DAS 2025 difficult airway guideline unanticipated difficult intubation videolaryngoscopy eFONA ABCD algorithm BJA

AHA 2025 CPR ECC guidelines cardioversion TOR criteria ETCO2 head-up CPR updates

Surviving Sepsis Campaign 2026 guidelines 129 statements post-discharge follow-up updates

EMHG 2025 malignant hyperthermia investigation guidelines MHG genotype IVCT genetic testing JSA 2025

NAP7 pericardiac arrest anaesthesia audit obstetric haemorrhage frailty ASRA LAST 2023 AAGBI ASA fasting GLP1 ESC 2022 perioperative OAA obstetric haemorrhage patient blood management 2024

mkdir -p /home/daytona/workspace/md-anaesthesia-finals && ls /home/daytona/works…

~/md-anaesthesia-finals/build_pdf.py

#!/usr/bin/env python3
"""
MD Anaesthesia Finals 2026 — Recent Guidelines & Updates
PDF generator using reportlab
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib.colors import HexColor, black, white
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import Frame, PageTemplate
from reportlab.pdfgen import canvas
import os

OUTPUT_PATH = "/home/daytona/workspace/md-anaesthesia-finals/MD_Anaesthesia_Finals_2026_Guidelines.pdf"

# ---------------------------------------------------------------------------
# Colour palette
# ---------------------------------------------------------------------------
DARK_NAVY   = HexColor("#1a2744")
MED_BLUE    = HexColor("#2b4a8b")
LIGHT_BLUE  = HexColor("#dce6f5")
ACCENT_TEAL = HexColor("#007b8a")
RULE_GREY   = HexColor("#c8d4e8")
BODY_GREY   = HexColor("#2d2d2d")
SECTION_BG  = HexColor("#f0f4fb")

# ---------------------------------------------------------------------------
# Page layout  –  generous margins (3 cm sides, 2.5 cm top/bottom)
# ---------------------------------------------------------------------------
LEFT_MARGIN  = 3.0 * cm
RIGHT_MARGIN = 3.0 * cm
TOP_MARGIN   = 2.5 * cm
BOT_MARGIN   = 2.5 * cm

# ---------------------------------------------------------------------------
# Header / footer callback
# ---------------------------------------------------------------------------
TITLE_SHORT = "MD Anaesthesia Finals 2026 — Recent Guidelines & Updates"

def header_footer(canvas_obj, doc):
    canvas_obj.saveState()
    w, h = A4

    # Top rule
    canvas_obj.setStrokeColor(MED_BLUE)
    canvas_obj.setLineWidth(1.5)
    canvas_obj.line(LEFT_MARGIN, h - TOP_MARGIN + 0.3*cm,
                    w - RIGHT_MARGIN, h - TOP_MARGIN + 0.3*cm)

    # Header text
    canvas_obj.setFont("Helvetica-Bold", 7.5)
    canvas_obj.setFillColor(MED_BLUE)
    canvas_obj.drawString(LEFT_MARGIN, h - TOP_MARGIN + 0.6*cm, TITLE_SHORT)
    canvas_obj.setFont("Helvetica", 7.5)
    canvas_obj.setFillColor(BODY_GREY)
    canvas_obj.drawRightString(w - RIGHT_MARGIN, h - TOP_MARGIN + 0.6*cm,
                               "Compiled July 2026")

    # Bottom rule
    canvas_obj.setStrokeColor(RULE_GREY)
    canvas_obj.setLineWidth(0.8)
    canvas_obj.line(LEFT_MARGIN, BOT_MARGIN - 0.4*cm,
                    w - RIGHT_MARGIN, BOT_MARGIN - 0.4*cm)

    # Page number
    canvas_obj.setFont("Helvetica", 7.5)
    canvas_obj.setFillColor(BODY_GREY)
    canvas_obj.drawCentredString(w / 2, BOT_MARGIN - 0.7*cm,
                                 f"Page {doc.page}")

    canvas_obj.restoreState()


# ---------------------------------------------------------------------------
# Styles
# ---------------------------------------------------------------------------
def build_styles():
    styles = {}

    styles["cover_title"] = ParagraphStyle(
        "cover_title",
        fontName="Helvetica-Bold",
        fontSize=22,
        leading=28,
        textColor=DARK_NAVY,
        alignment=TA_CENTER,
        spaceAfter=8,
    )
    styles["cover_subtitle"] = ParagraphStyle(
        "cover_subtitle",
        fontName="Helvetica",
        fontSize=12,
        leading=16,
        textColor=MED_BLUE,
        alignment=TA_CENTER,
        spaceAfter=4,
    )
    styles["cover_note"] = ParagraphStyle(
        "cover_note",
        fontName="Helvetica-Oblique",
        fontSize=9,
        leading=12,
        textColor=BODY_GREY,
        alignment=TA_CENTER,
        spaceAfter=4,
    )
    styles["section_head"] = ParagraphStyle(
        "section_head",
        fontName="Helvetica-Bold",
        fontSize=13,
        leading=17,
        textColor=white,
        alignment=TA_LEFT,
        spaceBefore=14,
        spaceAfter=6,
        leftIndent=0,
        borderPadding=(5, 8, 5, 8),
        backColor=MED_BLUE,
    )
    styles["body"] = ParagraphStyle(
        "body",
        fontName="Helvetica",
        fontSize=9.5,
        leading=14.5,
        textColor=BODY_GREY,
        alignment=TA_JUSTIFY,
        spaceBefore=0,
        spaceAfter=9,
        leftIndent=0,
        rightIndent=0,
    )
    styles["toc_item"] = ParagraphStyle(
        "toc_item",
        fontName="Helvetica",
        fontSize=9.5,
        leading=15,
        textColor=DARK_NAVY,
        leftIndent=8,
        spaceAfter=3,
    )
    styles["toc_head"] = ParagraphStyle(
        "toc_head",
        fontName="Helvetica-Bold",
        fontSize=11,
        leading=16,
        textColor=MED_BLUE,
        spaceAfter=8,
        spaceBefore=6,
    )
    styles["disclaimer"] = ParagraphStyle(
        "disclaimer",
        fontName="Helvetica-Oblique",
        fontSize=8,
        leading=11,
        textColor=BODY_GREY,
        alignment=TA_CENTER,
    )

    return styles


# ---------------------------------------------------------------------------
# Content
# ---------------------------------------------------------------------------
CONTENT = [
    # -----------------------------------------------------------------------
    # SECTION 1: AIRWAY MANAGEMENT
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "1. Airway Management",
    },
    {
        "type": "body",
        "text": (
            "The <b>Difficult Airway Society (DAS) 2025 Guidelines for Management of Unanticipated "
            "Difficult Tracheal Intubation in Adults</b> (Ahmad et al., <i>Br J Anaesth</i> 136:283–307, "
            "January 2026; published online November 2025; DOI: 10.1016/j.bja.2025.10.006) replace the "
            "DAS 2015 guideline and represent a fundamental philosophical shift from rescue-after-failure "
            "to optimisation-for-success. The A–B–C–D four-plan structure is retained but its purpose is "
            "redefined. Plan A is no longer a series of intubation attempts; it is a deliberate, "
            "physiology-optimised, team-coordinated single best attempt. Videolaryngoscopy (VL) is now the "
            "first-line device for all intubation attempts in adults, replacing direct laryngoscopy as the "
            "default. Continuous oxygenation throughout all plans — via nasal cannula or high-flow nasal "
            "oxygen (HFNO) — is expected rather than optional. Point-of-care ultrasound (POCUS) for airway "
            "and gastric assessment is endorsed as an extension of clinical judgment."
        ),
    },
    {
        "type": "body",
        "text": (
            "Neuromuscular blockade (NMB) is recommended earlier in the algorithm: if tracheal intubation "
            "is anticipated to be difficult and the patient is not already paralysed, earlier administration "
            "of a full intubating dose of NMB is recommended to optimise laryngoscopy conditions and reduce "
            "the risk of patient movement, laryngospasm, and failed intubation. The maximum number of "
            "laryngoscopy attempts before abandoning Plan A is clearly defined (no more than three attempts "
            "including the first-pass attempt), with an emphasis on not persisting beyond this. Plan B "
            "involves a supraglottic airway device (SAD) for oxygenation; Plan C is continuation with SAD "
            "and awakening the patient if feasible; Plan D is emergency front-of-neck access (eFONA)."
        ),
    },
    {
        "type": "body",
        "text": (
            "Emergency front-of-neck access is standardised as a single vertical skin incision technique "
            "using a scalpel, with a horizontal stab incision through the cricothyroid membrane, followed "
            "by a bougie-guided cuffed tracheal tube (6.0 mm ID). The guideline endorses this vertical "
            "incision approach as the standard eFONA technique, replacing the previous variety of described "
            "methods to reduce cognitive load and improve team training. Mandatory pre-induction airway "
            "assessment is emphasised throughout: every patient should undergo structured airway assessment "
            "before induction, with results communicated to the whole team, equipment confirmed available, "
            "and a clear primary plan and contingency plans agreed. Human factors — including shared mental "
            "models, closed-loop communication, explicit task allocation, and recognition of fixation errors "
            "— are integrated throughout the guideline rather than treated as an appendix."
        ),
    },
    {
        "type": "body",
        "text": (
            "The editorial accompanying the guidelines (Jagannathan and Aziz, <i>Br J Anaesth</i> "
            "136:9–11, January 2026; DOI: 10.1016/j.bja.2025.11.003) and subsequent <i>BJA</i> "
            "correspondence have debated three areas. First, whether VL should be considered truly "
            "'mandatory' for every intubation or whether 'first-line' allows contextual discretion "
            "(particularly in resource-limited environments). Second, precision of eFONA landmark "
            "identification: the guideline endorses ultrasound-guided cricothyroid membrane localisation "
            "when time permits, but critics have debated how readily palpable landmarks are in obese or "
            "neck-irradiated patients and whether a horizontal-first approach remains viable as a salvage. "
            "Third, human factors in the context of the 'cannot intubate, cannot oxygenate' (CICO) "
            "declaration: correspondence highlights the risk of premature CICO declaration when VL is used "
            "as a first-line tool by less experienced operators and the importance of explicit cognitive "
            "aids. The correspondence collectively reinforces the guideline's emphasis on simulation-based "
            "team training and regular airway-equipment audits."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>ASA 2022 Difficult Airway Management Practice Guideline</b> (Apfelbaum et al., "
            "<i>Anesthesiology</i> 136:31–81, 2022) updated the 2013 version and remains current American "
            "practice guidance. It introduced explicit recommendations for awake tracheal intubation in "
            "anticipated difficult airways, VL as a first-line technique alongside direct laryngoscopy, and "
            "a stepwise extubation strategy for high-risk patients. It also formalised the role of HFNO "
            "for apnoeic oxygenation, endorsed supraglottic airways as rescue devices in CICO scenarios, "
            "and emphasised documentation and post-event debriefing. The ASA 2022 guideline complements "
            "rather than conflicts with DAS 2025, with VL first-line being a point of convergence between "
            "North American and British practice."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 2: RESUSCITATION & PERI-OPERATIVE CARDIAC ARREST
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "2. Resuscitation and Peri-operative Cardiac Arrest",
    },
    {
        "type": "body",
        "text": (
            "The <b>2025 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation "
            "and Emergency Cardiovascular Care (CPR and ECC)</b> were published on 22 October 2025, "
            "replacing the 2020 guidelines. They represent the first full update in five years. Key "
            "structural changes include consolidation to a single unified Chain of Survival applicable "
            "to all ages and all settings (out-of-hospital and in-hospital), simplifying the previously "
            "separate chains. For lay rescuers, the guidelines now recommend a sequence of five back blows "
            "followed by five abdominal thrusts for choking (adults and children), harmonising with "
            "international guidance. Ventilation with compressions is recommended for both healthcare "
            "professionals and lay rescuers who are willing and capable, reinforcing breath delivery as "
            "standard rather than compression-only."
        ),
    },
    {
        "type": "body",
        "text": (
            "For cardioversion of atrial fibrillation and atrial flutter, the <b>2025 AHA guidelines</b> "
            "recommend an initial biphasic shock energy of at least 200 J as the preferred first-shock "
            "strategy, reflecting evidence that higher initial energies achieve more reliable first-shock "
            "success for AF/flutter and reduce the number of shocks required. This supersedes the "
            "previous recommendation for escalating energy starting from lower levels. Termination of "
            "resuscitation (TOR) criteria are revised and stratified by provider level: basic life "
            "support (BLS) TOR rules differ from advanced cardiovascular life support (ACLS) TOR rules, "
            "with separate criteria for EMS, in-hospital providers, and transport decisions. End-tidal "
            "CO2 (ETCO2) should not be used in isolation to terminate resuscitation efforts; while "
            "persistently low ETCO2 (&lt;10 mmHg after 20 minutes of CPR) is an adverse prognostic "
            "indicator, it must be interpreted alongside rhythm, duration, reversible causes, and overall "
            "clinical context. The European Resuscitation Council (ERC) 2025 guidelines echo this "
            "position, noting cases of survival despite ETCO2 below 10 mmHg."
        ),
    },
    {
        "type": "body",
        "text": (
            "Head-up CPR (elevated head and thorax positioning during CPR) is discouraged by the "
            "<b>2025 AHA guidelines</b> for routine use pending further evidence; early enthusiasm "
            "from haemodynamic modelling studies has not been borne out in consistent outcome benefit "
            "in clinical trials, and concerns about reduced cerebral perfusion and practical challenges "
            "in maintaining elevated positioning while delivering compressions led to this position. "
            "New emphasis is placed on closed-loop communication during cardiac arrest response — the "
            "team leader explicitly confirms receipt of each instruction, and tasks are delegated by "
            "role rather than name — and on structured systems-of-care handoffs during and after "
            "resuscitation, including post-cardiac arrest care protocols, targeted temperature management "
            "decisions, and early coronary angiography pathways."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>7th National Audit Project (NAP7) — Perioperative Cardiac Arrest</b>, conducted by "
            "the Royal College of Anaesthetists (RCoA), reported in 2022 and has continued to generate "
            "sub-analyses published through 2024–2025. The overall incidence of peri-operative cardiac "
            "arrest was approximately 1 in 3,076 anaesthetics (95% CI 1 in 2,976–3,183), with a 30-day "
            "mortality of approximately 35% in those who arrested. Cardiac causes (including arrhythmia "
            "and myocardial ischaemia) were the most common overall, but haemorrhage predominated in "
            "specific sub-populations including vascular surgery and obstetrics."
        ),
    },
    {
        "type": "body",
        "text": (
            "The NAP7 obstetric sub-analysis identified major obstetric haemorrhage as the leading "
            "identified cause of peripartum cardiac arrest in the anaesthetic context. Obstetric arrests "
            "differed from the general surgical population in that patients were predominantly younger "
            "and healthier at baseline, yet arrest still occurred — emphasising the importance of "
            "structured massive haemorrhage protocols and anticipatory preparation. The frailty and "
            "older-patient analysis from NAP7 found that frailty (as measured by Clinical Frailty "
            "Score) was independently associated with higher rates of peri-operative cardiac arrest and "
            "poorer survival. Older patients (aged &gt;70 years) accounted for a disproportionate share "
            "of arrests and deaths, and the audit highlighted that frailty scoring and pre-operative "
            "optimisation — including shared decision making regarding surgery risk — should be embedded "
            "in routine pre-operative assessment pathways. NAP7 recommendations include mandatory "
            "pre-operative structured risk assessment for elective patients, availability of a designated "
            "peri-operative resuscitation team, immediate access to defibrillators in all anaesthetic "
            "locations, and regular simulation training for peri-operative arrest scenarios."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 3: SEPSIS
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "3. Sepsis",
    },
    {
        "type": "body",
        "text": (
            "The <b>Surviving Sepsis Campaign (SSC) 2026 International Guidelines for Management of "
            "Sepsis and Septic Shock</b> were published simultaneously in <i>Intensive Care Medicine</i> "
            "and <i>Critical Care Medicine</i> in 2026, replacing the 2021 edition. They were developed "
            "by a 69-person international panel representing 23 countries, with 38% of panellists from "
            "or currently practising in low- or middle-income countries. The guidelines contain "
            "129 statements in total, of which 46 are entirely new (not addressed in 2021), reflecting "
            "the volume of sepsis research published since the last update. They are endorsed by "
            "24 professional societies."
        ),
    },
    {
        "type": "body",
        "text": (
            "Key clinical updates in the <b>SSC 2026 guidelines</b> include: lower mean arterial "
            "pressure (MAP) targets for older adults with septic shock (permissive lower targets, "
            "e.g. MAP 60–65 mmHg rather than the previous 65 mmHg minimum, in patients aged &gt;65), "
            "based on the OVATION-65 and related trials showing no benefit and possible harm from higher "
            "targets in older patients; continued support for crystalloid-based early fluid resuscitation "
            "(30 ml/kg within three hours where appropriate), with new guidance on fluid removal "
            "(de-resuscitation) after the acute phase; selective use of rapid diagnostic testing "
            "(including PCR-based multiplex panels) to guide and narrow antibiotic therapy; and "
            "increased flexibility in vasopressor selection for patients with concurrent cardiac "
            "dysfunction (noradrenaline remains first-line, but vasopressin and angiotensin II have "
            "clearer roles). Antibiotic optimisation — including pharmacokinetic/pharmacodynamic-guided "
            "dosing and prompt de-escalation based on microbiological results — receives strengthened "
            "recommendations. The guidelines emphasise individualised, tailored care over algorithmic "
            "check-box approaches."
        ),
    },
    {
        "type": "body",
        "text": (
            "A major structural addition in the <b>SSC 2026</b> guidelines is the formalised "
            "post-discharge follow-up recommendation. For adult survivors of hospitalisation for sepsis "
            "or septic shock, the guidelines suggest offering post-critical illness follow-up services "
            "encompassing physical rehabilitation, psychological support (addressing PTSD, anxiety, and "
            "depression, which affect up to 40% of ICU survivors), and cognitive rehabilitation. Health "
            "systems are advised in a good practice statement to implement strategies ensuring "
            "communication between in-hospital providers and primary care clinicians at discharge, with "
            "full documentation of the septic episode, residual organ dysfunction, and planned "
            "monitoring. The guidelines acknowledge insufficient evidence to recommend sepsis-focused "
            "educational materials for primary care providers as a formal recommendation, but endorse "
            "it as best practice."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>German S3 Sepsis Guideline 2025 Update</b> (Deutsche Sepsis-Gesellschaft and "
            "collaborating societies) aligned closely with the SSC 2021 recommendations while "
            "incorporating European evidence and German healthcare system context. The 2025 update "
            "strengthened recommendations around: early lactate-guided resuscitation; the use of "
            "procalcitonin to guide antibiotic de-escalation; balanced crystalloids over 0.9% saline "
            "for initial resuscitation; and structured sepsis recognition programmes in emergency "
            "departments and hospital wards. The German S3 guideline also included detailed "
            "recommendations for post-sepsis syndrome (PSS) — a chronic condition of persisting "
            "physical, cognitive, and psychological impairment — and recommended dedicated post-sepsis "
            "outpatient pathways, complementing the SSC 2026 position on follow-up care."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 4: PERIOPERATIVE FASTING, GLP-1 AGONISTS, AND CARDIAC RISK
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "4. Perioperative Fasting, GLP-1 Agonists, and Cardiac Risk Assessment",
    },
    {
        "type": "body",
        "text": (
            "The <b>ASA 2023 Modular Fasting Update</b> (Practice Guidelines for Preoperative Fasting, "
            "updated in <i>Anesthesiology</i> 2023) introduced several revisions to the classic "
            "6-2-1 fasting rule. Carbohydrate-containing clear liquids (e.g. commercial preoperative "
            "carbohydrate drinks) are permitted up to two hours before elective procedures in healthy "
            "non-diabetic adults, reflecting evidence for enhanced recovery benefits without increased "
            "aspiration risk. Chewing gum was addressed explicitly: the guideline states that chewing "
            "gum (including nicotine gum) in the pre-operative period does not meaningfully increase "
            "gastric volume or acidity and therefore does not warrant cancellation of an elective "
            "procedure, provided other nil-by-mouth instructions have been followed. For paediatric "
            "patients, the update endorses a one-hour clear liquid fast (rather than the previous "
            "two hours) for children undergoing elective surgery, bringing ASA guidance into alignment "
            "with guidelines from ESPA and other paediatric anaesthesia societies that already "
            "adopted the one-hour rule based on evidence of no increase in gastric content at one hour "
            "compared with two hours."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>ASA 2023 Consensus-Based Guidance on Preoperative Management of Patients on "
            "Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists</b> (Joshi et al., published June "
            "2023; Affirmation of Value for an updated multi-society guidance document issued "
            "October 2024) addresses the growing use of GLP-1 receptor agonists (semaglutide, "
            "dulaglutide, liraglutide, tirzepatide) for diabetes and obesity management. These agents "
            "significantly delay gastric emptying, with semaglutide's half-life of approximately one "
            "week meaning residual gastroparesis can persist well beyond standard fasting intervals. "
            "The guidance recommends: withholding daily GLP-1 agonists on the day of surgery; "
            "withholding weekly formulations for one full dose cycle (up to one week) before elective "
            "procedures; considering a 'full stomach' precaution (rapid sequence induction) even after "
            "adherence to standard fasting guidelines if GLP-1 was recently administered or the patient "
            "reports nausea, vomiting, or early satiety; and using point-of-care gastric ultrasound "
            "to assess gastric emptying where available. The Centre for Perioperative Care (CPOC) UK "
            "guidance (2024 update) and Australian Society of Anaesthetists (ASA Australia, 2024 Fact "
            "Sheet) broadly align with these recommendations, emphasising individualised risk "
            "stratification and shared decision-making regarding elective procedure deferral."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>ESC 2022 Guidelines on Cardiovascular Assessment and Management of Patients "
            "Undergoing Non-Cardiac Surgery</b> (Halvorsen et al., <i>Eur Heart J</i> 2022) represent "
            "a comprehensive rewrite of the previous 2014 ESC/ESA guidelines. Key changes include: "
            "broadened indications for pre-operative transthoracic echocardiography (TTE), which is "
            "now recommended (Class IIa/IIb depending on context) when there is unexplained dyspnoea, "
            "known or suspected structural heart disease influencing management, or when the patient "
            "is undergoing high-risk surgery and the cardiac status is uncertain — this represents a "
            "meaningful liberalisation from the 2014 criteria; introduction of the Revised Cardiac "
            "Risk Index (RCRI) alongside newer risk calculators (ACS-NSQIP, EURO-SCORE) with guidance "
            "on selecting the appropriate tool; a revised algorithm for perioperative beta-blockade "
            "(initiation not recommended unless already prescribed or high cardiac risk with planned "
            "high-risk surgery); and clear guidance on managing antiplatelet therapy around non-cardiac "
            "surgery in patients with coronary stents."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>2024 ESC Guidelines for the Management of Elevated Blood Pressure and "
            "Hypertension</b> (McEvoy et al., replacing the 2018 ESC/ESH guideline) and the "
            "<b>2023 ESH Hypertension Guidelines</b> introduced important terminological and "
            "therapeutic changes relevant to perioperative practice. A new category of 'elevated blood "
            "pressure' (systolic 120–129 mmHg, diastolic &lt;80 mmHg) is introduced, bridging normal "
            "and Grade 1 hypertension, acknowledging the cardiovascular risk gradient from this range. "
            "Systolic BP targets for treated hypertension are lowered: the new recommended target for "
            "most patients on treatment is 120–129 mmHg, with 130–139 mmHg for older patients or those "
            "with significant comorbidities and tolerability concerns — this represents a step toward "
            "convergence with the ACC/AHA (&lt;130 mmHg) position. Renal denervation is endorsed as an "
            "option for resistant hypertension (defined as BP uncontrolled despite three or more agents "
            "including a diuretic) in selected patients at specialist centres, following positive "
            "SPYRAL HTN and RADIANCE-HTN sham-controlled trial data. For anaesthetists, the key "
            "perioperative implication is that 'hypertensive urgency' thresholds at which elective "
            "surgery should be deferred are not changed (generally systolic &gt;180 mmHg or diastolic "
            "&gt;110 mmHg), but optimisation toward lower treatment targets preoperatively is "
            "increasingly expected."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 5: LOCAL ANAESTHETIC SYSTEMIC TOXICITY (LAST)
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "5. Local Anaesthetic Systemic Toxicity (LAST)",
    },
    {
        "type": "body",
        "text": (
            "The <b>ASRA LAST Checklist (2020)</b> from the American Society of Regional Anesthesia "
            "and Pain Medicine remains the current standard American reference for LAST management "
            "and has not been superseded by a new version. It recommends: immediate cessation of "
            "local anaesthetic injection at first sign of toxicity; calling for help; airway "
            "management (100% oxygen, ventilation, securing airway if needed); seizure suppression "
            "with benzodiazepines (avoiding high-dose propofol, which itself impairs cardiac "
            "contractility); 20% lipid emulsion (Intralipid) bolus of 1.5 ml/kg IV over 2–3 minutes "
            "followed by infusion at 0.25 ml/kg/min; and early notification of the nearest ECMO or "
            "cardiopulmonary bypass (CPB) centre if haemodynamic instability persists. Epinephrine "
            "doses should be reduced (&lt;1 mcg/kg) and vasopressin avoided during LAST-induced "
            "cardiac arrest."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>AAGBI 2023 LAST Update</b> (Association of Anaesthetists, published 2023) "
            "updated the 2010 AAGBI guideline and aligns closely with the ASRA 2020 checklist while "
            "adding several important points for UK practice. Cardiopulmonary bypass is explicitly "
            "listed as a rescue option for refractory LAST cardiac arrest that does not respond to "
            "lipid emulsion, and the guideline recommends early escalation to a cardiac surgical "
            "centre if LAST-induced arrest is not rapidly reversed by standard LAST treatment. "
            "A specific caution is issued regarding propofol — its use to treat LAST-associated "
            "seizures is discouraged because propofol is formulated in lipid emulsion but has cardiac "
            "depressant properties that can worsen the haemodynamic compromise of LAST; benzodiazepines "
            "are preferred for seizure control. Thiopental is similarly cautioned against for seizure "
            "termination in LAST given its myocardial depressant effects. The update also emphasises "
            "prevention: ultrasound guidance for all nerve blocks, aspirating before injection, "
            "incremental injection of local anaesthetic with intermittent aspiration, and using the "
            "lowest effective concentration and volume."
        ),
    },
    {
        "type": "body",
        "text": (
            "In 2025, emerging case series and pharmacovigilance literature began to characterise a "
            "distinct phenotype of lidocaine-associated LAST presenting with delayed onset (more than "
            "15–30 minutes after injection completion), particularly following large-volume tumescent "
            "infiltration, liposuction, and intravenous lidocaine infusions used for perioperative "
            "analgesia. These reports — published in <i>Regional Anesthesia and Pain Medicine</i> and "
            "<i>Anaesthesia</i> in 2024–2025 — highlight that plasma lidocaine levels continue to rise "
            "for up to 30–60 minutes after stopping an IV lidocaine infusion due to redistribution "
            "from tissue compartments. The clinical implication is that LAST monitoring must extend "
            "well beyond the injection period; IV lidocaine infusions warrant a minimum 30-minute "
            "post-infusion observation period before transfer or discharge from monitored care. "
            "Dose caps for IV lidocaine analgesia have been proposed (typically 1.5–3 mg/kg/h with "
            "a cumulative ceiling) but are not yet formally mandated in UK or US guidance."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 6: MALIGNANT HYPERTHERMIA
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "6. Malignant Hyperthermia (MH)",
    },
    {
        "type": "body",
        "text": (
            "The <b>EMHG 2025 Guidelines for the Investigation of Malignant Hyperthermia Susceptibility</b> "
            "(European Malignant Hyperthermia Group) update the previous 2015 investigation guidelines "
            "and reflect the expanding role of genetic testing alongside the continued gold-standard "
            "position of in vitro contracture testing (IVCT). The most significant conceptual addition "
            "is the new diagnostic classification <b>MH genotype (MHG)</b>: this label is applied to "
            "individuals who carry a pathogenic or likely pathogenic variant associated with MH "
            "(in the RYR1, CACNA1S, or STAC3 genes) but who have not undergone confirmatory IVCT. "
            "Patients with MHG should be managed with the same precautions as confirmed "
            "MH-susceptible (MHS) individuals — i.e., avoidance of volatile anaesthetics and "
            "suxamethonium — recognising that IVCT is the only method that can definitively exclude "
            "MH risk."
        ),
    },
    {
        "type": "body",
        "text": (
            "Genetic testing in the <b>EMHG 2025 guidelines</b> focuses on RYR1 (the most common "
            "locus, with 72 variants now classified as pathogenic or likely pathogenic by the EMHG "
            "scoring matrix as of 2025), CACNA1S, and occasionally STAC3. Two variant classification "
            "systems are used in parallel: the EMHG Scoring Matrix (stricter, requires functional "
            "contracture data for classification) and the ClinGen Variant Curation Expert Panel (VCEP) "
            "framework. For individuals with a variant of uncertain significance (VUS), IVCT or CHCT "
            "(caffeine-halothane contracture test, North American equivalent) is recommended to "
            "clarify risk. IVCT is performed on a fresh muscle biopsy (minimum age 10 years, minimum "
            "weight 30 kg). Referral for MH investigation is recommended for: clinical signs or "
            "history of a prior reaction suspicious for MH; a blood relative with confirmed or "
            "suspected MH; unexplained perioperative death in the context of triggering agents; "
            "identification of a potentially pathogenic variant; and clinical features including "
            "exertional/recurrent rhabdomyolysis, idiopathic hyperCKaemia, or exertional heat stroke "
            "(particularly under age 40)."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>EMHG 2024 MH Crisis Management Update</b> reaffirmed the core treatment algorithm "
            "for an acute MH crisis: immediate discontinuation of all triggering agents (volatile "
            "anaesthetics and suxamethonium); hyperventilation with 100% oxygen at high fresh gas "
            "flow; intravenous dantrolene (initial bolus 2–2.5 mg/kg, repeated every 5 minutes as "
            "needed, with total doses up to 10 mg/kg reported in severe cases) as the specific "
            "pharmacological antidote — stock of at least 36 vials immediately available and a further "
            "24 vials accessible within one hour is recommended; aggressive active cooling (cold IV "
            "fluids, ice packs to axillae and groin, cooling blanket); treatment of hyperkalaemia "
            "(calcium, sodium bicarbonate, glucose/insulin); correction of acidosis; and management "
            "of arrhythmias with amiodarone (calcium channel blockers are contraindicated). "
            "Dantrolene should be continued for at least 24 hours post-crisis given the risk of "
            "recrudescence. All cases should be reported to the EMHG registry."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>JSA 2025 Guidelines for Management of Malignant Hyperthermia</b> (Japanese Society "
            "of Anesthesiologists; published in Japanese March 2025, English translation in "
            "<i>Journal of Anesthesia</i> 2026) align broadly with EMHG recommendations but reflect "
            "Japanese regulatory context. The JSA guideline specifies an initial dantrolene dose of "
            "1 mg/kg (consistent with the Japanese product insert), with repeat doses as needed, "
            "rather than the EMHG/MHAUS initial 2–2.5 mg/kg recommendation — this reflects the "
            "approved dosing in Japan rather than a clinical difference in efficacy; the guideline "
            "authors acknowledge the international evidence supporting higher initial doses. The JSA "
            "guideline does not specify a mandatory vial stock number, adopting a flexible "
            "institution-determined approach, in contrast to the EMHG's specific requirements. "
            "Genetic testing for RYR1 and CACNA1S variants is endorsed in line with EMHG criteria."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>EMHG 2021 Perioperative Consensus Recommendations for MH-Susceptible Patients</b> "
            "remain current for planning anaesthesia in known or suspected MHS individuals. Key "
            "principles: use a total intravenous anaesthesia (TIVA) technique with a clean, "
            "vapour-free anaesthetic machine (flushed with 100% oxygen at high flow for at least "
            "10 minutes with a clean circuit, and ideally using a dedicated TIVA machine); avoid "
            "suxamethonium entirely; non-depolarising neuromuscular blocking agents are safe; monitor "
            "temperature and ETCO2 throughout; have dantrolene immediately available in the operating "
            "room; ensure the entire surgical team is briefed on MH risk and the location of "
            "dantrolene; and provide written information for the patient including an MH alert "
            "bracelet or card and referral to the national MH unit if not already investigated."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 7: OBSTETRIC ANAESTHESIA — HAEMORRHAGE AND PATIENT BLOOD MANAGEMENT
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "7. Obstetric Anaesthesia — Haemorrhage and Patient Blood Management",
    },
    {
        "type": "body",
        "text": (
            "Major obstetric haemorrhage (MOH) remains a leading cause of maternal morbidity and "
            "mortality worldwide and a key theme across multiple recent guidelines. The <b>OAA/AAGBI "
            "Guidelines for Obstetric Anaesthetic Services 2021</b> (updated edition), produced jointly "
            "by the Obstetric Anaesthetists' Association and the Association of Anaesthetists, "
            "reaffirm recommendations for 24-hour on-site consultant obstetric anaesthetist cover in "
            "units with more than 5,000 deliveries per year, availability of cell salvage for "
            "obstetric cases (including elective caesarean section in placenta praevia and suspected "
            "placenta accreta spectrum), and the use of a pre-defined massive haemorrhage protocol "
            "including a Massive Transfusion Protocol (MTP) activated at a locally agreed threshold "
            "(commonly estimated blood loss exceeding 1,500–2,000 ml or clinical shock)."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>RCOG Green-top Guideline 52 — Prevention and Management of Postpartum "
            "Haemorrhage (2016, with 2023 online update)</b> recommends active management of the "
            "third stage (oxytocin 10 IU IM/IV or carbetocin 100 mcg in caesarean section where "
            "available) for all women; structured 'HAEMOSTASIS' mnemonic for escalating management; "
            "tranexamic acid 1 g IV (repeated after 30 minutes if bleeding continues) within three "
            "hours of birth for all cases of PPH, consistent with the WOMAN trial evidence; "
            "uterotonic escalation through ergometrine, carboprost, and misoprostol; and surgical "
            "escalation including B-Lynch suture, bilateral uterine artery ligation, and "
            "peripartum hysterectomy as definitive haemostasis. Interventional radiology (uterine "
            "artery embolisation) is recommended where available and time permits."
        ),
    },
    {
        "type": "body",
        "text": (
            "Patient blood management (PBM) in obstetric practice is addressed in the <b>Network "
            "for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) "
            "guidelines</b> and the <b>British Society for Haematology (BSH) guideline on the "
            "management of massive haemorrhage (2023 update)</b>. Core PBM principles in obstetrics "
            "include: pre-operative optimisation of haemoglobin (treating iron deficiency anaemia "
            "in pregnancy from the first trimester with oral or intravenous iron); point-of-care "
            "viscoelastometric testing (TEG or ROTEM) to guide targeted haemostatic therapy in "
            "active haemorrhage; fibrinogen replacement as a priority in obstetric haemorrhage "
            "(fibrinogen falls rapidly; a threshold of &lt;2 g/L in the context of ongoing "
            "haemorrhage is an indication for fibrinogen concentrate or cryoprecipitate; the "
            "OBS2 trial data inform local protocols); 1:1:1 packed red cells:FFP:platelets ratio "
            "under empirical MTP pending POC results; and the use of intra-operative cell salvage "
            "in high-risk obstetric cases (placenta praevia, accreta spectrum disorder, Jehovah's "
            "Witness patients) where leucocyte depletion filters are used."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>AAGBI / OAA 2015 guidelines on cell salvage in obstetrics</b> and subsequent "
            "NICE guidance (IPG144) support intra-operative cell salvage as safe in obstetrics when "
            "a leucocyte depletion filter is used. Rhesus D-negative mothers should receive "
            "additional anti-D immunoglobulin after cell salvage (the standard dose covers up to "
            "4 ml foetal red cells but may not be sufficient for larger volumes, requiring Kleihauer "
            "testing to guide additional dosing). Concerns about amniotic fluid embolism from cell "
            "salvage have not been borne out in evidence, and the technique is no longer considered "
            "contraindicated in obstetrics by major guidelines, provided the filter is used and the "
            "suction field is managed to minimise amniotic fluid contamination. The <b>NHS England "
            "Patient Blood Management programme (2024 framework)</b> sets a national expectation "
            "that all trusts delivering obstetric care will have a PBM programme including "
            "pre-operative anaemia management pathways, structured MTP, and regular multidisciplinary "
            "simulation of MOH scenarios."
        ),
    },

    # -----------------------------------------------------------------------
    # SECTION 8: ADDITIONAL RELEVANT GUIDELINES
    # -----------------------------------------------------------------------
    {
        "type": "section",
        "title": "8. Additional Relevant Guidelines",
    },
    {
        "type": "body",
        "text": (
            "<b>ERC / ESICM 2022 Post-Resuscitation Care Guidelines</b> updated targeted temperature "
            "management (TTM) recommendations following the TTM2 trial: routine TTM at 33°C is no "
            "longer recommended over normothermia (36°C) for out-of-hospital cardiac arrest (OHCA) "
            "survivors with initial shockable rhythms. However, fever (temperature &gt;37.7°C) should "
            "be actively prevented for at least 72 hours post-ROSC as it is associated with worse "
            "neurological outcomes. Coronary angiography is not recommended as an emergency procedure "
            "in all OHCA survivors without ST-elevation on the post-ROSC ECG (informed by TOMAHAWK "
            "and COACT trials), but should be performed in those with clear STEMI or haemodynamic "
            "instability. Prognostication should be multimodal and delayed until at least 72 hours "
            "post-ROSC (longer if TTM was used), integrating clinical examination, EEG, SSEP, brain "
            "imaging, and biomarkers (NSE)."
        ),
    },
    {
        "type": "body",
        "text": (
            "<b>FICM / ICS Guideline on Enhanced Recovery After Critical Illness (2023)</b> and the "
            "<b>PICS (Post-Intensive Care Syndrome) Framework</b> increasingly inform how anaesthetists "
            "document and communicate impairments acquired during critical illness. PICS encompasses "
            "new or worsening cognitive, psychiatric, and physical impairments persisting after "
            "ICU discharge and affecting the patient or their family. ICU follow-up clinics, structured "
            "rehabilitation, early physiotherapy, and cognitive screening tools (MoCA, MMSE) are "
            "endorsed. Anaesthetic assessment for subsequent procedures should include recognition of "
            "PICS-related frailty and medication changes post-ICU."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>ESAIC (European Society of Anaesthesiology and Intensive Care) 2022 Guidelines on "
            "Regional Anaesthesia and Local Anaesthetics</b> provided updated safety thresholds for "
            "local anaesthetic dosing, endorsed ultrasound guidance as standard of care for most "
            "peripheral nerve blocks, and strengthened recommendations around neuraxial anaesthesia "
            "in the presence of anticoagulation — aligning closely with the <b>ASRA 2018 "
            "Anticoagulation Guidelines (3rd edition)</b>, which remain current and are the reference "
            "standard for timing of neuraxial procedures around anticoagulant agents. The <b>ASRA "
            "2022 Consensus Statement on the Use of Low-Molecular-Weight Heparins in Regional "
            "Anesthesia</b> updated timing recommendations for newer agents. The <b>ESA 2017 "
            "guidelines on pre-operative evaluation</b> are being revised (ESA/ESAIC update expected "
            "2025–2026) and anaesthetists should monitor for publication of these updates."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>PROSPECT (Procedure-Specific Postoperative Pain Management) collaborative "
            "guidelines</b> have published several updates relevant to anaesthetic technique selection, "
            "including recommendations for: thoracic surgery (erector spinae plane block as an "
            "alternative to thoracic epidural in VATS, 2022); caesarean section (intrathecal "
            "morphine 100 mcg as gold-standard, supplemented with regular NSAIDs/paracetamol and "
            "TAP block if intrathecal morphine is withheld); hip arthroplasty; and knee arthroplasty. "
            "PROSPECT recommendations are procedure-specific, evidence-graded, and freely accessible "
            "at www.postoppain.org, making them a practical reference for finals revision on regional "
            "techniques."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>NICE Guideline NG180 — Peri-operative Care in Adults (2020, surveillance review "
            "2024)</b> includes recommendations on pre-operative assessment, enhanced recovery "
            "protocols, VTE prophylaxis, and post-operative monitoring. The surveillance review "
            "affirmed the existing guidance without major changes pending further evidence. Key "
            "anaesthesia-relevant points include: routine pre-operative blood tests should not be "
            "ordered for healthy patients undergoing low-risk procedures without clinical indication; "
            "anaemia should be identified and treated before elective surgery; patients should be "
            "informed of their individualised surgical risk; and enhanced recovery programmes "
            "(combining pre-operative carbohydrate loading, multimodal analgesia, early mobilisation, "
            "and early oral nutrition) should be standard for major surgery."
        ),
    },
    {
        "type": "body",
        "text": (
            "The <b>AAGBI/RCoA Anaesthetic Team Governance Framework (2023)</b> and the <b>RCoA "
            "Curriculum for a CCT in Anaesthetics (2021, revised 2023)</b> define the competency "
            "framework within which the above guidelines are applied. The curriculum emphasises "
            "simulation-based assessment, structured debriefing, incident reporting (DATIX), and "
            "engagement with quality improvement projects as core professional activities. Final "
            "MD/FRCA candidates should be prepared to discuss the evidence base and practical "
            "implementation challenges of all major guidelines reviewed in this document, including "
            "recognition of resource constraints, human factors, and systems-level barriers to "
            "compliance."
        ),
    },
]


# ---------------------------------------------------------------------------
# PDF build
# ---------------------------------------------------------------------------
def build_pdf():
    doc = SimpleDocTemplate(
        OUTPUT_PATH,
        pagesize=A4,
        leftMargin=LEFT_MARGIN,
        rightMargin=RIGHT_MARGIN,
        topMargin=TOP_MARGIN + 0.8 * cm,   # extra room for header
        bottomMargin=BOT_MARGIN + 0.6 * cm,
        title="MD Anaesthesia Finals 2026 — Recent Guidelines & Updates",
        author="Compiled July 2026",
        subject="Anaesthesia guideline revision reference",
    )

    styles = build_styles()
    story = []

    # -----------------------------------------------------------------------
    # COVER PAGE
    # -----------------------------------------------------------------------
    story.append(Spacer(1, 3 * cm))
    story.append(Paragraph("MD Anaesthesia Finals 2026", styles["cover_title"]))
    story.append(Spacer(1, 0.3 * cm))
    story.append(HRFlowable(width="80%", thickness=2.5, color=MED_BLUE, spaceAfter=8))
    story.append(Paragraph("Recent Guidelines &amp; Updates", ParagraphStyle(
        "cover_main",
        fontName="Helvetica-Bold",
        fontSize=16,
        leading=22,
        textColor=ACCENT_TEAL,
        alignment=TA_CENTER,
        spaceAfter=12,
    )))
    story.append(HRFlowable(width="80%", thickness=1.5, color=RULE_GREY, spaceAfter=20))
    story.append(Spacer(1, 0.5 * cm))

    topics = [
        "Difficult Airway Society 2025 &amp; ASA 2022 Airway Guidelines",
        "AHA 2025 CPR/ECC Guidelines &amp; NAP7 Peri-operative Cardiac Arrest",
        "Surviving Sepsis Campaign 2026 &amp; German S3 Sepsis 2025",
        "ASA 2023 Fasting, GLP-1 Agonists, ESC 2022 Cardiac Risk &amp; 2024 Hypertension",
        "ASRA 2020 &amp; AAGBI 2023 LAST Guidelines",
        "EMHG 2025 MH Investigation, EMHG 2024 Crisis Management &amp; JSA 2025",
        "OAA/AAGBI Obstetric Haemorrhage &amp; Patient Blood Management",
        "Additional Guidelines: TTM, PICS, Regional Anaesthesia, NICE NG180",
    ]
    for t in topics:
        story.append(Paragraph(f"&#x25B6;&nbsp; {t}", ParagraphStyle(
            "topic_list",
            fontName="Helvetica",
            fontSize=10,
            leading=15,
            textColor=DARK_NAVY,
            alignment=TA_CENTER,
            spaceAfter=4,
        )))

    story.append(Spacer(1, 1.5 * cm))
    story.append(Paragraph(
        "Compiled July 2026 | For revision purposes only — verify current primary sources before clinical application.",
        styles["disclaimer"]
    ))
    story.append(Spacer(1, 0.5 * cm))
    story.append(Paragraph(
        "Margins left wide for handwritten annotations.",
        ParagraphStyle("note2", fontName="Helvetica-Oblique", fontSize=8.5,
                       textColor=ACCENT_TEAL, alignment=TA_CENTER)
    ))

    story.append(PageBreak())

    # -----------------------------------------------------------------------
    # MAIN CONTENT
    # -----------------------------------------------------------------------
    for item in CONTENT:
        if item["type"] == "section":
            story.append(Spacer(1, 0.4 * cm))
            story.append(Paragraph(item["title"], styles["section_head"]))
            story.append(Spacer(1, 0.15 * cm))
        elif item["type"] == "body":
            story.append(Paragraph(item["text"], styles["body"]))

    # -----------------------------------------------------------------------
    # BACK PAGE — quick reference table of guideline names
    # -----------------------------------------------------------------------
    story.append(PageBreak())
    story.append(Spacer(1, 0.5 * cm))
    story.append(Paragraph("Quick Reference — Guideline Index", ParagraphStyle(
        "qr_head",
        fontName="Helvetica-Bold",
        fontSize=13,
        leading=18,
        textColor=DARK_NAVY,
        spaceAfter=10,
    )))
    story.append(HRFlowable(width="100%", thickness=1.2, color=MED_BLUE, spaceAfter=10))

    ref_items = [
        ("<b>DAS 2025</b>", "Ahmad et al., Br J Anaesth 136:283–307 (Jan 2026); DOI 10.1016/j.bja.2025.10.006"),
        ("<b>ASA 2022 Airway</b>", "Apfelbaum et al., Anesthesiology 136:31–81 (2022)"),
        ("<b>AHA 2025 CPR/ECC</b>", "Published 22 October 2025; replaces AHA 2020"),
        ("<b>ERC 2025 ALS</b>", "Resuscitation journal, 2025; doi 10.1016/j.resuscitation (2025)"),
        ("<b>NAP7</b>", "RCoA 7th National Audit Project; 2022 report + sub-analyses 2023–2025"),
        ("<b>SSC 2026 Sepsis</b>", "Intensive Care Med / Crit Care Med, 2026; 129 statements, 46 new"),
        ("<b>German S3 Sepsis 2025</b>", "Deutsche Sepsis-Gesellschaft, updated 2025"),
        ("<b>ASA 2023 Fasting</b>", "Anesthesiology 2023; modular update — CHL 2 h, gum, paeds 1 h"),
        ("<b>ASA GLP-1 Guidance</b>", "Joshi et al., June 2023; Affirmation of Value Oct 2024"),
        ("<b>ESC 2022 Periop Cardiac</b>", "Halvorsen et al., Eur Heart J 2022; non-cardiac surgery"),
        ("<b>2024 ESC Hypertension</b>", "McEvoy et al.; new 'elevated BP' category, lower targets"),
        ("<b>2023 ESH Hypertension</b>", "New grade definitions; renal denervation for resistant HTN"),
        ("<b>ASRA LAST 2020</b>", "ASRA checklist; lipid emulsion, reduced-dose epinephrine"),
        ("<b>AAGBI LAST 2023</b>", "CPB as rescue; propofol/thiopental caution; ultrasound prevention"),
        ("<b>EMHG 2025 MH Investigation</b>", "New MHG genotype category; 72 RYR1 pathogenic variants"),
        ("<b>EMHG 2024 MH Crisis</b>", "Dantrolene 2–2.5 mg/kg, 36 vials stock, cooling, EMHG registry"),
        ("<b>JSA 2025 MH</b>", "J Anaesth 2026; 1 mg/kg initial dantrolene per Japanese licence"),
        ("<b>EMHG 2021 Periop MHS</b>", "TIVA; clean machine; dantrolene in OT; patient alert card"),
        ("<b>OAA/AAGBI 2021 Obstetric</b>", "24 h consultant cover; cell salvage; MTP activation"),
        ("<b>RCOG GTG 52 PPH 2023</b>", "TXA 1 g IV within 3 h; HAEMOSTASIS mnemonic; hysterectomy"),
        ("<b>BSH Major Haemorrhage 2023</b>", "ROTEM/TEG guidance; fibrinogen &lt;2 g/L threshold"),
        ("<b>ERC/ESICM Post-Resus 2022</b>", "TTM2: 36°C over 33°C; no routine emergency angio post-OHCA"),
        ("<b>NICE NG180 2020/2024</b>", "Perioperative care; ERAS; no routine tests low-risk surgery"),
        ("<b>ASRA Anticoag 2018 (3rd ed)</b>", "Neuraxial timing around anticoagulants; still current"),
    ]

    row_style_a = ParagraphStyle("ra", fontName="Helvetica", fontSize=8.5, leading=12,
                                 textColor=BODY_GREY, leftIndent=4, spaceAfter=2)
    row_style_b = ParagraphStyle("rb", fontName="Helvetica-Oblique", fontSize=8.5, leading=12,
                                 textColor=HexColor("#555555"), leftIndent=4, spaceAfter=2)

    for (label, ref) in ref_items:
        story.append(Paragraph(label + " &mdash; " + ref, row_style_a))
        story.append(HRFlowable(width="100%", thickness=0.3, color=RULE_GREY, spaceAfter=3))

    story.append(Spacer(1, 0.8 * cm))
    story.append(Paragraph(
        "This document synthesises publicly available guidelines for exam preparation only. "
        "Clinical practice must be guided by current primary sources, local protocols, and "
        "individual patient assessment. Drug doses and thresholds cited should be verified "
        "against current BNF, product information, and institutional policies.",
        styles["disclaimer"]
    ))

    # -----------------------------------------------------------------------
    # BUILD
    # -----------------------------------------------------------------------
    doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
    print(f"PDF written to: {OUTPUT_PATH}")


if __name__ == "__main__":
    build_pdf()

cd /home/daytona/workspace/md-anaesthesia-finals && python3 build_pdf.py 2>&1

ls -lh /home/daytona/workspace/md-anaesthesia-finals/MD_Anaesthesia_Finals_2026_…

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/…