Ambulatory Anesthesia — Seminar Slide Content (Miller's Anesthesia, 10th ed., Ch. 68)

"""
Build 'Ambulatory Anesthesia' seminar PPTX based on Miller's Anesthesia, 10th ed., Ch. 68
"""
from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.shapes import MSO_SHAPE
import copy

# ---------- THEME ----------
NAVY = RGBColor(0x0B, 0x2E, 0x4E)
TEAL = RGBColor(0x11, 0x8A, 0x8A)
LIGHT_TEAL = RGBColor(0xE4, 0xF3, 0xF3)
WHITE = RGBColor(0xFF, 0xFF, 0xFF)
DARK_GRAY = RGBColor(0x33, 0x33, 0x33)
ACCENT_ORANGE = RGBColor(0xE8, 0x7A, 0x2C)
LIGHT_GRAY = RGBColor(0xF2, 0xF2, 0xF2)

SW, SH = Inches(13.333), Inches(7.5)
CITE = "Miller's Anesthesia, 10th ed., Ch. 68 \u2013 Ambulatory Anesthesia"

prs = Presentation()
prs.slide_width = SW
prs.slide_height = SH
BLANK = prs.slide_layouts[6]


def add_slide():
    return prs.slides.add_slide(BLANK)


def set_bg(slide, color):
    bg = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, 0, 0, SW, SH)
    bg.fill.solid()
    bg.fill.fore_color.rgb = color
    bg.line.fill.background()
    bg.shadow.inherit = False
    # send to back
    spTree = slide.shapes._spTree
    spTree.remove(bg._element)
    spTree.insert(2, bg._element)
    return bg


def add_textbox(slide, l, t, w, h, text, size=18, color=DARK_GRAY, bold=False,
                 align=PP_ALIGN.LEFT, font="Calibri", anchor=None, italic=False, line_spacing=1.0):
    tb = slide.shapes.add_textbox(l, t, w, h)
    tf = tb.text_frame
    tf.word_wrap = True
    if anchor:
        tf.vertical_anchor = anchor
    p = tf.paragraphs[0]
    p.text = text
    p.alignment = align
    p.line_spacing = line_spacing
    r = p.runs[0]
    r.font.size = Pt(size)
    r.font.color.rgb = color
    r.font.bold = bold
    r.font.italic = italic
    r.font.name = font
    return tb


def footer(slide, page_num, section=""):
    line = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, 0, Inches(7.12), SW, Pt(2))
    line.fill.solid(); line.fill.fore_color.rgb = TEAL; line.line.fill.background(); line.shadow.inherit = False
    add_textbox(slide, Inches(0.4), Inches(7.18), Inches(8), Inches(0.3), CITE, size=9,
                color=RGBColor(0x88, 0x88, 0x88), italic=True)
    add_textbox(slide, Inches(12.4), Inches(7.18), Inches(0.6), Inches(0.3), str(page_num), size=10,
                color=RGBColor(0x88, 0x88, 0x88), align=PP_ALIGN.RIGHT)


def header_bar(slide, title, kicker=""):
    bar = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, 0, 0, SW, Inches(1.15))
    bar.fill.solid(); bar.fill.fore_color.rgb = NAVY; bar.line.fill.background(); bar.shadow.inherit = False
    accent = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, 0, Inches(1.15), SW, Pt(4))
    accent.fill.solid(); accent.fill.fore_color.rgb = ACCENT_ORANGE; accent.line.fill.background(); accent.shadow.inherit = False
    if kicker:
        add_textbox(slide, Inches(0.5), Inches(0.12), Inches(10), Inches(0.3), kicker.upper(), size=12,
                    color=RGBColor(0x9F, 0xC9, 0xD9), bold=True)
        add_textbox(slide, Inches(0.5), Inches(0.42), Inches(12), Inches(0.65), title, size=28, color=WHITE, bold=True)
    else:
        add_textbox(slide, Inches(0.5), Inches(0.28), Inches(12.3), Inches(0.75), title, size=30, color=WHITE, bold=True,
                    anchor=MSO_ANCHOR.MIDDLE)


def bullet_slide(title, bullets, kicker="", page_num=0, two_col=False):
    """bullets: list of (level, text) or (level, text, bold_lead) """
    slide = add_slide()
    set_bg(slide, WHITE)
    header_bar(slide, title, kicker)
    top = Inches(1.45)
    if two_col and len(bullets) > 7:
        mid = (len(bullets) + 1) // 2
        cols = [bullets[:mid], bullets[mid:]]
        widths = [Inches(6.0), Inches(6.0)]
        lefts = [Inches(0.55), Inches(6.75)]
    else:
        cols = [bullets]
        widths = [Inches(12.25)]
        lefts = [Inches(0.55)]

    for col_bullets, width, left in zip(cols, widths, lefts):
        tb = slide.shapes.add_textbox(left, top, width, Inches(5.55))
        tf = tb.text_frame
        tf.word_wrap = True
        first = True
        for item in col_bullets:
            level, text = item[0], item[1]
            p = tf.paragraphs[0] if first else tf.add_paragraph()
            first = False
            p.space_after = Pt(8 if level == 0 else 4)
            p.level = 0
            indent = Inches(0.0 + level * 0.3)
            p.text = ("\u25B8 " if level == 0 else "\u2013 ") + text
            r = p.runs[0]
            r.font.size = Pt(16 if level == 0 else 14)
            r.font.color.rgb = NAVY if level == 0 else DARK_GRAY
            r.font.bold = (level == 0)
            r.font.name = "Calibri"
            pPr = p._pPr
            if pPr is None:
                pPr = p._p.get_or_add_pPr()
            pPr.set('marL', str(int(indent)))
    footer(slide, page_num)
    return slide


def title_slide():
    slide = add_slide()
    set_bg(slide, NAVY)
    band = slide.shapes.add_shape(MSO_SHAPE.RECTANGLE, 0, Inches(4.6), SW, Inches(0.06))
    band.fill.solid(); band.fill.fore_color.rgb = ACCENT_ORANGE; band.line.fill.background(); band.shadow.inherit = False
    add_textbox(slide, Inches(0.9), Inches(0.9), Inches(11), Inches(0.5), "SEMINAR PRESENTATION", size=16,
                color=ACCENT_ORANGE, bold=True)
    add_textbox(slide, Inches(0.9), Inches(1.4), Inches(11.5), Inches(2.2), "Ambulatory Anesthesia",
                size=54, color=WHITE, bold=True)
    add_textbox(slide, Inches(0.9), Inches(3.15), Inches(11), Inches(1.1),
                "Patient Selection, Anesthetic Techniques, Recovery, and Discharge in Day-Case Surgery",
                size=20, color=RGBColor(0xCF, 0xE3, 0xEB))
    add_textbox(slide, Inches(0.9), Inches(5.0), Inches(11), Inches(0.5),
                "Based on Miller's Anesthesia, 10th Edition \u2013 Chapter 68: Ambulatory Anesthesia", size=15,
                color=RGBColor(0x9F, 0xC9, 0xD9), italic=True)
    add_textbox(slide, Inches(0.9), Inches(6.6), Inches(11), Inches(0.5),
                "Department of Anesthesiology  |  Seminar", size=13, color=RGBColor(0x7E, 0xA6, 0xB8))
    return slide


def section_slide(number, title, subtitle, page_num):
    slide = add_slide()
    set_bg(slide, TEAL)
    add_textbox(slide, Inches(0.9), Inches(2.5), Inches(3), Inches(1.5), number, size=72, color=RGBColor(0x0B,0x2E,0x4E), bold=True)
    add_textbox(slide, Inches(0.9), Inches(3.9), Inches(11), Inches(1.0), title, size=38, color=WHITE, bold=True)
    if subtitle:
        add_textbox(slide, Inches(0.9), Inches(4.75), Inches(11), Inches(0.8), subtitle, size=17, color=LIGHT_TEAL, italic=True)
    footer(slide, page_num)
    return slide


def table_slide(title, headers, rows, kicker="", page_num=0, col_widths=None, note=""):
    slide = add_slide()
    set_bg(slide, WHITE)
    header_bar(slide, title, kicker)
    n_rows = len(rows) + 1
    n_cols = len(headers)
    left, top = Inches(0.55), Inches(1.55)
    width = Inches(12.25)
    height = Inches(0.5 * n_rows) if 0.5*n_rows < 5.2 else Inches(5.2)
    gshape = slide.shapes.add_table(n_rows, n_cols, left, top, width, height)
    table = gshape.table
    if col_widths:
        for i, w in enumerate(col_widths):
            table.columns[i].width = w
    for j, h in enumerate(headers):
        cell = table.cell(0, j)
        cell.text = h
        cell.fill.solid(); cell.fill.fore_color.rgb = NAVY
        p = cell.text_frame.paragraphs[0]
        p.runs[0].font.color.rgb = WHITE
        p.runs[0].font.bold = True
        p.runs[0].font.size = Pt(13)
        cell.vertical_anchor = MSO_ANCHOR.MIDDLE
    for i, row in enumerate(rows, start=1):
        for j, val in enumerate(row):
            cell = table.cell(i, j)
            cell.text = str(val)
            cell.fill.solid()
            cell.fill.fore_color.rgb = LIGHT_TEAL if i % 2 == 0 else WHITE
            p = cell.text_frame.paragraphs[0]
            p.runs[0].font.size = Pt(12)
            p.runs[0].font.color.rgb = DARK_GRAY
            cell.vertical_anchor = MSO_ANCHOR.MIDDLE
    if note:
        add_textbox(slide, Inches(0.55), top + height + Inches(0.15), Inches(12.2), Inches(0.6), note, size=12,
                    color=RGBColor(0x66, 0x66, 0x66), italic=True)
    footer(slide, page_num)
    return slide


def key_takeaway_slide(title, points, page_num, kicker=""):
    slide = add_slide()
    set_bg(slide, WHITE)
    header_bar(slide, title, kicker)
    top = Inches(1.6)
    box_h = Inches(0.95)
    gap = Inches(0.18)
    for i, pt in enumerate(points):
        y = top + i * (box_h + gap)
        card = slide.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE, Inches(0.55), y, Inches(12.25), box_h)
        card.fill.solid(); card.fill.fore_color.rgb = LIGHT_GRAY
        card.line.color.rgb = TEAL; card.line.width = Pt(1)
        card.shadow.inherit = False
        num = slide.shapes.add_shape(MSO_SHAPE.OVAL, Inches(0.75), y + Inches(0.17), Inches(0.6), Inches(0.6))
        num.fill.solid(); num.fill.fore_color.rgb = ACCENT_ORANGE; num.line.fill.background(); num.shadow.inherit = False
        ntf = num.text_frame
        ntf.word_wrap = True
        ntf.vertical_anchor = MSO_ANCHOR.MIDDLE
        p = ntf.paragraphs[0]; p.text = str(i + 1); p.alignment = PP_ALIGN.CENTER
        p.runs[0].font.size = Pt(20); p.runs[0].font.bold = True; p.runs[0].font.color.rgb = WHITE
        tb = slide.shapes.add_textbox(Inches(1.6), y, Inches(11.0), box_h)
        tf = tb.text_frame; tf.word_wrap = True; tf.vertical_anchor = MSO_ANCHOR.MIDDLE
        p = tf.paragraphs[0]; p.text = pt
        p.runs[0].font.size = Pt(15); p.runs[0].font.color.rgb = NAVY
    footer(slide, page_num)
    return slide


pg = 0
def npg():
    global pg
    pg += 1
    return pg

# ================= SLIDE BUILD =================

# 1. Title
title_slide(); npg()

# 2. Learning objectives
bullet_slide("Learning Objectives", [
    (0, "Define ambulatory (day-case) anesthesia and describe the facility models in which it is delivered"),
    (0, "Apply evidence-based patient selection criteria (surgical, medical, and social factors)"),
    (0, "Outline preoperative assessment, fasting, and premedication strategies for day-case patients"),
    (0, "Compare general, regional, and sedation/MAC techniques used in ambulatory anesthesia"),
    (0, "Describe recovery phases, fast-tracking, and validated discharge scoring systems"),
    (0, "Discuss prevention/management of PONV and postoperative pain in the ambulatory setting"),
    (0, "Recognize complications, outcome indicators, and determinants of patient satisfaction"),
], kicker="Seminar Roadmap", page_num=npg())

# 3. Intro & history
bullet_slide("Introduction & History", [
    (0, "Origins in Glasgow (1898-1908): James Nicoll performed ~9000 ambulatory operations on children, championing early mobilization over prolonged bed rest"),
    (0, "Ralph Waters opened an early outpatient anesthesia clinic in Sioux City, Iowa, for minor procedures"),
    (0, "First hospital-based day units: Grand Rapids (1951), Los Angeles (1952); first freestanding ASC: Phoenix, Arizona (1970)"),
    (0, "Society for Ambulatory Anesthesia (SAMBA) founded 1984; British Association of Day Surgery, 1989"),
    (0, "International Association for Ambulatory Surgery (IAAS) formed 1995 from 11 national societies"),
    (0, "ASA guidelines for ambulatory anesthesia/surgery created 2003, updated 2018"),
    (0, "Ambulatory surgery now accounts for ~80% of elective surgery in the United States", ),
], kicker="Background", page_num=npg())

# 4. Definitions & facility types
bullet_slide("Definitions & Facility Types", [
    (0, "IAAS definition: a planned non-resident admission for investigation/operation, requiring recovery facilities but not an overnight bed \u2013 same-day discharge intended from the outset"),
    (0, "Short-stay surgery: shares ambulatory principles but includes a planned overnight stay (comorbidity, poor social support, late/extensive procedures)"),
    (1, "Hospital-integrated: ambulatory patients share ORs/PACU with inpatients"),
    (1, "Hospital self-contained: dedicated ambulatory unit within/adjacent to hospital"),
    (1, "Freestanding ambulatory surgery center (ASC): independent facility, no inpatient beds"),
    (1, "Office-based: procedures in a physician's office; fastest-growing, historically least regulated"),
], kicker="Setting the Scene", page_num=npg())

# 5. Benefits
bullet_slide("Benefits of Ambulatory Surgery", [
    (0, "Requires only reduced tissue trauma with enhanced recovery, effective analgesia, and minimal adverse events"),
    (0, "Patient benefits: efficient scheduling, comfort and convenience of recovering at home"),
    (0, "Financial benefits: eliminates overnight admission cost; many payers reimburse ambulatory-compatible procedures at a flat rate regardless of length of stay"),
    (0, "System benefits: reduces hospital-acquired infection exposure and frees inpatient bed capacity"),
    (0, "Enabled by better short-acting anesthetics/analgesics, minimally invasive surgery, and a shift away from routine overnight admission"),
], kicker="Why Ambulatory?", page_num=npg())

# 6. Patient selection - surgical factors
bullet_slide("Patient Selection: Surgical Factors", [
    (0, "Extent of surgical trauma \u2013 not duration \u2013 is the key determinant of suitability today"),
    (0, "No significant expected blood loss, major fluid shifts, or complex postoperative care"),
    (0, "Surgical complications remain the single greatest cause of unanticipated hospital admission"),
    (0, "Scope has expanded dramatically: laparoscopic cholecystectomy is now routine; hysterectomy, nephrectomy, prostatectomy, bariatric surgery, and total joint arthroplasty increasingly performed ambulatory"),
    (0, "Roux-en-Y gastric bypass series (n=2000): 84% discharged within 23 hours, <2% readmission"),
    (0, "Even selected craniotomies and aneurysm clippings are now same-day procedures"),
    (0, "Non-elective cases (abscess drainage, incarcerated hernia, appendectomy) increasingly managed via day-surgery pathways"),
], kicker="Patient Selection", page_num=npg())

# 7. Patient selection - medical factors
bullet_slide("Patient Selection: Medical Factors", [
    (0, "Rigid exclusion criteria historically used but are poorly predictive of unanticipated admission or readmission"),
    (0, "Overall ambulatory surgery perioperative mortality <1 in 11,000 \u2013 safer than background population rates"),
    (0, "No arbitrary exclusion by age, BMI, or ASA physical status class alone"),
    (0, "Increasing ASA class is associated with a stepwise rise in complications, readmission, and mortality risk"),
    (0, "Obesity is not an independent risk factor for admission/readmission; morbid (BMI >40) and super obesity (BMI >50) are no longer absolute contraindications"),
], kicker="Patient Selection", page_num=npg())

# 8. OSA
bullet_slide("Special Consideration: Obstructive Sleep Apnea", [
    (0, "More prevalent with obesity; most OSA patients can still be managed safely as ambulatory cases"),
    (0, "Anticipate potential difficult intubation and postoperative airway obstruction"),
    (0, "Less suitable if surgery is highly invasive, involves the airway/chest, or requires significant perioperative opioids"),
    (0, "STOP-Bang questionnaire useful for screening; insufficient evidence to delay surgery pending formal polysomnographic diagnosis"),
    (0, "Pediatric OSA is now a leading indication for tonsillectomy; same-day discharge is safe in the absence of other comorbidities"),
], kicker="Patient Selection", page_num=npg())

# 9. Age & frailty + table
table_slide("Age and Frailty", ["Grade", "Description"], [
    ["1 \u2013 Very fit", "Robust, active, exercises regularly"],
    ["2 \u2013 Well", "No active disease symptoms; less fit than grade 1"],
    ["3 \u2013 Managing well", "Comorbidities well controlled beyond routine medication"],
    ["4 \u2013 Vulnerable", "Not dependent, but symptoms limit activity"],
    ["5 \u2013 Mildly frail", "Needs help with some activities of daily living (ADLs)"],
    ["6 \u2013 Moderately frail", "Needs help with all outside ADLs and housekeeping"],
    ["7 \u2013 Severely frail", "Completely dependent for personal care"],
], kicker="Patient Selection \u2013 Clinical Frailty Scale (Rockwood et al.)",
    page_num=npg(), col_widths=[Inches(3.2), Inches(9.05)],
    note="No upper age limit for ambulatory surgery. Frailty \u2013 not chronological age \u2013 predicts adverse events; risk rises stepwise with higher frailty grade. Major risk factors: age >85, invasive surgery, recent hospitalization. Older patients have 2x risk of intraoperative CV events but LESS postoperative pain, dizziness, and nausea/vomiting than younger patients.")

# 10. Cardiovascular disease
bullet_slide("Cardiovascular Disease", [
    (0, "Hypertension is the most common comorbidity; meta-analysis (~13,000 patients) shows only a 1.35x increase in perioperative complication risk"),
    (0, "Not an independent risk factor if diastolic BP <110 mmHg; UK threshold to accept elective surgery: BP <160/100 mmHg"),
    (0, "Continue chronic antihypertensives, especially beta-blockers; current practice is to HOLD ACE inhibitors/ARBs on the day of surgery (associated risk of intraoperative hypotension)"),
    (0, "Unsuitable if severe/unstable angina with marked activity limitation or rest pain"),
    (0, "Cardiac risk returns toward baseline ~3 months after MI or revascularization, absent arrhythmia or ventricular dysfunction"),
    (0, "Inability to climb one flight of stairs (~4 METs) is 89% predictive of a postoperative cardiopulmonary complication"),
], kicker="Patient Selection", page_num=npg())

# 11. Social factors
bullet_slide("Social Factors & Discharge Escort", [
    (0, "A responsible escort after general anesthesia or sedation is a widely recommended safety requirement, with a companion advised for the first 24 hours"),
    (0, "US standard: patients receiving other-than-local anesthesia should be discharged with a responsible adult, or surgery should be postponed"),
    (0, "UK (AAGBI): an escort is not mandatory in every case if surgery is minor and anesthesia brief"),
    (0, "Patients must never drive themselves home; serious accidents have been reported, particularly after sedative benzodiazepine doses"),
    (0, "Patients from rural/remote areas may need to travel long distances; dedicated \"hospital hotels\" have largely proven impractical"),
], kicker="Patient Selection", page_num=npg())

# 12. Preop assessment
bullet_slide("Preoperative Assessment", [
    (0, "Three guiding questions: (1) Is there benefit to overnight admission? (2) Would delaying surgery worsen outcome? (3) What is needed to enable same-day discharge?"),
    (0, "History and physical examination remain the key elements of assessment; routine chest auscultation adds little value in adult ambulatory patients"),
    (0, "Routine preoperative laboratory testing generates false positives, added cost and delay, without changing management \u2013 selective testing is preferred"),
    (0, "Age alone should not trigger routine testing (NICE); a pilot eliminating all routine preop tests did not increase adverse events or admissions"),
    (0, "Preoperative counseling and education improve relaxation, satisfaction, and compliance with fasting and medication instructions"),
], kicker="Preparing the Patient", page_num=npg())

# 13. Fasting
bullet_slide("Preoperative Fasting", [
    (0, "Clear liquids: fast no more than 2 hours; light meals: 6 hours \u2013 safe even in obese adults, children, diabetics, and reflux patients"),
    (0, "Gastric emptying half-time for clear fluids is ~10 minutes, so the 2-hour rule is conservative"),
    (0, "Encourage drinking up to the safe limit rather than the bare minimum \u2013 reduces dehydration and thirst"),
    (0, "Unrestricted water access until called to the OR reduces PONV without increasing aspiration risk"),
    (0, "Excessive fasting causes harm: 14% of fasted healthy female ambulatory patients had glucose \u226445 mg/dL; preoperative oral carbohydrate drinks reduce thirst, hunger, and postoperative insulin resistance"),
    (0, "Routine antacids, metoclopramide, H2-blockers, or PPIs are NOT recommended before elective ambulatory surgery in fasted, low-risk patients"),
], kicker="Preparing the Patient", page_num=npg())

# 14. Premedication
bullet_slide("Premedication", [
    (0, "Anxiolytic premedication is uncommon in modern practice due to concern about delayed recovery, though meta-analyses show no real discharge delay"),
    (0, "Up to two-thirds of ambulatory patients report significant preoperative anxiety"),
    (0, "A preoperative consultation well before surgery plus an empathic anesthesiologist reduces anxiety and improves satisfaction more reliably than a drug"),
    (0, "Analgesic premedication is best considered as part of multimodal analgesia (see Pain Management)"),
    (0, "Antacid/gastrokinetic premedication is not routinely recommended; reserve prophylactic PPI + sodium citrate for very high-risk patients (e.g. super-morbidly obese undergoing bariatric surgery)"),
], kicker="Preparing the Patient", page_num=npg())

# 15. GA - IV agents
bullet_slide("Anesthetic Techniques: General Anesthesia \u2013 IV Agents", [
    (0, "No single ideal drug or technique \u2013 choice depends on surgical/patient factors and anesthesiologist skill; GA remains the most popular technique with patients and surgeons"),
    (0, "Propofol remains the most practical IV anesthetic for ambulatory anesthesia: rapid smooth induction, low early PONV, clear-headed recovery"),
    (1, "Disadvantages: injection pain, involuntary movement, transient apnea, hypotension"),
    (1, "Co-induction with midazolam 0.1 mg/kg reduces propofol dose and attenuates hemodynamic swings"),
    (1, "\"Autoinduction\": an initial 30 mg bolus reduces total induction dose without delaying recovery"),
    (1, "Maintenance infusion (sedation range): 25\u201375 mcg/kg/min, titrated to effect (often via target-controlled infusion, TCI)"),
    (0, "Etomidate, barbiturates, and induction-dose benzodiazepines/ketamine have little modern role (myoclonus, high PONV, or adrenal suppression concerns)"),
], kicker="Anesthetic Techniques", page_num=npg())

# 16. GA - inhaled + adjuvants
bullet_slide("General Anesthesia: Inhaled Agents & Adjuvants", [
    (0, "Sevoflurane: low airway irritation \u2013 ideal for inhalational induction (children, needle-phobic adults); earlier awakening than isoflurane; 8% bolus induction can rival propofol in speed"),
    (0, "Desflurane: very low blood solubility, but meta-analysis shows emergence only ~1 minute earlier than sevoflurane in practice \u2013 no real difference in PACU stay or PONV"),
    (0, "Emergence delirium is common in children with sevoflurane/desflurane; mitigated by low-dose fentanyl, propofol, ketamine, or alpha-2 agonists"),
    (0, "Nitrous oxide and high cumulative-dose remifentanil are generally minimized \u2013 both linked to increased PONV / opioid-induced hyperalgesia"),
    (0, "Esmolol infusion reduces volatile agent and opioid requirements, shortens emergence, and lowers PONV and pain scores in several ambulatory studies"),
    (0, "Neuromuscular blockers: succinylcholine causes myalgia; intermediate-duration NMBDs carry a risk of residual block after very brief procedures"),
], kicker="Anesthetic Techniques", page_num=npg())

# 17. Airway management
bullet_slide("Airway Management for Ambulatory Anesthesia", [
    (0, "Supraglottic airway (SGA) devices cause significantly less sore throat, hoarseness, cough, and laryngospasm than tracheal intubation"),
    (0, "Second-generation SGAs (e.g. ProSeal LMA) provide a higher seal pressure, reduce gastric inflation, and allow gastric drainage \u2013 better aspiration protection"),
    (0, "ProSeal LMA use has been shown to reduce absolute PONV risk by ~40% and reduce sore throat, analgesic needs, and recovery time in several studies"),
    (0, "i-gel: non-inflating cuff with a gastric drainage channel; faster insertion and less sore throat than classic LMA"),
], kicker="Anesthetic Techniques", page_num=npg())

# 18. Regional anesthesia
bullet_slide("Anesthetic Techniques: Regional Anesthesia", [
    (0, "Extends ambulatory eligibility to patients where GA risk is excessive and increases patient participation in care"),
    (0, "Spinal anesthesia: suited to TURP, incontinence surgery, and lower-limb procedures; pencil-point needles reduce PDPH to 0.5\u20131%"),
    (1, "Lidocaine largely abandoned for spinal use \u2013 transient neurologic symptoms (TNS) up to 18%"),
    (1, "Preferred agents: prilocaine, 2-chloroprocaine, mepivacaine, and low-dose bupivacaine (\u226410 mg) \u2013 faster recovery, though less predictable duration"),
    (1, "Unilateral / low-dose spinal techniques (5\u20137.5 mg bupivacaine) can speed recovery but increase failure rate"),
    (0, "Epidural and intravenous regional (Bier block) anesthesia: useful for selected upper/lower limb procedures but used less often than spinal or peripheral blocks"),
    (0, "Peripheral nerve blocks/infiltration: excellent analgesia and reduced PONV, yet used in only ~3.3% of appropriate US ambulatory cases"),
    (1, "Local infiltration analgesia (major joint surgery): ropivacaine 300 mg + ketorolac 30 mg + epinephrine 1.5 mg, diluted to 150\u2013200 mL, infiltrated into all tissue planes"),
], kicker="Anesthetic Techniques", page_num=npg())

# 19. Sedation / MAC
bullet_slide("Sedation & Monitored Anesthesia Care (MAC)", [
    (0, "Sedation is NOT inherently safer than general anesthesia \u2013 requires the same standards of personnel, monitoring, and perioperative care"),
    (0, "Propofol sedation (25\u201375 mcg/kg/min): superior recovery to midazolam, but risk of rapid, unintended progression to general anesthesia even at \u201csedative\u201d doses"),
    (0, "Remimazolam: ultra-short-acting ester benzodiazepine, rapidly inactivated by tissue esterases; reversible with flumazenil; bolus 2.5\u20135 mg, redose 1.25\u20132.5 mg; less hypotension than propofol"),
    (0, "Analgesic adjuvants: remifentanil (hyperalgesia risk), dexmedetomidine/clonidine (slow onset/offset, CV instability), ketamine (increases PONV at higher doses)"),
    (0, "Combining drugs (e.g. propofol + remifentanil, or midazolam + remifentanil) produces synergistic respiratory depression \u2013 vigilance required"),
    (0, "Depth-of-anesthesia (BIS) monitoring gives only small reductions in awakening time/PACU stay and does not reliably speed home discharge; over-titrating to lower BIS to save time may increase awareness risk"),
], kicker="Anesthetic Techniques", page_num=npg())

# 20. Recovery
bullet_slide("Recovery from Ambulatory Anesthesia", [
    (0, "Phase 1 (early/PACU): awakening, pain and nausea control, hemodynamic monitoring"),
    (0, "Phase 2 (intermediate/step-down): continues until home-discharge criteria are met"),
    (0, "Typical ambulatory PACU nurse-to-patient ratio: 1:3 (lower acuity than inpatient PACU)"),
    (0, "Modified Aldrete Score commonly used for Phase 1 discharge: scores Activity, Respiration, Circulation, Consciousness, Oxygenation (0\u20132 each, max 10); score \u22659 = fit to leave Phase 1"),
    (0, "Fast-tracking: patients already meeting discharge criteria bypass Phase 1 PACU entirely and go straight to Phase 2, reducing unnecessary delay \u2013 the norm after local anesthesia, sedation, or low-dose spinal, and increasingly used after GA"),
    (0, "One facility achieved fast-tracking in just over 60% of eligible patients; economic benefit is mixed \u2013 costs/staffing often simply shift between units"),
], kicker="Recovery & Discharge", page_num=npg())

# 21. PONV
bullet_slide("Postoperative Nausea and Vomiting (PONV)", [
    (0, "A major cause of unplanned admission and poor satisfaction; postdischarge incidence can exceed 40% even with prophylaxis"),
    (0, "Apfel score (4 simplified risk factors, 1 point each): female sex, non-smoker, history of PONV/motion sickness, postoperative opioid use"),
    (1, "Predicted risk: 0 pts \u2248 10%, 1 \u2248 20%, 2 \u2248 40%, 3 \u2248 60%, 4 \u2248 80%"),
    (0, "Strategy: minimize baseline emetogenic risk first (hydration, regional techniques, reduced volatile/N2O/opioid exposure), then add prophylaxis stratified by risk"),
    (0, "Key agents: 5-HT3 antagonists (ondansetron \u2013 NNT 4 for vomiting; palonosetron \u2013 longer acting), dexamethasone 4\u20138 mg IV (give at induction), low-dose droperidol \u22641.25 mg, antihistamines (useful for vestibular-type nausea), NK1 antagonists (aprepitant) for high-risk patients"),
    (0, "Simple, effective policy: 2 antiemetic interventions for all male patients, 3 for all female patients"),
], kicker="Recovery & Discharge", page_num=npg())

# 22. Pain management
bullet_slide("Postoperative Pain Management", [
    (0, "Inadequate analgesia is a leading cause of unnecessary admission, second only to opioid-related adverse effects \u2013 prevention begins with preoperative counseling"),
    (0, "Multimodal analgesia is the cornerstone: local/regional anesthesia + scheduled NSAIDs/acetaminophen \u00b1 small opioid doses \u2013 reduces opioid dose and its side effects (PONV, sedation, urinary retention, respiratory depression)"),
    (0, "Acetaminophen: comparable efficacy to other agents, favorable safety profile, PO/PR/IV routes"),
    (0, "NSAIDs (ketorolac, diclofenac, ibuprofen, celecoxib): effective single-dose analgesia; use caution in peptic ulcer disease, bleeding risk, CKD, or established CV disease"),
    (0, "PACU rescue: fentanyl 20\u201325 mcg boluses give faster control with less PONV than morphine"),
    (0, "Home analgesia: prescriptions or standardized take-home packs; continuous peripheral nerve catheters with elastomeric pumps enable major shoulder/knee surgery to remain ambulatory (avoid intra-articular LA catheters \u2013 chondrotoxicity risk)"),
], kicker="Recovery & Discharge", page_num=npg())

# 23. Discharge criteria
table_slide("Discharge Criteria \u2013 PADSS Scoring System", ["Category", "2 points", "1 point", "0 points"], [
    ["Vital signs", "Within 20% of baseline", "20\u201340% of baseline", ">40% of baseline"],
    ["Activity / mental status", "Oriented + steady gait", "Oriented OR steady gait", "Neither"],
    ["Pain / nausea / vomiting", "Minimal", "Moderate", "Severe"],
    ["Surgical bleeding", "Minimal", "Moderate", "Severe"],
    ["Oral intake / voiding", "Tolerates fluids AND voided", "Fluids OR voided", "Neither"],
], kicker="Recovery & Discharge \u2013 Postanesthetic Discharge Scoring System",
    page_num=npg(), col_widths=[Inches(3.0), Inches(3.35), Inches(3.0), Inches(2.9)],
    note="Voiding is no longer mandatory before discharge in low urinary-retention-risk patients. No routine minimum observation period is required, EXCEPT tonsillectomy (traditionally 6\u20138 hr to detect primary hemorrhage, though \u22644 hr is increasingly accepted). Written discharge instructions with a 24-hr contact number are mandatory for every patient. Unanticipated hospital admission occurs in 1\u20136% of cases worldwide; surgical complications are the leading cause.")

# 24. Office-based
bullet_slide("Office-Based Anesthesia Practice", [
    (0, "Rapidly expanding model; substantially lower cost than hospital/ASC settings (e.g. laparoscopic hernia repair ~3.5x costlier in hospital)"),
    (0, "Historically less regulated \u2013 one study found a >10-fold increase in adverse incidents/deaths versus accredited ASCs, mainly linked to untrained personnel and deep, unmonitored sedation"),
    (0, "ASA closed-claims data: 40% of MAC-related deaths occurred during facial/eye surgery, usually from unrecognized hypoxia/hypoventilation \u2013 about half judged preventable"),
    (0, "Core safety requirements (Box 68.2): credentialed anesthesia personnel, properly maintained equipment, ASA-standard monitoring, staffed recovery area, emergency equipment and a written transfer plan, quality-assurance and continuing-education programs"),
    (0, "\"Safety standards must never be compromised for convenience or cost savings\" \u2013 selection criteria in the office setting should be at least as strict, if not stricter, than in hospital-based ambulatory units"),
], kicker="Special Settings", page_num=npg())

# 25. Outcomes/complications/satisfaction
bullet_slide("Adverse Effects, Outcomes & Patient Satisfaction", [
    (0, "Minor adverse effects are common after discharge: drowsiness (62%), sore throat/aches after intubation (47\u201349%), headache (25%), dizziness (20%), nausea (17%), vomiting (7%); most patients need 2\u20133 days before resuming usual activity"),
    (0, "Acute cardiovascular events: ~2.9% incidence (higher with pre-existing CV disease); respiratory events: ~0.1% (higher in smokers, asthmatics, obese patients)"),
    (0, "IAAS outcome indicators: failure to attend, cancellation on the day, unplanned return to OR, unplanned overnight admission, unplanned readmission (<24h and 24h\u201328 days)"),
    (0, "Patient satisfaction is generally very high; staff friendliness and the surgeon discussing findings before discharge are rated as more important than pain control or IV comfort in some studies"),
    (0, "Overall: ambulatory surgery remains very popular with patients, with infrequent adverse events and complications"),
], kicker="Quality & Outcomes", page_num=npg())

# 26. Recent evidence
bullet_slide("Recent Evidence Update (2024\u20132025)", [
    (0, "Perioperative adverse events in OSA patients undergoing ambulatory surgery \u2013 updated systematic review/meta-analysis (Ceban et al., J Clin Anesth 2024, PMID 38718686): reinforces that carefully selected OSA patients can safely undergo ambulatory surgery"),
    (0, "Optimal local anesthetic for spinal anesthesia in ambulatory non-arthroplasty surgery \u2013 Bayesian network meta-analysis (Singh et al., Can J Anaesth 2025, PMID 40199797): supports short/intermediate-acting spinal agents (e.g. chloroprocaine, prilocaine) over bupivacaine for faster recovery"),
    (0, "Use of ambulatory pathways in emergency general surgery \u2013 systematic review (Fox et al., BMJ Open 2025, PMID 41022441): growing evidence base for extending day-case pathways to selected emergency general surgical patients"),
    (0, "Take-home point: current literature continues to support and extend Miller's core themes \u2013 individualized, non-arbitrary patient selection and agent choice geared to fast, predictable recovery"),
], kicker="Evidence Check", page_num=npg())

# 27. Key takeaways
key_takeaway_slide("Key Takeaways", [
    "Ambulatory anesthesia now accounts for ~80% of US elective surgery \u2013 patient selection is individualized, not based on arbitrary age, BMI, or ASA cutoffs",
    "Frailty, not chronological age, predicts adverse outcomes; surgical complications remain the leading cause of unplanned admission",
    "Propofol-based TIVA or short-acting volatiles, supraglottic airways, and targeted regional techniques optimize fast, clear-headed recovery",
    "Multimodal analgesia and risk-stratified PONV prophylaxis (e.g. Apfel score) are essential to avoid unplanned admission and improve satisfaction",
    "Validated tools (Modified Aldrete score, PADSS) standardize safe discharge; written instructions and a 24-hour contact number are mandatory",
], npg(), kicker="Summary")

# 28. References
bullet_slide("References", [
    (0, "Miller RD, et al. Miller's Anesthesia, 10th Edition, Chapter 68: Ambulatory Anesthesia. Elsevier, 2024."),
    (0, "American Society of Anesthesiologists. Guidelines for Ambulatory Anesthesia and Surgery (2018 update). asahq.org"),
    (0, "Rockwood K, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495."),
    (0, "Ceban F, et al. Perioperative adverse events in adult patients with OSA undergoing ambulatory surgery: an updated systematic review and meta-analysis. J Clin Anesth. 2024. PMID 38718686."),
    (0, "Singh NP, et al. Optimal local anesthetic for spinal anesthesia in ambulatory non-arthroplasty surgery: a systematic review and Bayesian network meta-analysis. Can J Anaesth. 2025. PMID 40199797."),
    (0, "Fox B, et al. Use of ambulatory pathways in emergency general surgery: a systematic review. BMJ Open. 2025. PMID 41022441."),
], kicker="Sources", page_num=npg())

import os
os.makedirs("/tmp/workspace/ambulatory-anesthesia-ppt", exist_ok=True)
out_path = "/tmp/workspace/ambulatory-anesthesia-ppt/Ambulatory_Anesthesia_Seminar.pptx"
prs.save(out_path)
print("Saved:", out_path, "| slides:", len(prs.slides.__iter__.__self__._sldIdLst))