrine infusion vs. bolus for spinal anaesthesia in caesarean section. Anesth Analg 2004;98:815–821.",
    "Goodwin APL. Management of maternal hypotension — vasopressors in obstetric anaesthesia. CEACCP 2010;10:126–131.",
    "WHO Essential Medicines List — Ephedrine listed for spinal anaesthesia during delivery.",
  ];
  refs.forEach((r,i)=>{
    s.addText(`${i+1}.  ${r}`,{x:0.4,y:1.15+i*0.67,w:12.5,h:0.6,fontSize:12,color:i%2===0?C.white:C.grey,fontFace:"Calibri",valign:"middle"});
  });
}

// WRITE
pres.writeFile({fileName:"/home/daytona/workspace/vasopressor-ppt/Vasopressors_MD_Anesthesia.pptx"})
  .then(()=>console.log("SUCCESS"))
  .catch(e=>{console.error(e);process.exit(1);});

Running Command

cd /home/daytona/workspace/vasopressor-ppt && node vasopressors.js 2>&1

Editing File

~/vasopressor-ppt/vasopressors.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/vasopressor-ppt/vasopressors.js'

Editing File

~/vasopressor-ppt/vasopressors.js

Error: String not found in file: '    box(s,0.35,4.22,12.6,2.9,"CLINICAL USES IN ANAESTHESIA",C.gold,['

Running Command

cd /home/daytona/workspace/vasopressor-ppt && node vasopressors.js 2>&1

Running Command

ls -lh /home/daytona/workspace/vasopressor-ppt/Vasopressors_MD_Anesthesia.pptx

Your presentation is ready!

Vasopressors MD Anesthesia

Presentation · PPTX

16 slides with a tri-color design (Red = Ephedrine, Amber = Mephentermine, Blue = Phenylephrine):

Slide	Content
1	Title slide — three-panel split design
2	Contents
3	Adrenergic receptor classification (α1, α2, β1, β2, β3)
4	Ephedrine — Mechanism (indirect NE release + direct β, tachyphylaxis explained)
5	Ephedrine — Full pharmacokinetics table
6	Ephedrine — Pharmacodynamics & clinical uses
7	Ephedrine — Dosing, adverse effects & tachyphylaxis detail
8	Mephentermine — Mechanism, pharmacokinetics & pharmacodynamics
9	Mephentermine — Clinical uses, dosing & adverse effects
10	Phenylephrine — Mechanism (pure α1, reflex bradycardia, NOT arrhythmogenic)
11	Phenylephrine — Pharmacokinetics & dosing guide
12	Phenylephrine — Clinical uses & adverse effects
13	Ephedrine vs Phenylephrine — Obstetric spinal anaesthesia comparison
14	Head-to-head comparison table (19 parameters, all three drugs)
15	Clinical decision guide — 8 scenarios with drug of choice + rationale
16	References (Morgan & Mikhail, Barash, Goodman & Gilman, Miller's)

Key clinical pearl highlighted: Phenylephrine is now the preferred vasopressor for obstetric spinal anaesthesia (better fetal pH, faster onset, easy titration). Ephedrine/Mephentermine remain preferred when hypotension is accompanied by bradycardia.

Cardioplegia in MD Anesthesia

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Running Command

mkdir -p /home/daytona/workspace/cardioplegia-ppt && echo "ready"

Writing File

~/cardioplegia-ppt/cardioplegia.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.author = "MD Anesthesia";
pres.title = "Cardioplegia & Myocardial Protection";

// ── PALETTE ─────────────────────────────────────────────────
const C = {
  bg:     "07111E",
  navy:   "0A1C2E",
  teal:   "0097A7",
  ltTeal: "00BCD4",
  gold:   "FFB300",
  red:    "C62828",
  green:  "2E7D32",
  blue:   "1565C0",
  purple: "6A1B9A",
  white:  "FFFFFF",
  grey:   "90A4AE",
  lt:     "E0F7FA",
  panel:  "0D2137",
  dark:   "060E18",
};

// ── HELPERS ─────────────────────────────────────────────────
function bg(s,c=C.bg){s.addShape(pres.ShapeType.rect,{x:0,y:0,w:13.3,h:7.5,fill:{color:c}});}
function hdr(s,title,ac=C.teal){
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:13.3,h:1.0,fill:{color:ac}});
  s.addText(title,{x:0.3,y:0.1,w:12.7,h:0.82,fontSize:25,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});
  s.addShape(pres.ShapeType.rect,{x:0,y:7.22,w:13.3,h:0.28,fill:{color:ac}});
  s.addText("MD Anesthesia  |  Cardioplegia & Myocardial Protection",{x:0.3,y:7.22,w:12.7,h:0.28,fontSize:9,color:C.white,fontFace:"Calibri",align:"right",valign:"middle"});
}
function buls(s,items,opts={}){
  const base={x:0.4,y:1.1,w:12.5,h:6.1,fontSize:16,color:C.white,fontFace:"Calibri",valign:"top",paraSpaceAfter:5};
  const cfg={...base,...opts};
  const rich=[];
  items.forEach((item,i)=>{
    const last=i===items.length-1;
    if(typeof item==="string"){
      rich.push({text:item,options:{bullet:{color:C.gold,indent:14},breakLine:!last,paraSpaceAfter:5}});
    } else {
      rich.push({text:item.text,options:{bullet:{color:item.bc||C.gold,indent:14},breakLine:true,bold:!!item.bold,color:item.color||C.white,paraSpaceAfter:4,fontSize:item.sz||cfg.fontSize}});
      if(item.sub){
        item.sub.forEach((sv,si)=>{
          rich.push({text:"    \u2013  "+sv,options:{bullet:false,breakLine:!(si===item.sub.length-1&&last),color:C.grey,fontSize:(item.sz||cfg.fontSize)-2,paraSpaceAfter:3}});
        });
      }
    }
  });
  s.addText(rich,cfg);
}
function box(s,x,y,w,h,title,ac,items,fs=13.5){
  s.addShape(pres.ShapeType.rect,{x,y,w,h,fill:{color:C.panel},line:{color:ac,width:1.5}});
  s.addShape(pres.ShapeType.rect,{x,y,w,h:0.42,fill:{color:ac}});
  s.addText(title,{x,y,w,h:0.42,fontSize:13,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  const rich=items.map((t,i)=>({text:t,options:{bullet:{color:ac},breakLine:i<items.length-1,paraSpaceAfter:5,fontSize:fs,color:C.white}}));
  s.addText(rich,{x:x+0.1,y:y+0.48,w:w-0.2,h:h-0.55,fontFace:"Calibri",valign:"top"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s);
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:13.3,h:3.0,fill:{color:"0A1E30"}});
  s.addShape(pres.ShapeType.rect,{x:0,y:3.0,w:13.3,h:4.5,fill:{color:C.dark}});
  s.addShape(pres.ShapeType.rect,{x:0,y:2.9,w:13.3,h:0.12,fill:{color:C.gold}});
  // Accent left bar
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:0.18,h:7.5,fill:{color:C.teal}});
  s.addShape(pres.ShapeType.rect,{x:13.12,y:0,w:0.18,h:7.5,fill:{color:C.teal}});

  s.addText("CARDIOPLEGIA",{x:0.4,y:0.4,w:12.5,h:1.5,fontSize:70,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:10});
  s.addText("& MYOCARDIAL PROTECTION",{x:0.4,y:1.85,w:12.5,h:0.85,fontSize:28,bold:true,color:C.gold,fontFace:"Calibri",align:"center",charSpacing:4});

  s.addText("Definition  ·  Rationale  ·  Mechanisms  ·  Types of Solutions  ·  Routes of Delivery",{x:0.4,y:3.2,w:12.5,h:0.42,fontSize:15,color:C.lt,fontFace:"Calibri",align:"center"});
  s.addText("del Nido · HTK · Blood · Crystalloid · Antegrade · Retrograde · Warm vs Cold · Hot Shot · Reperfusion Injury",{x:0.4,y:3.7,w:12.5,h:0.42,fontSize:13,color:C.grey,fontFace:"Calibri",align:"center"});
  s.addShape(pres.ShapeType.rect,{x:2.5,y:4.25,w:8.3,h:0.06,fill:{color:C.teal}});
  s.addText("MD ANESTHESIA  |  2026",{x:0.4,y:4.45,w:12.5,h:0.5,fontSize:16,bold:true,color:C.grey,fontFace:"Calibri",align:"center",charSpacing:5});
  s.addText("Sources: Miller's Anesthesia 10e · Morgan & Mikhail 7e · Barash 9e · Bailey & Love's Surgery · Schwartz's Surgery",{x:0.4,y:5.1,w:12.5,h:0.38,fontSize:10,italic:true,color:C.grey,fontFace:"Calibri",align:"center"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 2 — CONTENTS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Contents",C.teal);
  buls(s,[
    "1.  Definition & Historical Background",
    "2.  Rationale for Cardioplegia — Why Stop the Heart?",
    "3.  Myocardial Protection — Triad of Protection",
    "4.  Mechanism of Cardioplegic Arrest",
    "5.  Components of Cardioplegia Solution (Ingredients)",
    "6.  Types of Cardioplegia Solutions",
    "7.  Blood vs Crystalloid Cardioplegia",
    "8.  Cardioplegia Solutions — Comparison Table (St Thomas, del Nido, HTK)",
    "9.  Routes of Delivery — Antegrade vs Retrograde",
    "10. Temperature of Cardioplegia — Cold · Warm · Tepid",
    "11. Dosing Regimens — Multidose vs Single-Dose",
    "12. Ischaemia–Reperfusion Injury & Hot Shot",
    "13. Monitoring Adequacy of Cardioplegia",
    "14. Complications & Inadequate Cardioplegia",
    "15. Role of Anaesthesiologist During Cardioplegia",
  ],{fontSize:17});
}

// ══════════════════════════════════════════════════════════
// SLIDE 3 — DEFINITION & HISTORY
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Definition & Historical Background",C.teal);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.9,fill:{color:C.panel},line:{color:C.teal,width:2}});
  s.addText('"Cardioplegia is the deliberate, temporary, reversible cessation of cardiac electromechanical activity induced by pharmacologic or physical means, to provide a still, bloodless operative field while protecting the myocardium from ischaemic injury."',{
    x:0.45,y:1.1,w:12.4,h:0.88,fontSize:15,italic:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});

  buls(s,[
    {text:"Etymology",bold:true,sz:16,bc:C.teal,sub:[
      "'Cardio' = heart   |   'Plegia' = paralysis/arrest",
      "Literally means: arrest of the heart",
    ]},
    {text:"Historical milestones",bold:true,sz:16,bc:C.gold,sub:[
      "1950s: Bigelow et al. — first used hypothermia for myocardial protection",
      "1955: Melrose introduced high-potassium cardiac arrest (first chemical cardioplegia)",
      "1970s: Gay & Ebert — low-dose K⁺ cardioplegia refined (Melrose's solution had tissue toxicity)",
      "1976: Buckberg — Blood cardioplegia introduced; St Thomas Hospital solution developed",
      "1980s: HTK (Bretschneider) solution — prolonged single-dose arrest",
      "2010s: del Nido solution — single-dose pediatric & adult use",
      "WHO Essential Medicines List includes potassium chloride for cardiac surgery",
    ]},
    {text:"Why it matters",bold:true,sz:16,bc:C.ltTeal,sub:[
      "Permanent myocardial damage can occur within 15–20 minutes of ischaemia at normothermia",
      "Cardioplegia extends safe ischaemic time to 20–90 min depending on solution type",
    ]},
  ],{y:2.08,h:5.1,fontSize:16});
}

// ══════════════════════════════════════════════════════════
// SLIDE 4 — RATIONALE
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Rationale for Cardioplegia — Why Stop the Heart?",C.teal);

  const boxes=[
    {title:"SURGICAL REQUIREMENT",ac:C.blue,items:[
      "Cardiac surgery requires a motionless, bloodless operative field",
      "Even small cardiac movements compromise suture placement",
      "Aortic cross-clamping: stops all coronary blood flow",
      "Beating heart during surgery = movement + bleeding = poor repair",
    ]},
    {title:"ISCHAEMIA RISK",ac:C.red,items:[
      "Aortic cross-clamp → complete cessation of coronary perfusion",
      "At normothermia: irreversible injury within 15–20 minutes",
      "Beating heart consumes 8–10 mL O₂/100g/min",
      "Arrested heart (diastole, cold): <1 mL O₂/100g/min",
    ]},
    {title:"METABOLIC PROTECTION",ac:C.green,items:[
      "Electromechanical arrest alone (K⁺) → ↓ O₂ consumption by 90%",
      "Combined K⁺ arrest + hypothermia → ↓ O₂ by 97%",
      "Goal: reduce demand to near zero while interrupting supply",
      "Enables operations lasting 20–90 minutes safely",
    ]},
  ];
  boxes.forEach((b,i)=>{
    const x=0.35+i*4.3;
    box(s,x,1.1,4.1,5.9,b.title,b.ac,b.items,13.5);
  });

  s.addText("Cardioplegia = the bridge between surgical necessity and myocardial viability",{
    x:0.35,y:7.1,w:12.6,h:0.3,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center"});
}

// ══════════════════════════════════════════════════════════
// SLIDE 5 — TRIAD OF MYOCARDIAL PROTECTION
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Myocardial Protection — The Triad",C.teal);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.08,w:12.6,h:0.42,fill:{color:C.panel}});
  s.addText("Myocardial protection is achieved by THREE complementary strategies acting in concert (Barash 9e)",{
    x:0.35,y:1.08,w:12.6,h:0.42,fontSize:13,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  const triad=[
    {n:"1",title:"CARDIOPLEGIA",subtitle:"Pharmacological arrest",ac:C.teal,items:[
      "High-K⁺ → reduces transmembrane potential → diastolic arrest",
      "Stops electromechanical activity → ↓ O₂ consumption 90%",
      "Delivered via antegrade or retrograde route",
      "Repeated every 20–30 min (multidose) OR single-dose (del Nido/HTK)",
    ]},
    {n:"2",title:"HYPOTHERMIA",subtitle:"Temperature reduction",ac:C.blue,items:[
      "Each 1°C below 37°C → ↓ cellular metabolism by ~8%",
      "At 28°C: metabolic rate 50% of normal",
      "Systemic hypothermia (20–32°C) via CPB heat exchanger",
      "Topical cooling: cold saline/ice slush poured over heart",
      "Cold cardioplegia solution (4–15°C): local cardiac cooling",
    ]},
    {n:"3",title:"LV DECOMPRESSION",subtitle:"Venting the ventricle",ac:C.green,items:[
      "LV distension → ↑ wall tension → ↑ O₂ consumption",
      "LV vent catheter maintains empty, decompressed heart",
      "Especially critical in patients with severe AI",
      "Monitored with intraoperative TEE (LV filling state)",
      "Prevents LV overdistension and subendocardial ischaemia",
    ]},
  ];

  triad.forEach((t,i)=>{
    const x=0.35+i*4.3;
    s.addShape(pres.ShapeType.rect,{x,y:1.6,w:4.1,h:5.6,fill:{color:C.panel},line:{color:t.ac,width:2}});
    s.addShape(pres.ShapeType.rect,{x,y:1.6,w:4.1,h:0.75,fill:{color:t.ac}});
    s.addText(t.n,{x,y:1.6,w:0.55,h:0.75,fontSize:26,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    s.addText(t.title,{x:x+0.55,y:1.63,w:3.5,h:0.38,fontSize:14,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});
    s.addText(t.subtitle,{x:x+0.55,y:2.01,w:3.5,h:0.3,fontSize:11,italic:true,color:C.white,fontFace:"Calibri",valign:"middle"});
    const rich=t.items.map((it,j)=>({text:it,options:{bullet:{color:t.ac},breakLine:j<t.items.length-1,paraSpaceAfter:6,fontSize:13,color:C.white}}));
    s.addText(rich,{x:x+0.1,y:2.42,w:3.9,h:4.7,fontFace:"Calibri",valign:"top"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 6 — MECHANISM OF CARDIOPLEGIC ARREST
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Mechanism of Cardioplegic Arrest",C.teal);

  buls(s,[
    {text:"Normal cardiac action potential",bold:true,sz:16,bc:C.ltTeal,sub:[
      "Resting membrane potential: −90 mV (K⁺ gradient maintained by Na⁺/K⁺-ATPase)",
      "Depolarisation → Na⁺ influx → Phase 0 upstroke → mechanical contraction",
    ]},
    {text:"Potassium-induced arrest — mechanism",bold:true,sz:16,bc:C.gold,sub:[
      "Cardioplegia solution contains K⁺ 10–40 mEq/L (supraphysiologic — normal plasma K⁺ = 3.5–5 mEq/L)",
      "High extracellular K⁺ → depolarises the resting membrane potential",
      "Membrane potential shifts from −90 mV toward 0 mV",
      "Fast Na⁺ channels become INACTIVATED (cannot open) → no action potential possible",
      "Heart arrested in DIASTOLE (depolarised, but no electromechanical activity)",
      "This is the single most important step: ↓ O₂ consumption by 90%",
    ]},
    {text:"Maintaining arrest",bold:true,sz:16,bc:C.teal,sub:[
      "Cardioplegia is gradually washed out by bronchial venous return and thebesian veins",
      "Heart warms up over time (contact with ambient air and blood in adjacent descending aorta)",
      "Multidose cardioplegia: repeat doses every 20–30 min to maintain arrest",
      "Electrical activity (ECG) is used to monitor arrest — isoelectric = arrested",
    ]},
    {text:"Reversal of arrest",bold:true,sz:16,bc:C.green,sub:[
      "Aortic cross-clamp removed → warm normokalemic blood reperfuses coronary arteries",
      "'Hot shot' warm blood cardioplegia administered just before clamp release",
      "Heart usually resumes spontaneous rhythm; DC cardioversion if VF persists",
    ]},
  ],{y:1.1,h:6.1,fontSize:16});
}

// ══════════════════════════════════════════════════════════
// SLIDE 7 — COMPONENTS OF CARDIOPLEGIA SOLUTION
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Components of Cardioplegia Solution — Ingredients",C.teal);

  const comps=[
    {comp:"Potassium (K⁺)",role:"Arrest agent",detail:"10–40 mEq/L (induction: 20–30 mEq; maintenance: ~10 mEq)\nDepolarises sarcolemma → diastolic arrest\n> 40 mEq/L → excessive K⁺ load at bypass termination",color:C.gold},
    {comp:"Sodium (Na⁺)",role:"Reduced from plasma",detail:"< 140 mEq/L (plasma level)\nIschaemia → ↑ intracellular Na⁺; lower Na⁺ in solution limits Na⁺ influx",color:C.blue},
    {comp:"Calcium (Ca²⁺)",role:"Cellular integrity",detail:"0.7–1.2 mmol/L (near-zero, not zero)\nPrevents 'calcium paradox' — reintroduction of Ca²⁺ after Ca²⁺-free perfusion causes lethal injury",color:C.red},
    {comp:"Magnesium (Mg²⁺)",role:"Ca²⁺ antagonist",detail:"1.5–15 mmol/L\nBlocks excessive intracellular Ca²⁺ influx\nMembrane stabilisation",color:C.teal},
    {comp:"Buffer (HCO₃⁻ / Histidine / THAM)",role:"pH control",detail:"Counters accumulation of acid metabolites\nAlkaline (pH 7.6–7.8) perfusates → better preservation\ndel Nido/HTK use histidine as buffer",color:C.green},
    {comp:"Mannitol",role:"Oncotic agent + free radical scavenger",detail:"Prevents cellular oedema (slightly hypertonic solution)\nFree radical scavenger → reduces reperfusion injury",color:C.purple},
    {comp:"Energy substrates",role:"ATP support",detail:"Glucose, glutamate, aspartate\nSubstrate for anaerobic metabolism during ischaemia",color:C.ltTeal},
    {comp:"Lidocaine",role:"Membrane stabiliser",detail:"Used in del Nido solution\nSodium channel blocker → aids arrest and prevents reperfusion arrhythmias",color:C.blue},
  ];

  comps.forEach((c,i)=>{
    const col=i%2; const row=Math.floor(i/2);
    const x=col===0?0.35:6.85;
    const y=1.1+row*1.55;
    s.addShape(pres.ShapeType.rect,{x,y,w:6.1,h:1.42,fill:{color:C.panel},line:{color:c.color,width:1.5}});
    s.addShape(pres.ShapeType.rect,{x,y,w:6.1,h:0.35,fill:{color:c.color}});
    s.addText(c.comp+" — "+c.role,{x,y,w:6.1,h:0.35,fontSize:12,bold:true,color:c.color===C.gold||c.color===C.ltTeal?C.dark:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    s.addText(c.detail,{x:x+0.1,y:y+0.4,w:5.9,h:0.95,fontSize:12,color:C.white,fontFace:"Calibri",valign:"top"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 8 — TYPES OF SOLUTIONS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Types of Cardioplegia Solutions",C.teal);

  const types=[
    {
      name:"St Thomas Hospital Solution",
      desc:"Classic crystalloid — most widely studied\nNa⁺ 110 mEq/L, K⁺ 16 mEq/L, Ca²⁺ 1.2 mmol/L, Mg²⁺ 16 mmol/L, HCO₃⁻ 10 mEq/L\nTypically mixed 4:1 or 8:1 with blood (Buckberg formula)\nRepeat every 20–30 min",
      color:C.blue,
      feature:"Standard multidose reference solution",
    },
    {
      name:"del Nido Solution",
      desc:"Blood:crystalloid 1:4 ratio\nAdditives: K⁺ 26 mEq/L, lidocaine 13 mg%, MgSO₄ 3.26%, NaHCO₃, mannitol\nSINGLE DOSE: safe arrest time ~45 minutes\nOriginated in pediatric cardiac surgery; now widely used in adults\nExcellent for short to moderate cross-clamp times",
      color:C.teal,
      feature:"Single-dose; pediatric origin; adult use growing",
    },
    {
      name:"HTK Solution (Bretschneider / Custodiol)",
      desc:"Histidine–Tryptophan–Ketoglutarate solution\nCrystalloid only (no blood)\nK⁺ 9 mEq/L (low!), high histidine buffer, tryptophan, ketoglutarate (energy substrate)\nSINGLE DOSE: safe arrest time up to 90–120 minutes\nAlso used for organ preservation (liver, kidney, heart transplant)\nLarge volume required (2–3 L); dilutes intravascular volume",
      color:C.purple,
      feature:"Longest single-dose arrest; also organ preservation",
    },
  ];

  types.forEach((t,i)=>{
    const y=1.1+i*2.05;
    s.addShape(pres.ShapeType.rect,{x:0.35,y,w:12.6,h:1.9,fill:{color:C.panel},line:{color:t.color,width:1.5}});
    s.addShape(pres.ShapeType.rect,{x:0.35,y,w:3.5,h:1.9,fill:{color:t.color}});
    s.addText(t.name,{x:0.4,y:y+0.1,w:3.4,h:0.7,fontSize:14,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",align:"center"});
    s.addText("⭐ "+t.feature,{x:0.4,y:y+0.85,w:3.4,h:0.9,fontSize:11.5,italic:true,color:C.white,fontFace:"Calibri",valign:"top",align:"center"});
    s.addText(t.desc,{x:4.0,y:y+0.08,w:8.8,h:1.75,fontSize:12.5,color:C.white,fontFace:"Calibri",valign:"top"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 9 — BLOOD VS CRYSTALLOID
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Blood Cardioplegia vs Crystalloid Cardioplegia",C.teal);

  s.addShape(pres.ShapeType.rect,{x:0.35,y:1.1,w:12.6,h:0.4,fill:{color:C.panel}});
  s.addText("Current trend: most centres now use BLOOD cardioplegia (physiologically superior oxygenated vehicle) — Miller's Anesthesia 10e",{
    x:0.35,y:1.1,w:12.6,h:0.4,fontSize:12,italic:true,color:C.gold,fontFace:"Calibri",align:"center",valign:"middle"});

  box(s,0.35,1.6,5.9,5.5,"BLOOD CARDIOPLEGIA",C.red,[
    "Oxygen-carrying capacity — oxygenated during arrest",
    "Physiological buffering (plasma proteins, RBC)",
    "Colloid oncotic pressure maintains, minimising oedema",
    "Free radical scavengers (endogenous antioxidants in blood)",
    "Evidence favours blood CP in high-risk patients",
    "Blood:crystalloid ratios: 4:1 or 8:1 (Buckberg/St Thomas); 1:4 (del Nido)",
    "Warm blood cardioplegia: 'warm' induction and reperfusion + intermittent cold maintenance",
    "Disadvantage: opaque solution — obscures surgical field",
  ],13.5);

  box(s,6.85,1.6,6.1,5.5,"CRYSTALLOID CARDIOPLEGIA",C.blue,[
    "Clear solution — provides a bloodless surgical field",
    "HTK/Bretschneider is purely crystalloid",
    "Simpler to prepare and administer",
    "Prolonged safe arrest time (HTK: up to 90 min single dose)",
    "Less oxygen carrying; relies on anaerobic metabolism",
    "Risk of haemodilution with large volumes (HTK requires 2–3 L)",
    "Adequate for most routine cases without high-risk features",
    "Used in paediatric patients and some transplant centres",
  ],13.5);
}

// ══════════════════════════════════════════════════════════
// SLIDE 10 — COMPARISON TABLE (del Nido vs HTK vs St Thomas)
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Cardioplegia Solutions — Comparison Table",C.teal);

  const rows=[
    ["Parameter","St Thomas / Buckberg","del Nido","HTK (Bretschneider)"],
    ["Type","Blood:Crystalloid 4:1 or 8:1","Blood:Crystalloid 1:4","Pure Crystalloid"],
    ["K⁺ concentration","Induction: 20–30 mEq/L\nMaintenance: ~10 mEq/L","26 mEq/L","9 mEq/L (low K⁺)"],
    ["Arrest mechanism","Depolarisation (K⁺)","Depolarisation (K⁺ + lidocaine)","Depolarisation (K⁺) + intracellular Na⁺ ↓"],
    ["Key additives","MgCl₂, NaHCO₃, procaine","Lidocaine, MgSO₄, NaHCO₃, mannitol","Histidine (buffer), tryptophan, ketoglutarate"],
    ["Buffer","Bicarbonate","Bicarbonate","Histidine (superior buffer for long ischaemia)"],
    ["Dosing","MULTIDOSE: every 20–30 min","SINGLE DOSE","SINGLE DOSE"],
    ["Safe arrest time","20–30 min per dose","~45 minutes","Up to 90–120 minutes"],
    ["Volume required","200–500 mL per dose","1000 mL single dose","2–3 L single dose"],
    ["Surgical field","Partially obstructed (blood)","Partially obstructed (blood)","CLEAR (crystalloid)"],
    ["Main use","Standard multidose adult surgery","Paediatric + short–moderate adult cases","Complex/long adult cases; organ preservation"],
    ["Limitations","Requires repeat dosing every 20–30 min","Not ideal for >60 min cross-clamp","Haemodilution; no oxygen carrying capacity"],
  ];

  const cols=[0.3,3.45,7.0,10.45];
  const cw=[3.1,3.5,3.4,2.8];
  const hC=[C.teal,C.red,C.teal,C.purple];

  rows[0].forEach((h,ci)=>{
    s.addShape(pres.ShapeType.rect,{x:cols[ci],y:1.08,w:cw[ci],h:0.4,fill:{color:hC[ci]}});
    s.addText(h,{x:cols[ci],y:1.08,w:cw[ci],h:0.4,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  });

  rows.slice(1).forEach((row,i)=>{
    const y=1.48+i*0.49;
    const bgc=i%2===0?C.panel:C.dark;
    row.forEach((cell,ci)=>{
      s.addShape(pres.ShapeType.rect,{x:cols[ci],y,w:cw[ci],h:0.46,fill:{color:bgc}});
      s.addText(cell,{x:cols[ci]+0.04,y,w:cw[ci]-0.08,h:0.46,fontSize:10.5,color:ci===0?C.lt:C.white,fontFace:"Calibri",valign:"middle",bold:ci===0});
    });
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 11 — ROUTES OF DELIVERY
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Routes of Delivery — Antegrade, Retrograde & Combined",C.teal);

  box(s,0.35,1.1,5.9,3.4,"ANTEGRADE CARDIOPLEGIA",C.teal,[
    "Delivery: antegrade into coronary arteries via aortic root",
    "Needle placed proximal to aortic cross-clamp (between aortic cannula and aortic valve)",
    "Pressure: 60–100 mmHg into aortic root",
    "Alternatively: directly into coronary ostia (if aortic valve opened — e.g., AVR)",
    "Most physiological — follows coronary artery anatomy",
    "Onset of arrest: 30–60 seconds",
    "Limitation: obstructive CAD or AI may limit uniform distribution",
  ],13.5);

  box(s,6.85,1.1,6.1,3.4,"RETROGRADE CARDIOPLEGIA",C.gold,[
    "Delivery: via balloon-tipped catheter placed in coronary sinus",
    "Pressure: 30–50 mmHg; Flow: 200–400 mL/min",
    "Bypasses coronary artery obstructions — useful in severe CAD",
    "Onset of arrest: 2–4 minutes (slower than antegrade)",
    "Limitation: poor perfusion of RV free wall and posterior 1/3 of IVS (RCA territory)",
    "Microvascular areas less able to sustain normal energy metabolism",
    "TEE used to monitor coronary sinus catheter position",
  ],13.5);

  box(s,0.35,4.65,12.6,2.5,"COMBINED ANTEGRADE + RETROGRADE (PREFERRED for Complex Cases)",C.green,[
    "Most complete technique for myocardial protection (Miller's Anesthesia 10e)",
    "Antegrade for initial arrest + retrograde to reach territories with CAD obstructions",
    "Can be delivered simultaneously in both routes",
    "Cardioplegia also delivered through completed vein grafts (CABG) for individual territory protection",
    "Especially recommended in: severe diffuse CAD, aortic valve insufficiency (retrograde avoids seeping into LV)",
  ],13.5);
}

// ══════════════════════════════════════════════════════════
// SLIDE 12 — TEMPERATURE
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Temperature of Cardioplegia — Cold, Warm & Tepid",C.teal);

  const temps=[
    {
      label:"COLD CARDIOPLEGIA",temp:"4–15°C",color:C.blue,
      pros:["Reduces metabolic rate by up to 97% (combined with K⁺ arrest)","Provides 20–45 min safe arrest per dose","Traditional standard — well established","Suppresses enzyme degradation and free radical production"],
      cons:["Hypothermia may impair enzyme function needed for recovery","Repeated cooling — coagulopathy, platelet dysfunction","Requires rewarming time at end of bypass"],
    },
    {
      label:"WARM CARDIOPLEGIA (Normothermic)",temp:"37°C",color:C.red,
      pros:["Maintains enzymatic function — better metabolic recovery","Better postoperative cardiac indices reported (Barash 9e)","May reduce reperfusion injury"],
      cons:["Must be given CONTINUOUSLY (no safe window without perfusion at warm temperature)","Obscures surgical field (blood + constant flow)","Technically more demanding"],
    },
    {
      label:"TEPID CARDIOPLEGIA",temp:"29–34°C",color:C.green,
      pros:["Compromise between cold and warm","Better myocardial recovery than cold in some studies","Less hypothermic systemic effects","More practical than warm continuous"],
      cons:["Less metabolic protection than cold","Less well-studied than cold or warm extremes"],
    },
  ];

  temps.forEach((t,i)=>{
    const x=0.35+i*4.3;
    s.addShape(pres.ShapeType.rect,{x,y:1.1,w:4.1,h:5.95,fill:{color:C.panel},line:{color:t.color,width:2}});
    s.addShape(pres.ShapeType.rect,{x,y:1.1,w:4.1,h:0.75,fill:{color:t.color}});
    s.addText(t.label,{x,y:1.1,w:4.1,h:0.42,fontSize:14,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    s.addText("Temperature: "+t.temp,{x,y:1.52,w:4.1,h:0.33,fontSize:12,italic:true,color:C.white,fontFace:"Calibri",align:"center"});

    s.addShape(pres.ShapeType.rect,{x:x+0.05,y:1.9,w:4.0,h:0.28,fill:{color:C.green}});
    s.addText("ADVANTAGES",{x:x+0.05,y:1.9,w:4.0,h:0.28,fontSize:11,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    const proR=t.pros.map((p,j)=>({text:p,options:{bullet:{color:C.green},breakLine:j<t.pros.length-1,paraSpaceAfter:4,fontSize:12,color:C.white}}));
    s.addText(proR,{x:x+0.1,y:2.22,w:3.9,h:2.0,fontFace:"Calibri",valign:"top"});

    s.addShape(pres.ShapeType.rect,{x:x+0.05,y:4.28,w:4.0,h:0.28,fill:{color:C.red}});
    s.addText("DISADVANTAGES",{x:x+0.05,y:4.28,w:4.0,h:0.28,fontSize:11,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    const conR=t.cons.map((c,j)=>({text:c,options:{bullet:{color:C.red},breakLine:j<t.cons.length-1,paraSpaceAfter:4,fontSize:12,color:C.white}}));
    s.addText(conR,{x:x+0.1,y:4.6,w:3.9,h:2.35,fontFace:"Calibri",valign:"top"});
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 13 — DOSING REGIMENS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Dosing Regimens — Multidose vs Single-Dose",C.teal);

  box(s,0.35,1.1,5.9,5.8,"MULTIDOSE CARDIOPLEGIA",C.blue,[
    "Standard approach for most cardiac centres",
    "Induction (arrest) dose:",
    "   High-K⁺: ~1000–1500 mL administered over 3–5 min",
    "   K⁺ concentration: 20–30 mEq/L",
    "   Arrest typically achieved in 30–60 sec (antegrade)",
    "Maintenance doses:",
    "   200–500 mL every 20–30 minutes",
    "   Lower K⁺: ~10 mEq/L",
    "   Purpose: wash out metabolites + maintain hypothermia + maintain arrest",
    "Reperfusion (terminal) dose:",
    "   Reduced K⁺ solution to wash out metabolites before clamp release",
    "   OR 'hot shot' warm blood cardioplegia",
    "Repeated doses: improve myocardial preservation by preventing accumulation of inhibitory metabolites",
  ],13);

  box(s,6.85,1.1,6.1,5.8,"SINGLE-DOSE CARDIOPLEGIA",C.gold,[
    "del Nido solution — safe arrest time ~45 minutes",
    "HTK solution — safe arrest time 90–120 minutes",
    "Advantages:",
    "   Simple to administer — no interruptions to surgery",
    "   Less time pressure on surgeon",
    "   No repeated cardioplegia-related interruptions",
    "del Nido composition per 1000 mL dose:",
    "   Plasma-lyte A 800 mL + additives:",
    "   K⁺ 26 mEq, MgSO₄ 3.26%, NaHCO₃ 13 mEq",
    "   Mannitol 16.3%, lidocaine 130 mg",
    "   Blood 200 mL (1:4 ratio)",
    "HTK: large volume (2–3 L) — watch haemodilution",
    "Monitoring: isoelectric ECG throughout arrest period",
  ],13);
}

// ══════════════════════════════════════════════════════════
// SLIDE 14 — ISCHAEMIA-REPERFUSION INJURY & HOT SHOT
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Ischaemia–Reperfusion Injury & The Hot Shot",C.red);

  box(s,0.35,1.1,6.0,3.4,"ISCHAEMIA–REPERFUSION INJURY",C.red,[
    "Reperfusion after ischaemia paradoxically worsens injury",
    "Mechanisms:",
    "   Rapid intracellular Ca²⁺ overload → mitochondrial dysfunction",
    "   Oxygen-derived free radical (ROS) burst on reperfusion",
    "   Abnormal endothelial–leukocyte interactions",
    "   Myocardial cellular oedema",
    "Clinically: myocardial stunning → systolic + diastolic dysfunction (reversible)",
    "Severe: myocardial necrosis (irreversible)",
    "Risk factors: long cross-clamp time, poor preop LV function, LVH, diffuse CAD",
  ],13);

  box(s,6.85,1.1,6.1,3.4,"PREVENTION STRATEGIES",C.teal,[
    "Limit cross-clamp time (ideally <90–120 min)",
    "Mannitol in cardioplegia — free radical scavenger",
    "Controlled reperfusion: gradual pressure increase",
    "Reperfusion pressure: start ~40 mmHg → gradually to 70 mmHg",
    "Avoid hypercalcaemia in immediate reperfusion period",
    "Maintain LV decompression — prevent distension",
    "Warm blood reperfusion (hot shot) before unclamping",
    "Reduce cardioplegia washout accumulation of metabolites",
  ],13);

  // Hot Shot box
  s.addShape(pres.ShapeType.rect,{x:0.35,y:4.65,w:12.6,h:2.55,fill:{color:C.panel},line:{color:C.gold,width:2}});
  s.addShape(pres.ShapeType.rect,{x:0.35,y:4.65,w:12.6,h:0.4,fill:{color:C.gold}});
  s.addText("THE 'HOT SHOT' — Warm Blood Cardioplegia Before Clamp Release",{x:0.35,y:4.65,w:12.6,h:0.4,fontSize:14,bold:true,color:C.dark,fontFace:"Calibri",align:"center",valign:"middle"});
  buls(s,[
    "Administered just BEFORE removal of aortic cross-clamp",
    "Warm (37°C), normokalemic (or low-K⁺) oxygenated blood perfused into coronary arteries",
    "Purpose: washes out accumulated metabolic byproducts + replenishes high-energy phosphates (ATP) + activates metabolic machinery before reperfusion",
    "Delivered via cardioplegia cannulas or simply by releasing the cross-clamp with warm circuit blood",
    "Evidence: reduces reperfusion injury, improves post-bypass cardiac function, faster return of electromechanical activity",
  ],{x:0.5,y:5.1,w:12.3,h:2.0,fontSize:13.5,color:C.white});
}

// ══════════════════════════════════════════════════════════
// SLIDE 15 — MONITORING ADEQUACY & COMPLICATIONS
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Monitoring Adequacy & Complications of Inadequate Cardioplegia",C.teal);

  box(s,0.35,1.1,5.9,3.1,"MONITORING ADEQUACY OF CARDIOPLEGIA",C.teal,[
    "ECG — isoelectric (flat) = arrested; any electrical activity = inadequate",
    "Myocardial temperature monitoring (e.g., temperature probe on LV epicardium)",
    "Time since last dose — every 20–30 min for multidose",
    "TEE: LV filling state — assess ventricular distension",
    "Infusion pressure monitoring (antegrade: 60–100 mmHg; retrograde: 30–50 mmHg)",
    "Surgical observation: quiescent vs any mechanical activity",
  ],13.5);

  box(s,6.85,1.1,6.1,3.1,"INADEQUATE CARDIOPLEGIA — INTRAOPERATIVE SIGNS",C.red,[
    "Resumption of electrical activity on ECG",
    "Cardiac movement during surgery",
    "ECG changes suggesting myocardial ischaemia",
    "LV distension detected on TEE",
    "Heart warms rapidly between doses — indicates inadequate cooling",
    "⚠ Areas distal to high-grade coronary stenoses may not receive adequate cardioplegia (retrograde indicated)",
  ],13.5);

  box(s,0.35,4.35,12.6,2.7,"COMPLICATIONS — POST-BYPASS MANIFESTATIONS",C.gold,[
    "Asystole — inadequate washout and recovery from cardioplegia (persisting high K⁺)",
    "Conduction blocks (AVB) — persistent hyperkalemia",
    "Low cardiac output syndrome — poor ventricular protection → stunning",
    "Ventricular fibrillation — on reperfusion (usually responds to DC cardioversion)",
    "Excessive hyperkalemia at end of bypass — from large volume high-K⁺ solutions (K⁺ > 40 mEq/L risk)",
    "Reperfusion injury — if inadequate protection during cross-clamp period",
    "Stunned myocardium — reversible; responds to inotropes and time",
  ],13.5);
}

// ══════════════════════════════════════════════════════════
// SLIDE 16 — ROLE OF ANAESTHESIOLOGIST
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Role of the Anaesthesiologist During Cardioplegia",C.teal);

  buls(s,[
    {text:"Before aortic cross-clamp",bold:true,sz:16,bc:C.teal,sub:[
      "Confirm adequate anticoagulation (ACT ≥ 400 sec) before CPB initiation",
      "Ensure systemic hypothermia achieved (if planned) before cross-clamp",
      "Discontinue ventilation once full CPB flows established",
      "Continue anaesthetic agent via CPB circuit (volatile via oxygenator or IV TIVA)",
    ]},
    {text:"During cardioplegia administration",bold:true,sz:16,bc:C.gold,sub:[
      "Monitor ECG continuously — confirm isoelectric arrest",
      "Monitor TEE — confirm LV decompression and adequate venting",
      "Coordinate with perfusionist: cardioplegia pressure, volume, temperature",
      "Alert surgeon if electrical activity resumes (redose needed)",
      "Monitor for LV distension — especially in AI patients",
    ]},
    {text:"Monitoring cardioplegia adequacy",bold:true,sz:16,bc:C.ltTeal,sub:[
      "Track time since last dose — alert at 20–25 min mark",
      "Monitor myocardial temperature if probe available",
      "Communicate with surgeon regarding areas of concern (severe CAD → retrograde)",
    ]},
    {text:"At aortic cross-clamp release and reperfusion",bold:true,sz:16,bc:C.green,sub:[
      "Anticipate reperfusion arrhythmias — prepare defibrillator, lidocaine, amiodarone",
      "Resume ventilation when heart begins to eject",
      "Correct electrolytes: K⁺ (post-cardioplegia hyperkalemia possible), Ca²⁺, Mg²⁺",
      "Assess ventricular function with TEE — watch for stunned myocardium",
      "Prepare vasopressors / inotropes if poor ventricular recovery",
    ]},
    {text:"Post-bypass complications — anticipate",bold:true,sz:16,bc:C.red,sub:[
      "Persistent asystole or heart block → temporary epicardial pacing (wires placed by surgeon)",
      "Low CO: inotropes (milrinone, dobutamine, adrenaline) + IABP if needed",
    ]},
  ],{y:1.1,h:6.1,fontSize:15.5});
}

// ══════════════════════════════════════════════════════════
// SLIDE 17 — REFERENCES
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"References",C.teal);
  const refs=[
    "Miller RD et al. Miller's Anesthesia, 10th Edition. Elsevier; 2023. Chapter 50 — Cardiopulmonary Bypass.",
    "Morgan GE, Mikhail MS. Morgan & Mikhail's Clinical Anesthesiology, 7th Edition. McGraw-Hill; 2022. Chapter on Cardiac Anaesthesia & CPB.",
    "Barash PG et al. Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition. Wolters Kluwer; 2022. Chapter 52 — Myocardial Protection.",
    "Bailey H, Love M. Bailey and Love's Short Practice of Surgery, 28th Edition. CRC Press; 2023. Cardiac Surgery Chapter.",
    "Schwartz SI et al. Schwartz's Principles of Surgery, 11th Edition. McGraw-Hill; 2019. Chapter on Cardiac Surgery.",
    "Buckberg GD. Development of blood cardioplegia and retrograde techniques. J Card Surg. 1998;13:1–14.",
    "del Nido PJ et al. del Nido cardioplegia: current use and outcomes. J Thorac Cardiovasc Surg. 2012.",
    "Bretschneider HJ. Myocardial protection — HTK solution. Thorac Cardiovasc Surgeon 1980;28:295.",
    "Guru V et al. Blood vs crystalloid cardioplegia in adult cardiac surgery. Meta-analysis. J Thorac Cardiovasc Surg 2006.",
  ];
  refs.forEach((r,i)=>{
    s.addText(`${i+1}.  ${r}`,{x:0.4,y:1.12+i*0.67,w:12.5,h:0.62,fontSize:12,color:i%2===0?C.white:C.grey,fontFace:"Calibri",valign:"middle"});
  });
}

// WRITE
pres.writeFile({fileName:"/home/daytona/workspace/cardioplegia-ppt/Cardioplegia_MD_Anesthesia.pptx"})
  .then(()=>console.log("SUCCESS"))
  .catch(e=>{console.error(e);process.exit(1);});

Your credits are exhausted. You can purchase a top-up or subscribe to a plan to continue using Orris. If you're already subscribed, your daily credits will reset tomorrow.

Proceed without making ppt

Your credits are exhausted. You can purchase a top-up or subscribe to a plan to continue using Orris. If you're already subscribed, your daily credits will reset tomorrow.

This is a shared conversation. Sign in to Orris to start your own chat.