mkdir -p /home/daytona/workspace/icu-master-guide && ls /home/daytona/workspace/…

~/icu-master-guide/create_icu_guide.js

const {
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  HeadingLevel, AlignmentType, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageNumber, PageBreak, Header, Footer, TableOfContents,
  LevelFormat
} = require('docx');
const fs = require('fs');

// ─── COLOUR PALETTE ────────────────────────────────────────────────────────
const NAVY   = "1B3A6B";
const TEAL   = "0D7377";
const LTBLUE = "D6E8F7";
const LTGRAY = "F2F4F7";
const WHITE  = "FFFFFF";
const DARK   = "1A1A2E";
const RED    = "C0392B";
const AMBER  = "D35400";

// ─── HELPERS ────────────────────────────────────────────────────────────────
function h1(text) {
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function makeTable(headers, rows, shade_header_color) {
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    margins: { top: 0, bottom: 0, left: 0, right: 0 }
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}

// ─── COVER PAGE ─────────────────────────────────────────────────────────────
function coverPage() {
  return [
    new Paragraph({ text: "", spacing: { before: 1200, after: 0 } }),
    new Paragraph({
      children: [new TextRun({ text: "ICU MASTER GUIDE", bold: true, size: 72, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 200, after: 0 }
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    new Paragraph({
      children: [new TextRun({ text: "Critical Care Reference for Residents & Registrars", size: 30, color: WHITE, italics: true })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: TEAL, fill: TEAL },
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    new Paragraph({
      children: [new TextRun({ text: "2026 Edition", size: 24, color: LTBLUE, italics: true })],
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      spacing: { before: 0, after: 200 }
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    new Paragraph({ text: "", spacing: { before: 600, after: 0 } }),
    new Paragraph({
      children: [new TextRun({ text: "Contents:", bold: true, size: 24, color: NAVY })],
      spacing: { before: 200, after: 80 }
    }),
    ...["1. Mechanical Ventilation & ARDS", "2. Hemodynamic Monitoring & Shock", "3. Sepsis & Septic Shock", "4. Sedation, Analgesia & Delirium", "5. Vasopressors & Vasoactive Drugs", "6. Organ Support: Renal, Cardiac & Hepatic", "7. ICU Bundles & Quick-Reference Tables"].map(item =>
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    new Paragraph({ children: [new PageBreak()] })
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}

// ─── SECTION 1: MECHANICAL VENTILATION ─────────────────────────────────────
function section1() {
  return [
    new Paragraph({
      children: [new TextRun({ text: "SECTION 1", bold: true, size: 20, color: WHITE })],
      alignment: AlignmentType.CENTER,
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      spacing: { before: 100, after: 0 }
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    new Paragraph({
      children: [new TextRun({ text: "MECHANICAL VENTILATION & ARDS", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("Goals of Mechanical Ventilation"),
    body("Mechanical ventilation (MV) is a life-sustaining therapy in which a mechanical device provides partial or full support for patients with respiratory failure. The main goals are:"),
    bullet("Maintain adequate gas exchange (oxygenation and CO2 removal)", null),
    bullet("Rest the respiratory muscles and decrease the oxygen cost of breathing", null),
    bullet("Minimise iatrogenic injury (ventilator-induced lung injury, infection, oxygen toxicity)", null),
    body("Modern strategies accept permissive hypercapnia and mild hypoxaemia to avoid lung injury. A conservative oxygen target (PaO2 70-100 mmHg, SpO2 94-98%) is at least as good as liberal therapy. Further reducing SpO2 target to 90% is not beneficial. (Goldman-Cecil Medicine, 12th block)"),

    spacer(),
    h2("Indications for Intubation"),
    body("Clinical decision - not dictated by any single ABG value. Intubate if:"),
    bullet("Declining mental status (GCS ≤ 8 or rapidly falling)", null),
    bullet("Inability to protect airway / loss of airway reflexes", null),
    bullet("Respiratory fatigue: RR > 35, accessory muscle use, paradoxical breathing", null),
    bullet("Worsening acidosis pH < 7.25 despite NIV trial", null),
    bullet("Refractory hypoxaemia (PaO2/FiO2 < 150 on high-flow O2)", null),
    bullet("Haemodynamic instability: MAP < 65 or hypotension requiring vasopressors", null),

    spacer(),
    h2("Non-Invasive Ventilation (NIV / NIPPV)"),
    body("Preferred in COPD exacerbation with acute hypercapnic respiratory failure in cooperative patients WITHOUT:"),
    subbullet("Marked decreased mental status"),
    subbullet("Hypotension or haemodynamic instability"),
    subbullet("Inability to tolerate tight-fitting face mask"),
    body("Reassess at 30-120 minutes: if pH worsens, mental status declines, or oxygenation worsens → intubate."),

    spacer(),
    h2("Ventilator Modes"),
    makeTable(
      ["Mode", "Description", "Use Case"],
      [
        ["Volume Control (VC)", "Fixed tidal volume delivered at set rate regardless of effort. Guarantees minute ventilation.", "Paralysed / heavily sedated patients; severe ARDS"],
        ["Pressure Control (PC)", "Fixed inspiratory pressure; tidal volume varies with lung compliance.", "When precise pressure limits are needed (ARDS, air leak)"],
        ["SIMV", "Set breaths + patient-triggered spontaneous breaths. Weaning mode historically.", "Less preferred now; may cause dyssynchrony"],
        ["Pressure Support (PS)", "Patient-triggered; clinician sets support pressure only. Used during weaning.", "SBT, weaning, spontaneously breathing patients"],
        ["CPAP", "Continuous positive pressure; no mandatory breaths.", "Spontaneously breathing patients; post-extubation support"],
        ["APRV (Bi-Vent)", "High Phigh sustained with brief Plow releases. Recruits lung.", "Refractory ARDS; requires expertise"]
      ]
    ),

    spacer(),
    h2("Initial Ventilator Settings"),
    makeTable(
      ["Parameter", "Initial Setting", "Target / Comment"],
      [
        ["FiO2", "Start 1.0, wean down", "SpO2 94-98% (PaO2 70-100 mmHg)"],
        ["Tidal Volume (Vt)", "6 mL/kg IBW", "Reduce to 4-6 mL/kg in ARDS"],
        ["RR", "12-18 breaths/min", "Adjust to target pH 7.35-7.45"],
        ["PEEP", "5-8 cmH2O (start)", "Higher in ARDS (see ARDS table)"],
        ["I:E Ratio", "1:2 (standard)", "Extend expiration in COPD (1:3 or 1:4)"],
        ["Plateau Pressure (Pplat)", "≤ 30 cmH2O", "Limit to minimise volutrauma"],
        ["Driving Pressure", "< 15 cmH2O", "Pplat - PEEP; strongest mortality predictor"]
      ]
    ),

    spacer(),
    h2("ARDS: Berlin Definition & Management"),
    callout("ARDS = Acute onset bilateral pulmonary infiltrates + PaO2/FiO2 < 300 on ≥5 cmH2O PEEP + NOT explained by cardiac failure", NAVY),
    spacer(),
    makeTable(
      ["Severity", "PaO2/FiO2 (P/F Ratio)", "Mortality"],
      [
        ["Mild", "200-300 mmHg", "~27%"],
        ["Moderate", "100-200 mmHg", "~32%"],
        ["Severe", "< 100 mmHg", "~45%"]
      ]
    ),
    spacer(),
    h3("Lung-Protective Ventilation in ARDS"),
    bullet("Tidal volume 6 mL/kg IBW (reduce to 4 mL/kg if Pplat > 30 cmH2O)", "Vt"),
    bullet("Plateau pressure ≤ 30 cmH2O", "Pplat"),
    bullet("Driving pressure (Pplat - PEEP) < 15 cmH2O", "DP"),
    bullet("PEEP: titrate with FiO2 using ARDSNet PEEP/FiO2 table (higher PEEP in moderate-severe)", "PEEP"),
    bullet("Prone positioning ≥ 12 hrs/day in moderate-severe ARDS (P/F < 150) - reduces mortality by ~16%", "Prone"),
    bullet("Neuromuscular blockade (cisatracurium 48 hrs) facilitates proning and reduces dyssynchrony", "NMB"),
    bullet("VV-ECMO if refractory (P/F < 80 despite optimal settings) in experienced centres", "ECMO"),

    spacer(),
    h2("Ventilator-Associated Pneumonia (VAP) Prevention Bundle"),
    bullet("Head of bed elevation 30-45°", null),
    bullet("Daily sedation interruption + spontaneous breathing trial (SBT)", null),
    bullet("Oral decontamination with chlorhexidine", null),
    bullet("Subglottic secretion drainage (if intubation > 48-72 hrs expected)", null),
    bullet("Stress ulcer prophylaxis (H2 blocker or PPI)", null),
    bullet("DVT prophylaxis (LMWH or UFH)", null),

    spacer(),
    h2("Weaning & Extubation"),
    body("Perform daily SBT once the following are met:"),
    subbullet("Underlying cause improving"),
    subbullet("FiO2 ≤ 0.4, PEEP ≤ 5-8 cmH2O"),
    subbullet("Haemodynamically stable (off or low vasopressors)"),
    subbullet("Patient arousable, able to follow simple commands"),
    subbullet("Intact cough/gag reflex, secretions manageable"),
    body("SBT methods: T-piece 30-120 min OR low-level PS (5-8 cmH2O). Extubate if tolerated. Failure criteria: RR > 35, SpO2 < 90%, HR change > 20%, signs of distress."),
    body("Rapid Shallow Breathing Index (RSBI) = RR / Vt (L). RSBI < 105 predicts successful extubation."),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 2: HEMODYNAMIC MONITORING & SHOCK ──────────────────────────────
function section2() {
  return [
    new Paragraph({
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      spacing: { before: 100, after: 0 }
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    new Paragraph({
      children: [new TextRun({ text: "HEMODYNAMIC MONITORING & SHOCK", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("Classification of Shock"),
    makeTable(
      ["Type", "CI", "SVR", "PAOP", "SvO2", "Examples"],
      [
        ["Cardiogenic", "↓", "↑", "↑", "↓", "AMI, cardiomyopathy, severe valvular disease"],
        ["Hypovolaemic", "↓", "↑", "↓", "↓", "Haemorrhage, GI loss, burns, DI"],
        ["Distributive (Septic)", "N-↑", "↓", "N-↓", "N-↑", "Sepsis, anaphylaxis, neurogenic shock"],
        ["Obstructive", "↓", "↑-N", "N-↓", "N-↓", "PE, tension pneumothorax, tamponade"]
      ]
    ),
    body("CI = Cardiac Index; SVR = Systemic Vascular Resistance; PAOP = Pulmonary Artery Occlusion Pressure; SvO2 = Mixed venous O2 saturation. (Washington Manual of Medical Therapeutics, Table 8-5)"),

    spacer(),
    h2("Haemodynamic Monitoring Modalities"),
    makeTable(
      ["Method", "Parameters", "Invasiveness", "Clinical Use"],
      [
        ["Arterial Line (A-line)", "Continuous BP, pulse pressure variation (PPV)", "Invasive arterial", "All shocked patients; guide fluid responsiveness"],
        ["Central Venous Catheter (CVC)", "CVP, ScvO2", "Central venous", "Drug delivery; CVP unreliable for preload in isolation"],
        ["Pulmonary Artery Catheter (PAC)", "CO, CI, PAOP, SVR, SvO2", "Highly invasive", "Complex cardiac/ARDS; NOT routine in ARDS"],
        ["Echocardiography (TTE/TOE)", "LV/RV function, IVC, tamponade", "Non-invasive/semi", "First-line bedside assessment of all shocked patients"],
        ["Pulse Contour Analysis (PiCCO, LiDCO)", "CO, SVV, ITBV", "Minimally invasive", "Goal-directed fluid therapy; ICU haemodynamics"],
        ["Point-of-Care Lactate", "Tissue perfusion marker", "Non-invasive", "Serial lactate-guided resuscitation"]
      ]
    ),

    spacer(),
    h2("Fluid Responsiveness"),
    body("Not all shocked patients are fluid-responsive. Giving fluid to non-responders causes harm. Predict fluid responsiveness before giving a fluid challenge:"),
    bullet("Pulse Pressure Variation (PPV) > 13% on controlled MV → fluid responsive", "Static"),
    bullet("Stroke Volume Variation (SVV) > 10-15% → fluid responsive", "Dynamic"),
    bullet("Passive Leg Raise (PLR) test: raise legs 45° → auto-transfusion of ~300 mL. If CO increases ≥ 10% within 60 seconds → fluid responsive. Rapidly reversible.", "PLR"),
    bullet("End-expiratory occlusion test (EEOT): 15-sec pause → if CO rises ≥ 5% → fluid responsive", "EEOT"),
    body("CVP alone is a POOR predictor of fluid responsiveness and should not be used in isolation to guide resuscitation."),

    spacer(),
    h2("Cardiogenic Shock"),
    callout("Definition: Persistent hypotension (SBP < 90 for > 30 min or MAP < 60) with reduced CI (<2.2 L/min/m2) and elevated filling pressures (PAOP > 18 mmHg)", DARK),
    spacer(),
    h3("Management Priorities"),
    bullet("Identify and treat cause: AMI (emergency PCI), arrhythmia (cardioversion), tamponade (pericardiocentesis)", null),
    bullet("Avoid excessive fluid (causes pulmonary oedema)", null),
    bullet("Inotropes: Dobutamine first-line (2.5-20 mcg/kg/min); add norepinephrine if hypotensive", null),
    bullet("Mechanical circulatory support: IABP (reduces afterload), Impella, VA-ECMO for refractory cases", null),
    bullet("Treat pulmonary oedema: diuresis once BP stable, consider vasodilators (nitrates) if BP allows", null),

    spacer(),
    h2("Hypovolaemic / Haemorrhagic Shock"),
    makeTable(
      ["Class", "Blood Loss", "HR", "BP", "RR", "Mental Status"],
      [
        ["I", "< 15% (< 750 mL)", "< 100", "Normal", "14-20", "Normal/anxious"],
        ["II", "15-30% (750-1500 mL)", "100-120", "Normal", "20-30", "Mildly anxious"],
        ["III", "30-40% (1500-2000 mL)", "120-140", "Decreased", "30-40", "Confused"],
        ["IV", "> 40% (> 2000 mL)", "> 140", "Very low", "> 35", "Lethargic/obtunded"]
      ]
    ),
    body("Massive haemorrhage protocol (MHP): 1:1:1 ratio (pRBC:FFP:Platelets). Damage control resuscitation. Avoid crystalloid excess. Target: SBP 80-90 in penetrating trauma (permissive hypotension) until surgical control. Tranexamic acid within 3 hours if traumatic haemorrhage."),

    spacer(),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 3: SEPSIS ──────────────────────────────────────────────────────
function section3() {
  return [
    new Paragraph({
      children: [new TextRun({ text: "SECTION 3", bold: true, size: 20, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: TEAL, fill: TEAL },
      spacing: { before: 100, after: 0 }
    }),
    new Paragraph({
      children: [new TextRun({ text: "SEPSIS & SEPTIC SHOCK", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("Sepsis-3 Definitions (2016)"),
    callout("SEPSIS: Life-threatening organ dysfunction caused by a dysregulated host response to infection. SOFA score increase ≥ 2 from baseline in a patient with suspected/confirmed infection.", DARK),
    spacer(),
    callout("SEPTIC SHOCK: Sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg + Lactate > 2 mmol/L despite adequate fluid resuscitation. Hospital mortality > 40%.", RED),
    spacer(),
    body("qSOFA (bedside screening tool): Altered mentation + RR ≥ 22 + SBP ≤ 100. Score ≥ 2 → investigate further for sepsis."),
    body("SOFA score includes: Respiratory (PaO2/FiO2), Coagulation (platelets), Liver (bilirubin), Cardiovascular (MAP/vasopressors), CNS (GCS), Renal (creatinine/urine output)."),

    spacer(),
    h2("Surviving Sepsis Campaign: 1-Hour Bundle"),
    callout("The 2021 SSC guidelines recommend treating sepsis as a MEDICAL EMERGENCY - bundle completion within 1 hour", AMBER),
    spacer(),
    makeTable(
      ["Action", "Detail"],
      [
        ["Measure lactate", "Remeasure if initial lactate > 2 mmol/L. Target < 2 mmol/L."],
        ["Blood cultures x2", "Before antibiotics. Do NOT delay antibiotics for cultures."],
        ["Broad-spectrum antibiotics", "Within 1 hour of recognition. Reassess when micro results available."],
        ["IV fluid resuscitation", "30 mL/kg IV crystalloid within first 3 hours if hypotension or lactate ≥ 4 mmol/L"],
        ["Vasopressors", "If MAP remains < 65 mmHg despite fluid. Target MAP ≥ 65 mmHg."]
      ]
    ),

    spacer(),
    h2("Source Control"),
    body("Identify and control infection source promptly. Imaging (CT/US) to find occult focus. Interventions: drain abscess, debride infected tissue, remove infected lines/devices. Timing: as soon as feasible, ideally within 6-12 hours."),
    body("Sepsis mimics (25% of 'septic' ICU admissions): heart failure, PE, COPD exacerbation, mesenteric ischaemia, vasculitis, adrenal insufficiency. Continuous re-evaluation is imperative."),

    spacer(),
    h2("Antimicrobial Therapy in Sepsis"),
    makeTable(
      ["Source", "Empiric Coverage", "Common Agents"],
      [
        ["Unknown / community", "Gram +ve + Gram -ve ± anaerobes", "Pip-tazo + vancomycin (if MRSA risk)"],
        ["Healthcare/hospital", "Extended spectrum GNR + MRSA", "Meropenem + vancomycin ± antifungal"],
        ["Urine (UTI/pyelonephritis)", "Enterobacteriaceae", "Ceftriaxone or pip-tazo (local resistance guided)"],
        ["Pneumonia (CAP)", "S. pneumoniae, atypicals", "Beta-lactam + macrolide OR respiratory FQ"],
        ["Pneumonia (HAP/VAP)", "MRSA, Pseudomonas, Acinetobacter", "Anti-pseudomonal beta-lactam + vancomycin/linezolid"],
        ["Intra-abdominal", "GNR + anaerobes", "Pip-tazo OR meropenem (severe)"],
        ["Neutropaenic fever", "Pseudomonas, Candida", "Cefepime or pip-tazo + consider antifungal"]
      ]
    ),
    body("De-escalate to targeted therapy once cultures available. Procalcitonin can guide duration (stop when < 0.5 ng/mL or falls > 80% from peak). Typical duration: 5-7 days for most infections."),

    spacer(),
    h2("Corticosteroids in Septic Shock"),
    body("Hydrocortisone 200 mg/day (continuous infusion or 50 mg q6h) if shock persists despite adequate fluids AND vasopressors (norepinephrine ≥ 0.25 mcg/kg/min). Associated with faster shock reversal; survival benefit uncertain. Taper once vasopressors weaned."),

    spacer(),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 4: SEDATION & DELIRIUM ─────────────────────────────────────────
function section4() {
  return [
    new Paragraph({
      children: [new TextRun({ text: "SECTION 4", bold: true, size: 20, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: TEAL, fill: TEAL },
      spacing: { before: 100, after: 0 }
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    new Paragraph({
      children: [new TextRun({ text: "SEDATION, ANALGESIA & DELIRIUM", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("PADIS Guidelines (2018) Framework"),
    body("Pain, Agitation/Sedation, Delirium, Immobility, and Sleep disruption (PADIS). The 2018 SCCM PADIS guidelines form the modern framework for ICU sedation management."),
    callout("Core Principle: Analgesia-first (A1C). Treat pain before sedation. Aim for LIGHT sedation (RASS -1 to 0). Avoid benzodiazepines as first-line sedatives.", DARK),

    spacer(),
    h2("Sedation-Agitation Scales"),
    makeTable(
      ["RASS Score", "Description", "Action"],
      [
        ["+4 Combative", "Violent, immediate danger to staff", "Bolus + consider paralysis if on MV"],
        ["+3 Very Agitated", "Pulls tubes, aggressive", "Titrate sedation up"],
        ["+2 Agitated", "Frequent purposeless movement", "Increase sedation"],
        ["+1 Restless", "Anxious but not aggressive", "Reassess, treat pain first"],
        ["0 Alert & Calm", "Target for most ICU patients", "Maintain; daily SBT"),
        ["-1 Drowsy", "Briefly awakens to voice (>10 sec eye contact)", "Acceptable; assess if appropriate"],
        ["-2 Light Sedation", "Briefly awakens (<10 sec)", "Assess if deep sedation necessary"],
        ["-3 Moderate Sedation", "Movement without eye contact", "Consider DSI trial"],
        ["-4 Deep Sedation", "No response to voice, moves to physical", "Justify ongoing deep sedation"],
        ["-5 Unarousable", "No response to physical stimulation", "Paralysed or near-death"]
      ]
    ),

    spacer(),
    h2("Analgesic Agents"),
    makeTable(
      ["Drug", "Dose (IV)", "Onset/Duration", "Notes"],
      [
        ["Fentanyl", "25-100 mcg bolus; 25-200 mcg/hr infusion", "Rapid / 30-60 min", "Preferred in renal failure; lipophilic, accumulates"],
        ["Morphine", "2-4 mg bolus; 2-5 mg/hr", "5-10 min / 3-4 hrs", "Avoid in renal failure (active metabolite); histamine release"],
        ["Hydromorphone", "0.2-0.6 mg bolus; 0.2-0.6 mg/hr", "5-15 min / 3-4 hrs", "More potent than morphine; use in opioid-tolerant"],
        ["Remifentanil", "0.05-0.2 mcg/kg/min", "1-3 min / 5-10 min", "Ultra-short acting; rapid emergence; risk of hyperalgesia"],
        ["Ketamine", "0.1-0.5 mg/kg/hr (analgesia)", "1-2 min", "Opioid-sparing; bronchodilator; dissociative at higher doses"]
      ]
    ),

    spacer(),
    h2("Sedative Agents"),
    makeTable(
      ["Drug", "Dose (IV)", "Mechanism", "Notes"],
      [
        ["Propofol", "5-50 mcg/kg/min", "GABA-A agonist", "Fast on/off; monitor for PRIS (triglycerides, gap, rhabdo). Preferred non-benzo sedative."],
        ["Dexmedetomidine", "0.2-1.5 mcg/kg/hr", "Alpha-2 agonist", "Cooperative sedation, patient arousable. Reduces delirium, shortens MV duration. First-line for light sedation."],
        ["Midazolam", "0.02-0.1 mg/kg/hr", "Benzo/GABA-A", "Accumulates; associated with increased delirium and prolonged MV. Avoid as first-line in ICU."],
        ["Lorazepam", "1-4 mg q2-6h PRN or infusion", "Benzo/GABA-A", "Longer-acting; propylene glycol toxicity with infusions. Avoid as first-line."],
        ["Ketamine", "0.5-2 mg/kg/hr", "NMDA antagonist", "Minimal respiratory depression; useful in intractable bronchospasm. Watch for emergence reactions."]
      ]
    ),
    body("Fentanyl-dominant sedation is associated with increased delirium, composite delirium/death, and longer MV duration compared with propofol- or midazolam-dominant regimens (Miller's Anesthesia 10e)."),
    body("Dexmedetomidine compared to benzodiazepines: reduces delirium incidence and shortens MV duration (Harrison's, 2025)."),

    spacer(),
    h2("Daily Sedation Interruption (DSI)"),
    body("Stop all sedative infusions once daily at a set time. Assess patient. If agitated or at risk, restart at half the previous dose and titrate. Paired with daily SBT. Reduces ventilator days and ICU length of stay."),
    body("DSI may not be necessary if the team uses light sedation protocol (RASS -1 to 0) consistently."),

    spacer(),
    h2("ICU Delirium"),
    callout("Delirium affects 60-80% of mechanically ventilated ICU patients. Associated with increased mortality, prolonged MV, long-term cognitive impairment, and higher cost.", RED),
    spacer(),
    h3("Screening Tools"),
    bullet("CAM-ICU (Confusion Assessment Method - ICU): Acute onset change in mental status + inattention + disorganised thinking OR altered LOC. Sensitivity ~80%, Specificity ~96%.", null),
    bullet("ICDSC (Intensive Care Delirium Screening Checklist): 8-item scale; score ≥ 4 = delirium.", null),
    spacer(),
    h3("Delirium Types"),
    bullet("Hyperactive: Agitation, pulling tubes, disorganised. Easier to recognise.", null),
    bullet("Hypoactive: Drowsy, withdrawn, slow responses. More common (70%+) and often missed. Worse prognosis.", null),
    bullet("Mixed: Both components alternate.", null),
    spacer(),
    h3("ABCDEF Bundle (Delirium Prevention)"),
    bullet("Assess, prevent and manage PAIN", "A"),
    bullet("Both SAT (Spontaneous Awakening Trial) + SBT (Spontaneous Breathing Trial)", "B"),
    bullet("Choice of sedation/analgesia (light, non-benzo)", "C"),
    bullet("Delirium monitoring (CAM-ICU) and management", "D"),
    bullet("Early mobility and Exercise", "E"),
    bullet("Family engagement and empowerment", "F"),
    spacer(),
    h3("Pharmacological Management of Delirium"),
    body("Haloperidol (IV or PO) remains commonly used despite lack of mortality benefit in RCTs. Quetiapine may reduce agitation. Treat underlying cause (infection, metabolic, medication). Dexmedetomidine is preferred for sedation when delirium is present."),
    body("Benzodiazepines are a major modifiable risk factor for delirium - use only for alcohol/benzo withdrawal, seizures, or procedural sedation."),

    spacer(),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 5: VASOPRESSORS ─────────────────────────────────────────────────
function section5() {
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    new Paragraph({
      children: [new TextRun({ text: "SECTION 5", bold: true, size: 20, color: WHITE })],
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      spacing: { before: 0, after: 200 }
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    h2("Receptor Pharmacology Overview"),
    makeTable(
      ["Receptor", "Location / Effect", "Agonists"],
      [
        ["Alpha-1 (α1)", "Vasoconstriction (↑SVR), ↑BP", "Norepinephrine, phenylephrine, epinephrine"],
        ["Beta-1 (β1)", "↑HR, ↑contractility, ↑CO", "Norepinephrine (modest), epinephrine, dobutamine, dopamine"],
        ["Beta-2 (β2)", "Vasodilation, bronchodilation", "Epinephrine (low dose), salbutamol"],
        ["Dopamine (D1/D2)", "Renal/splanchnic vasodilation (D1); ↓prolactin (D2)", "Dopamine (low dose)"],
        ["V1 (Vasopressin)", "Vasoconstriction via V1; renal water retention via V2", "Vasopressin, terlipressin"]
      ]
    ),

    spacer(),
    h2("Vasopressor & Inotrope Drug Reference"),
    makeTable(
      ["Drug", "Receptors", "Dose Range", "Primary Effect", "Key Indications / Notes"],
      [
        ["Norepinephrine", "α1 ↑↑↑, β1 ↑", "0.01-3 mcg/kg/min", "↑↑SVR, mild ↑CO", "FIRST-LINE vasopressor in septic shock. Fewer arrhythmias than dopamine."],
        ["Epinephrine", "α1 ↑↑, β1 ↑↑↑, β2 ↑↑", "0.01-1 mcg/kg/min", "↑CO ↑↑, ↑HR ↑↑, ↑SVR", "Anaphylaxis (IM 0.5 mg), cardiogenic shock add-on, cardiac arrest (1 mg IVB)"],
        ["Dopamine", "D1 (low), β1 (mod), α1 (high)", "1-20 mcg/kg/min", "Dose-dependent mixed", "Avoid in septic shock (higher arrhythmia rate). Use only in selected bradycardia."],
        ["Dobutamine", "β1 ↑↑↑, β2 ↑", "2.5-20 mcg/kg/min", "↑CO, ↓SVR", "Cardiogenic shock with low CO; add to NE. Can worsen hypotension alone."],
        ["Vasopressin", "V1 ↑↑↑", "0.01-0.04 units/min (fixed)", "↑SVR, ↓NE requirements", "Adjunct to NE when dose ≥ 0.25 mcg/kg/min. NOT titrated - fixed dose."],
        ["Phenylephrine", "α1 ↑↑↑ (pure)", "0.5-6 mcg/kg/min", "↑↑SVR, ↓CO (reflex brady)", "Avoid in septic shock (↓CO). Use in: vasodilatory shock + tachycardia, neurogenic shock."],
        ["Milrinone", "PDE3 inhibitor", "0.125-0.75 mcg/kg/min", "↑CO, ↓SVR (inovasodilator)", "Cardiogenic shock; RV failure. Reduces afterload. Caution in hypotension."],
        ["Levosimendan", "Ca2+ sensitiser + PDE3", "Loading + 0.05-0.2 mcg/kg/min", "↑contractility, ↓afterload", "Acute decompensated HF; NOT recommended per SSC 2021."]
      ]
    ),

    spacer(),
    h2("Vasopressor Escalation Algorithm in Septic Shock"),
    callout("Step 1: IV fluid 30 mL/kg crystalloid (check fluid responsiveness)", DARK),
    callout("Step 2: Start NOREPINEPHRINE via CVC. Target MAP ≥ 65 mmHg", NAVY),
    callout("Step 3: If NE ≥ 0.25 mcg/kg/min → Add VASOPRESSIN 0.03 units/min (fixed)", TEAL),
    callout("Step 4: If MAP still < 65 or persistent shock → Add EPINEPHRINE; consider HYDROCORTISONE 200 mg/day", AMBER),
    callout("Step 5: If cardiogenic component → Add DOBUTAMINE or consider MCS (IABP/Impella/VA-ECMO)", RED),

    spacer(),
    h2("Common ICU Vasopressor Pitfalls"),
    bullet("Dopamine is NOT first-line in septic shock - causes more arrhythmias and no mortality benefit", null),
    bullet("Phenylephrine reduces CO by reflex bradycardia - avoid in cardiogenic shock", null),
    bullet("Vasopressin must be used at fixed dose (0.03-0.04 u/min) - do NOT titrate like other pressors", null),
    bullet("High-dose epinephrine causes lactic acidosis (beta-2 mediated lactate production) - do not use elevated lactate as resuscitation failure", null),
    bullet("Dobutamine alone in hypotension will worsen BP - always pair with a vasopressor", null),

    spacer(),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 6: ORGAN SUPPORT ────────────────────────────────────────────────
function section6() {
  return [
    new Paragraph({
      children: [new TextRun({ text: "SECTION 6", bold: true, size: 20, color: WHITE })],
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    new Paragraph({
      children: [new TextRun({ text: "ORGAN SUPPORT: RENAL, CARDIAC & HEPATIC", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("Acute Kidney Injury (AKI) in ICU"),
    h3("KDIGO Staging"),
    makeTable(
      ["Stage", "Serum Creatinine", "Urine Output"],
      [
        ["1", "1.5-1.9x baseline OR ≥ 26.5 umol/L rise within 48 hrs", "< 0.5 mL/kg/hr for 6-12 hours"],
        ["2", "2.0-2.9x baseline", "< 0.5 mL/kg/hr for ≥ 12 hours"],
        ["3", "≥ 3.0x baseline OR Cr ≥ 354 umol/L OR RRT initiated", "< 0.3 mL/kg/hr for ≥ 24 hrs OR anuria ≥ 12 hrs"]
      ]
    ),
    spacer(),
    h3("AKI Management Principles"),
    bullet("Identify and remove precipitating cause (sepsis, nephrotoxins, obstruction, hypovolaemia)", null),
    bullet("Optimise haemodynamics: MAP ≥ 65 mmHg (may target 75-80 in known CKD or hypertension)", null),
    bullet("Avoid nephrotoxins: NSAIDs, aminoglycosides, IV contrast (if alternatives available), ACEi/ARB", null),
    bullet("Balanced crystalloids (Lactated Ringer's / Plasmalyte) preferred over normal saline to reduce hyperchloraemic acidosis", null),
    bullet("Monitor fluid balance closely: avoid both hypovolaemia and fluid overload", null),
    bullet("Nutrition: Protein 1.2-2.0 g/kg/day; no protein restriction in AKI (worsens outcomes)", null),

    spacer(),
    h3("Renal Replacement Therapy (RRT)"),
    body("Indications (absolute): refractory hyperkalaemia (K+ > 6.5), refractory acidosis (pH < 7.1), refractory fluid overload, uraemia (encephalopathy, pericarditis, bleeding)."),
    makeTable(
      ["Modality", "Rate/Duration", "Advantage", "Disadvantage"],
      [
        ["IHD (Intermittent Haemodialysis)", "3-4 hrs, 3-7x/week", "Efficient solute removal", "Haemodynamic instability; not for shock"],
        ["CRRT (Continuous RRT)", "24 hrs/day continuous", "Haemodynamically stable; fluid removal controllable", "Requires anticoagulation; immobility; filter clotting"],
        ["SLED (Sustained Low-Efficiency)", "6-12 hrs daily", "Compromise: efficiency + stability", "Less widely available"],
        ["PD (Peritoneal Dialysis)", "Dwell/drain cycles", "No vascular access needed", "Slow; limited in critically ill; infection risk"]
      ]
    ),
    body("CRRT is preferred in haemodynamically unstable ICU patients. KDIGO recommends RRT when AKI causes life-threatening electrolyte, acid-base, or fluid disturbances not manageable by other means."),

    spacer(),
    h2("Cardiac Support in ICU"),
    h3("Mechanical Circulatory Support (MCS) Overview"),
    makeTable(
      ["Device", "Mechanism", "CO Support", "Indications"],
      [
        ["IABP (Intra-aortic Balloon Pump)", "Counterpulsation: inflates in diastole, deflates in systole", "Modest (0.5 L/min)", "Cardiogenic shock (adjunct); limited evidence"],
        ["Impella CP/5.0", "Microaxial pump: LV → aorta", "Up to 5.5 L/min", "Cardiogenic shock; high-risk PCI"],
        ["VA-ECMO", "Extracorporeal oxygenation + perfusion", "Full cardiac + respiratory support", "Refractory cardiogenic shock; cardiac arrest (E-CPR); severe ARDS + haemodynamic failure"]
      ]
    ),

    spacer(),
    h3("Post-Cardiac Arrest Care"),
    bullet("Targeted Temperature Management (TTM): 32-36°C for 24+ hours. Fever avoidance (< 37.7°C) in comatose patients post-ROSC.", null),
    bullet("Avoid hyperoxia: PaO2 target 70-100 mmHg (wean FiO2 quickly after ROSC)", null),
    bullet("Haemodynamic targets: MAP ≥ 65-80 mmHg; avoid hypotension (SBP < 90)", null),
    bullet("CAG/PCI: emergent PCI if STEMI or suspected culprit lesion on ECG/clinical features", null),
    bullet("Neurological prognostication: not before 72 hours post-arrest (or 72 hrs after TTM rewarming)", null),

    spacer(),
    h2("Acute Hepatic Failure (ALF) in ICU"),
    callout("ALF = Acute liver injury + encephalopathy + coagulopathy (INR ≥ 1.5) in patient WITHOUT prior liver disease, within 26 weeks of onset", DARK),
    spacer(),
    bullet("Monitor: ICP monitoring if Grade III-IV encephalopathy (controversial); target CPP > 50 mmHg", null),
    bullet("Lactulose / rifaximin for hepatic encephalopathy", null),
    bullet("N-acetylcysteine (NAC): for ALL ALF (even non-paracetamol) - improves transplant-free survival", null),
    bullet("Coagulopathy: correct only for procedures or active bleeding; do NOT prophylactically correct INR", null),
    bullet("Hypoglycaemia: frequent monitoring; 10% dextrose infusion to maintain glucose 5-10 mmol/L", null),
    bullet("Infections: broad-spectrum antibiotics for proven/highly suspected infection; antifungals if deteriorating", null),
    bullet("Hepatorenal syndrome (HRS): terlipressin + albumin (20% 1 g/kg loading); consider MARS/SPAD dialysis", null),
    bullet("Transplant evaluation: early contact with liver transplant centre for ALF with poor prognosis criteria (King's College Criteria or MELD > 30)", null),

    spacer(),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ─── SECTION 7: QUICK REFERENCE & BUNDLES ────────────────────────────────────
function section7() {
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      children: [new TextRun({ text: "SECTION 7", bold: true, size: 20, color: WHITE })],
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    new Paragraph({
      children: [new TextRun({ text: "ICU BUNDLES & QUICK-REFERENCE TABLES", bold: true, size: 34, color: WHITE })],
      alignment: AlignmentType.CENTER,
      shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
      spacing: { before: 0, after: 200 }
    }),

    h2("ICU Admission Checklist"),
    makeTable(
      ["Category", "Action"],
      [
        ["Lines & Monitoring", "A-line, CVC, IDC with urometer, SpO2, continuous ECG, capnography if ventilated"],
        ["Airway", "Confirm ETT position (XR), cuff pressure 20-30 cmH2O, secure ETT"],
        ["Ventilation", "Set initial settings (Vt 6 mL/kg IBW, check Pplat ≤ 30), FiO2 titrate"],
        ["Haemodynamics", "ECHO/POCUS assessment, IV access x2, resuscitation if needed"],
        ["Labs", "ABG, FBC, U&E, LFT, coags, lactate, blood cultures, ECG, CXR"],
        ["Medications", "DVT prophylaxis, stress ulcer PX, insulin protocol, home medications review"],
        ["Sedation", "Analgesia-first protocol, RASS target, daily SAT + SBT plan"],
        ["Nutrition", "EN within 24-48 hrs; dietitian referral; protein 1.2-2 g/kg/day"],
        ["Skin", "Pressure area care, regular turns, heel protection"],
        ["Communication", "Goals of care discussion; next-of-kin contact; advance care planning review"]
      ]
    ),

    spacer(),
    h2("Acid-Base Quick Reference"),
    makeTable(
      ["Disorder", "pH", "PaCO2", "HCO3-", "Compensation", "Common Causes"],
      [
        ["Metabolic Acidosis", "↓", "↓ (compensated)", "↓↓", "Winter's: PaCO2 = 1.5×HCO3 + 8 (±2)", "DKA, lactic acidosis, renal failure, toxins"],
        ["Metabolic Alkalosis", "↑", "↑ (compensated)", "↑↑", "PaCO2 rises 0.7 per 1 mmol/L HCO3 rise", "Vomiting, diuretics, hypokalaemia"],
        ["Respiratory Acidosis", "↓", "↑↑", "↑ (renal)", "Acute: HCO3 +1/10 mmHg CO2; Chronic: +3.5", "COPD, hypoventilation, CNS depression"],
        ["Respiratory Alkalosis", "↑", "↓↓", "↓ (renal)", "Acute: HCO3 -2/10 mmHg CO2; Chronic: -5", "Anxiety, PE, sepsis (early), altitude, MV"]
      ]
    ),

    spacer(),
    h2("Common ICU Electrolyte Emergencies"),
    makeTable(
      ["Electrolyte", "Emergency Threshold", "Management"],
      [
        ["Hyperkalaemia", "K+ > 6.5 mEq/L or ECG changes", "Ca gluconate 1g IV (membrane stabilise); Insulin-dextrose; Salbutamol neb; Kayexalate; RRT if refractory"],
        ["Hypokalaemia", "K+ < 2.5 or arrhythmia", "IV KCl: max 20 mEq/hr via CVC; replace Mg simultaneously (target Mg > 0.8)"],
        ["Hypernatraemia", "Na > 155 (symptomatic)", "Free water deficit = 0.6 × wt × (Na/140 -1). Correct ≤ 0.5 mEq/L/hr. Use D5W or enterally"],
        ["Hyponatraemia", "Na < 120 or seiz/coma", "3% NaCl: 100 mL bolus (repeat x2 if seizure). Correct ≤ 10-12 mEq/day to avoid ODS"],
        ["Hypocalcaemia", "iCa < 1.0 mmol/L", "Ca gluconate 1-2g IV over 10-20 min; recheck"],
        ["Hypomagnesaemia", "Mg < 0.5 mmol/L", "MgSO4 2-4g IV over 20-60 min; replace pre-emptively when K+ low"]
      ]
    ),

    spacer(),
    h2("Normal ICU Haemodynamic Values"),
    makeTable(
      ["Parameter", "Normal Range", "Comment"],
      [
        ["MAP", "65-100 mmHg", "Target ≥ 65 in sepsis; ≥ 75-80 in known HTN/CKD"],
        ["CVP", "2-8 mmHg", "Poor predictor of preload; do NOT use in isolation"],
        ["PCWP/PAOP", "4-12 mmHg", "Elevated in cardiogenic shock; low in hypovolaemic"],
        ["CI (Cardiac Index)", "2.2-4.0 L/min/m2", "< 2.2 = cardiogenic shock"],
        ["SVR", "800-1200 dyn.s/cm5", "Elevated in hypovolaemic/cardiogenic; low in sepsis"],
        ["SvO2", "60-75%", "< 65% = increased O2 demand or poor delivery"],
        ["ScvO2", "≥ 70%", "Surrogate for SvO2 via CVC"],
        ["Lactate", "< 2 mmol/L", "Elevated = tissue hypoperfusion or altered metabolism"]
      ]
    ),

    spacer(),
    h2("Common Drug Infusion Reference"),
    makeTable(
      ["Drug", "Standard Concentration", "Usual Range", "Special Instructions"],
      [
        ["Norepinephrine", "4 mg in 250 mL (16 mcg/mL) or 8/250 (32 mcg/mL)", "0.01-3 mcg/kg/min", "Central line only; titrate to MAP target"],
        ["Vasopressin", "20 units in 100 mL (0.2 u/mL)", "0.01-0.04 units/min (FIXED)", "Fixed dose - not titrated; add-on to NE"],
        ["Dobutamine", "250 mg in 250 mL (1000 mcg/mL)", "2.5-20 mcg/kg/min", "Monitor for tachycardia and hypotension"],
        ["Propofol (2%)", "200 mg/20 mL pre-filled", "5-50 mcg/kg/min", "Max 4 mg/kg/hr; check TGs every 48-72 hrs"],
        ["Dexmedetomidine", "200 mcg in 50 mL (4 mcg/mL)", "0.2-1.5 mcg/kg/hr", "Bradycardia and hypotension; no loading in ICU"],
        ["Insulin", "50 units in 50 mL NS (1 unit/mL)", "Per protocol", "Target glucose 7.8-10 mmol/L (avoid < 4)"],
        ["Heparin (UFH)", "25,000 u in 250 mL (100 u/mL)", "Per APTT protocol", "DVT/PE/AF/circuits; check HIT if platelets ↓"],
        ["Amiodarone", "300 mg load then 900 mg/24 hr", "See protocol", "Central line preferred; phlebitis peripherally"]
      ]
    ),

    spacer(),
    h2("End-of-Life & Goals of Care in ICU"),
    body("Early goals-of-care discussions improve patient/family satisfaction, reduce ICU length of stay, and prevent non-beneficial interventions."),
    bullet("Establish ceiling of care: CPR yes/no, intubation, vasopressors, dialysis, ECMO", null),
    bullet("Identify surrogate decision-maker if patient lacks capacity", null),
    bullet("Document Advance Care Directives and prior wishes", null),
    bullet("Palliative care consultation for complex symptom management or withdrawal planning", null),
    bullet("Proportionate care: transition goals from curative to comfort when appropriate", null),
    bullet("Symptom management during withdrawal: opioids for dyspnoea (do NOT withhold); midazolam for distress", null),

    spacer(),
    h2("References & Sources"),
    body("This guide is compiled from the following authoritative textbooks:"),
    bullet("Goldman-Cecil Medicine, International Edition (2 Volume Set)", null),
    bullet("Harrison's Principles of Internal Medicine, 22nd Edition (2025)", null),
    bullet("Miller's Anesthesia, 2-Volume Set, 10th Edition", null),
    bullet("Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition", null),
    bullet("The Washington Manual of Medical Therapeutics", null),
    bullet("Fishman's Pulmonary Diseases and Disorders, 2-Volume Set", null),
    bullet("Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume", null),
    bullet("Fischer's Mastery of Surgery, 8th Edition", null),
    body("Supplemented by: Surviving Sepsis Campaign 2021 Guidelines, SCCM PADIS Guidelines 2018, KDIGO AKI Guidelines 2012, Berlin ARDS Definition 2012."),

    spacer()
  ];
}

// ─── ASSEMBLE DOCUMENT ───────────────────────────────────────────────────────
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cd /home/daytona/workspace/icu-master-guide && node create_icu_guide.js 2>&1

~/icu-master-guide/create_icu_guide.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/icu-master-guide/create_icu_guide.js'

cd /home/daytona/workspace/icu-master-guide && node create_icu_guide.js 2>&1

~/icu-master-guide/create_icu_guide.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/icu-master-guide/create_icu_guide.js'

cd /home/daytona/workspace/icu-master-guide && node create_icu_guide.js 2>&1

python /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/worksp…

python3 -c "import zipfile; z=zipfile.ZipFile('/home/daytona/workspace/icu-maste…

ls -lh /home/daytona/workspace/icu-master-guide/ICU_Master_Guide_2026.docx