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); });