const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE";
pres.title = "Cleft Lip & Palate – Anaesthesia Management";
pres.author = "MD Anaesthesia";

// ─── THEME ─────────────────────────────────────────────────────────────────
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  ltgray:  "CBD5E1",
  midgray: "64748B",
  red:     "E74C3C",
  green:   "27AE60",
  bg:      "0D1B2A",
};

const FONT_TITLE  = "Calibri";
const FONT_BODY   = "Calibri";

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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ════════════════════════════════════════════════════════════════════════════
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – OVERVIEW & CLASSIFICATION
// ════════════════════════════════════════════════════════════════════════════
{
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  sectionBadge(s, "OVERVIEW & CLASSIFICATION");

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    [
      { text: "Incidence", options: { bold: true, color: C.teallt } },
      { text: "1 : 700 live births (one of the most common congenital anomalies)", options: { color: C.white } },
    ],
    [
      { text: "Aetiology", options: { bold: true, color: C.teallt } },
      { text: "Multifactorial: genetic + environmental (drugs, folate deficiency, smoking)", options: { color: C.white } },
    ],
    [
      { text: "Association", options: { bold: true, color: C.teallt } },
      { text: "~1/3 linked to syndromes (Pierre Robin, Treacher Collins, 22q11 deletion)", options: { color: C.white } },
    ],
    [
      { text: "Timing – Lip", options: { bold: true, color: C.teallt } },
      { text: "Millard rule of 10s: 10 weeks, 10 lbs, Hb ≥ 10 g/dL  (3–6 months)", options: { color: C.white } },
    ],
    [
      { text: "Timing – Palate", options: { bold: true, color: C.teallt } },
      { text: "9–18 months (before speech development; Veau / Wardill / Furlow techniques)", options: { color: C.white } },
    ],
    [
      { text: "Classification (Veau)", options: { bold: true, color: C.teallt } },
      { text: "I – Soft palate only  |  II – Hard + soft palate  |  III – Unilateral CLP  |  IV – Bilateral CLP", options: { color: C.white } },
    ],
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – PREOPERATIVE ASSESSMENT
// ════════════════════════════════════════════════════════════════════════════
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  sectionBadge(s, "PREOPERATIVE ASSESSMENT");

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    { text: "AIRWAY EVALUATION (MOST CRITICAL)", bold: true, color: C.amber, fontSize: 14 },
    { text: "Retrognathia / micrognathia → difficult laryngoscopy", indent: 0 },
    { text: "Pierre Robin sequence: micrognathia + glossoptosis + airway obstruction", indent: 0 },
    { text: "Assess mouth opening, neck mobility, Mallampati", indent: 0 },
    { text: "Large / bilateral cleft → tongue falls into cleft, obstructing airway", indent: 0 },
    { text: "ASSOCIATED SYNDROMES", bold: true, color: C.amber, fontSize: 14 },
    { text: "Pierre Robin, Treacher Collins, CHARGE, Stickler, 22q11.2 (DiGeorge)", indent: 0 },
    { text: "Check for cardiac defects (echo if indicated)", indent: 0 },
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    { text: "GENERAL ASSESSMENT", bold: true, color: C.amber, fontSize: 14 },
    { text: "Age & weight – rule of 10s for lip repair", indent: 0 },
    { text: "Haemoglobin ≥ 10 g/dL (check preop)", indent: 0 },
    { text: "Nutritional status – feeding difficulties common", indent: 0 },
    { text: "FASTING GUIDELINES", bold: true, color: C.amber, fontSize: 14 },
    { text: "Clear fluids – 2 h  |  Breast milk – 4 h  |  Formula/solids – 6 h", indent: 0 },
    { text: "INVESTIGATIONS", bold: true, color: C.amber, fontSize: 14 },
    { text: "CBC, blood group & cross-match, serum electrolytes, ECG/echo if syndromic", indent: 0 },
    { text: "PREMEDICATION", bold: true, color: C.amber, fontSize: 14 },
    { text: "Oral midazolam 0.5 mg/kg (< 6 months: avoid); atropine 0.02 mg/kg", indent: 0 },
  ];

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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – AIRWAY MANAGEMENT
// ════════════════════════════════════════════════════════════════════════════
{
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  addBg(s);
  addLeftBar(s);
  sectionBadge(s, "AIRWAY MANAGEMENT – THE CORE CHALLENGE", C.red);

  const boxes = [
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      color: "0E4D6E",
      border: C.teallt,
      x: 0.22, y: 0.9, w: 4.1,
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        "Usually straightforward airway",
        "Preformed RAE tube (oral, south-facing) preferred",
        "Taped securely at MIDLINE",
        "ETT size: (Age/4)+3.5 mm uncuffed",
        "Check – laryngoscope blade may lodge in cleft → use gauze packing as needed",
        "Alternatively: LMA (surgeon must accept shared airway)",
      ],
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      color: "0E4D6E",
      border: C.amber,
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        "Reinforce ETT (armoured/RAE) strongly recommended",
        "Recheck ETT position after gag insertion",
        "Risk of accidental extubation with gag removal",
        "Dexamethasone 0.25 mg/kg reduces post-op oedema",
        "EXTUBATE AWAKE (not deep) → risk of post-op airway obstruction",
      ],
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        "Pierre Robin / Treacher Collins: plan fibreoptic awake / gas induction",
        "Keep spontaneous ventilation during induction if difficult airway anticipated",
        "Video laryngoscope available",
        "Fibreoptic intubation through LMA technique",
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – INDUCTION & MAINTENANCE
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s);
  addLeftBar(s);
  sectionBadge(s, "INDUCTION & MAINTENANCE OF ANAESTHESIA");

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      { text: "Secure IV before induction (> 6 months); gas induction option in infants", options: { color: C.ltgray } },
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      { text: "100% O₂ × 3–5 min (or 8 vital-capacity breaths)", options: { color: C.white } },
      { text: "Neonates desat rapidly – no apnoeic reserve", options: { color: C.red } },
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      { text: "Propofol 2–3 mg/kg  OR  Ketamine 2 mg/kg + atropine", options: { color: C.white } },
      { text: "Ketamine preserves airway tone – useful if airway concern", options: { color: C.ltgray } },
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      { text: "Preferred for anticipated difficult airway", options: { color: C.amber } },
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      { text: "Suxamethonium 2 mg/kg (RSI) OR Atracurium 0.5 mg/kg (after airway confirmed)", options: { color: C.white } },
      { text: "Oral preformed RAE ETT; confirm bilateral air entry", options: { color: C.ltgray } },
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      { text: "N₂O optional; avoid if concern of trapped gas", options: { color: C.ltgray } },
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      { text: "Fluid mgmt", options: { color: C.white } },
      { text: "Deficit + maintenance: RL/NS; glucose-containing if < 1 yr (2.5% dextrose)", options: { color: C.white } },
      { text: "Estimated blood loss ≤ 15–20 mL in cleft lip; more in palate", options: { color: C.ltgray } },
    ],
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      { text: "Temperature", options: { color: C.white } },
      { text: "Warming blanket, warm IV fluids, humidified gases", options: { color: C.white } },
      { text: "Neonates / infants – hypothermia risk", options: { color: C.red } },
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – ANALGESIA
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s);
  addLeftBar(s);
  sectionBadge(s, "ANALGESIA – MULTIMODAL APPROACH");

  // Left half – nerve blocks
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    { text: "Landmark: infraorbital foramen (just below orbital rim, pupil mid-line)" },
    { text: "LA: Bupivacaine 0.25% 0.5–1 mL per side (max 2 mg/kg)" },
    { text: "Superior to peri-incisional infiltration (Prabhu et al., SJPS 1999)" },
    { text: "↓ intraoperative opioids, ↓ post-op pain scores, ↓ PONV" },
    { text: "Suprazygomatic Maxillary Nerve Block (CLEFT PALATE)", bold: true, color: C.amber },
    { text: "Entry: zygomatic arch – temporal fossa" },
    { text: "0.1 mL/kg Ropivacaine 0.2% per side" },
    { text: "Opioid-free postoperative pain management possible (Mesnil et al., 2010)" },
    { text: "External Nasal Nerve Block – combined with infraorbital for lip repair", bold: false, color: C.ltgray },
    { text: "Palatine nerve block – greater palatine canal for palate", color: C.ltgray },
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    { text: "PR / IV: 15–20 mg/kg loading, then 10–15 mg/kg q6h" },
    { text: "Regular scheduled dosing – cornerstone of multimodal plan" },
    { text: "NSAIDs", bold: true, color: C.teallt },
    { text: "Ibuprofen 5–10 mg/kg q8h (>3 months, adequate hydration)" },
    { text: "Ketorolac 0.5 mg/kg IV – avoid if platelet concern" },
    { text: "OPIOIDS (judicious use)", bold: true, color: C.teallt },
    { text: "Fentanyl 1–2 mcg/kg intraoperatively (titrate)" },
    { text: "Morphine 0.05–0.1 mg/kg IV q4h PRN (monitor for resp depression)" },
    { text: "Codeine – CONTRAINDICATED (CYP2D6 ultra-rapid metabolisers risk)" },
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    { text: "0.25 mg/kg IV – reduces oedema, PONV & analgesic requirement" },
    { text: "LOCAL INFILTRATION", bold: true, color: C.teallt },
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – INTRAOPERATIVE CONCERNS
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBg(s);
  addLeftBar(s);
  sectionBadge(s, "INTRAOPERATIVE CONCERNS & MONITORING");

  const concerns = [
    {
      icon: "⚠",
      title: "Shared Airway",
      text: "Surgeon and anaesthetist share the airway. Clear communication essential. Surgeon uses Dingman gag (palate) – always recheck ETT position after insertion.",
      color: C.red,
    },
    {
      icon: "🌡",
      title: "Hypothermia",
      text: "Infants have large BSA:weight ratio. Forced-air warming, warm IV fluids, warm theatre (25°C). Target core temp > 36.5°C.",
      color: C.teallt,
    },
    {
      icon: "💉",
      title: "Blood Loss",
      text: "Cleft lip: minimal (< 15 mL). Cleft palate: 20–50 mL (may be significant in infant). Adrenaline infiltration (1:200,000) by surgeon reduces bleeding. Ensure cross-match available.",
      color: C.amber,
    },
    {
      icon: "😮",
      title: "Throat Pack",
      text: "Used by surgeons to prevent blood/secretion aspiration. MUST be counted and removed before extubation. Record in anaesthesia chart. Failure to remove → catastrophic.",
      color: C.red,
    },
    {
      icon: "💊",
      title: "Drug Interactions",
      text: "Avoid morphine if OSA present. Dexamethasone reduces inflammation. Ondansetron 0.15 mg/kg for PONV. Avoid succinylcholine if family h/o malignant hyperthermia.",
      color: C.teallt,
    },
    {
      icon: "📊",
      title: "Position & Padding",
      text: "Supine with shoulder roll (neck extension). Protect eyes. Neutral head position after ETT fixation. Pressure-point padding essential.",
      color: C.ltgray,
    },
  ];

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  const H = 2.55;
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  const yStart = [0.88, 3.6];

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    const x = xStart[cols[i]];
    const y = yStart[rows[i]];
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – EMERGENCE & POSTOPERATIVE CARE
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    "Lateral (recovery) position – protects airway",
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    "Airway obstruction – most feared; have re-intubation trolley ready",
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – ASSOCIATED SYNDROMES & SPECIAL SCENARIOS
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – VIVA Q&A (PART 1)
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    },
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      q: "Q2. Why use a preformed RAE tube for cleft lip repair?",
      a: "South-facing oral RAE keeps the breathing circuit away from the surgical field. Fixed midline position prevents accidental extubation. Must be securely taped at midline of lower lip.",
    },
    {
      q: "Q3. What is the danger of the laryngoscope blade in cleft lip surgery?",
      a: "The blade may lodge in the cleft, making visualisation of the larynx difficult. Pack the cleft with moist gauze or use a straight (Miller) blade to keep it lateral.",
    },
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      q: "Q4. Why extubate awake after cleft palate repair?",
      a: "Palatal oedema + blood and secretions in the oropharynx can cause life-threatening post-extubation airway obstruction. Child must be fully awake with intact laryngeal reflexes before extubation.",
    },
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      a: "Provides excellent analgesia for the upper lip and anterior nose (V2 territory). Bupivacaine 0.25% 0.5–1 mL/side. Superior to peri-incisional infiltration. Reduces intraoperative opioid requirements and post-op pain scores.",
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – VIVA Q&A (PART 2)
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      q: "Q6. How do you manage a neonate with Pierre Robin sequence presenting for palate repair?",
      a: "Inhalation induction (sevoflurane) maintaining spontaneous respiration. Video laryngoscope or fibreoptic scope on standby. LMA as intermediate airway if needed. Avoid muscle relaxants until airway secured. Senior anaesthetist + tracheostomy kit available.",
    },
    {
      q: "Q7. What is the significance of the throat pack in cleft surgery?",
      a: "Prevents blood and secretions from entering the trachea. MUST be documented and counted before insertion and AGAIN before extubation. Retained throat pack → post-extubation airway obstruction and fatality. Common cause of anaesthetic morbidity.",
    },
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      q: "Q8. What postoperative monitoring does an ex-premature infant need after cleft lip repair?",
      a: "Apnoea monitoring for ≥ 12–24 h. All ex-preterm infants < 56 weeks postmenstrual age (PMA) are at risk for postoperative apnoea after general anaesthesia. Prophylactic caffeine citrate IV may reduce risk. No same-day discharge.",
    },
    {
      q: "Q9. Why is codeine contraindicated in children post-cleft surgery?",
      a: "CYP2D6 ultra-rapid metabolisers convert codeine to morphine rapidly → morphine toxicity, respiratory depression, death. Codeine is contraindicated in children < 12 years post-adenotonsillectomy (and generally avoided in any paediatric surgical context by most guidelines since 2013).",
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      q: "Q10. What is the suprazygomatic maxillary nerve block and when is it used?",
      a: "Injection into the pterygopalatine fossa via the suprazygomatic approach. Used for cleft palate repair analgesia. Blocks maxillary nerve (V2) – covers palate, gingiva, upper lip. Allows opioid-free postoperative analgesia. Ropivacaine 0.2% 0.1 mL/kg per side.",
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – VIVA Q&A (PART 3)
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      a: "Lip (3–6 mo): simpler airway, RAE tube, brief surgery, minimal blood loss, infraorbital block. Palate (9–18 mo): shared airway with Dingman gag, longer surgery, more blood loss, oedema risk, AWAKE extubation mandatory, suprazygomatic block.",
    },
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      q: "Q12. How do you calculate ETT size for a 6-month-old infant?",
      a: "Uncuffed ETT: (Age in years/4) + 3.5 = 3.5 mm for a 6-month-old. Or length-based (Broselow tape). Cuffed ETT: (Age/4) + 3 mm. Insert to depth: (Age/2) + 12 cm at lips. Always confirm with bilateral air entry and chest rise.",
    },
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      q: "Q13. What are the respiratory concerns in post-palate repair recovery?",
      a: "Oropharyngeal/palatal oedema, residual blood clots, loss of airway tone, tongue-based obstruction. Lateral recovery position, nasopharyngeal airway if needed. Oral airways can disrupt repair. SpO₂ monitoring minimum 2 h. Re-intubation trolley at bedside.",
    },
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      q: "Q14. What is a 'shared airway' problem and how do you address it?",
      a: "Both surgeon and anaesthetist require access to the oral cavity. ETT must be secured to PREVENT displacement; surgeon must not pull on tube; anaesthetist must recheck ETT after every positional change or gag insertion. Clear verbal communication is essential.",
    },
    {
      q: "Q15. Name the key anaesthetic differences when managing a child with DiGeorge syndrome presenting for palate repair.",
      a: "Check serum calcium (hypocalcaemia common). Evaluate cardiac defects (TOF, IAA). Use irradiated, CMV-negative blood products (T-cell deficiency). Avoid hypotension. Immune precautions. Cardiac clearance before elective surgery.",
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – CLINICAL SUMMARY / EXAM MEMORY AID
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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – REFERENCES & THANK YOU
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  const refs = [
    "1. Miller's Anesthesia, 10th ed. – Chapter on Pediatric Anesthesia (Cleft Lip & Palate, p. 10644)",
    "2. Bosenberg AT, Kimble FW. Infraorbital nerve block in neonates for cleft lip repair. Br J Anaesth. 1995;74:506–508",
    "3. Prabhu KP et al. Bilateral infraorbital nerve block is superior to peri-incisional infiltration for cleft lip repair. Scand J Plast Reconstr. 1999;33:83–87",
    "4. Mesnil M et al. Bilateral suprazygomatic maxillary nerve block for cleft palate repair. Paediatr Anaesth. 2010;20:343–349",
    "5. Echaniz G et al. Suprazygomatic maxillary vs infraorbital/palatine blocks in CLP repair. Eur J Anaesthesiol. 2019;36:40–47",
    "6. Esfaharian M et al. Enhanced recovery after cleft palate surgery. Paediatr Anaesth. 2021",
    "7. Schwartz's Principles of Surgery, 11th ed. – Pierre Robin Sequence & mandibular distraction",
    "8. Cummings Otolaryngology, 7th ed. – Classification of Cleft Lip and Palate",
  ];

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